What’s next for England’s ambulance services?

Adobe Spark (7)Details of the delivery of new ambulance standards were outlined by the National Clinical Director for Urgent Care at the Health and Care Innovation Expo in Manchester (NHS England, 2017a). Professor Jonathan Benger provided delegates with an overview of the Ambulance Response Programme, which he called: ‘the way we should do change in the NHS—change that is evidence based from the very beginning.’

Outlining the programme

The implementation of the Ambulance Response Programme was announced by NHS England (2017b) in July, following recommendations by the NHS England National Medical Director, Professor Sir Bruce Keogh, to the Health Secretary (Keogh, 2017). It consists of three initiatives that were developed to try and improve clinical responses for patients.

Phase 1 involved changes to the triage of calls to allow more time for call handlers in cases that are not deemed as immediately life-threatening. This has been referred to as dispatch on disposition. Traditionally, handlers had up to 60 seconds to assess calls and establish the urgency of the problem, and the type of response required. It is at this point that the clock is started for the performance measurement. The subsequent issue was that in an effort to meet an 8-minute response standard, ambulance services were sending multiple vehicles to the same patient and standing down the vehicles they thought wouldn’t get there first. Response cars would frequently be used as a way of ‘stopping the clock’ but then the patient would have a long wait for the transporting ambulance, which was detrimental to the patient but not measured on the system. According to Benger:

‘The problem created was one whereby a paramedic in a response car might spend their entire day just driving from one call to another but never actually reaching a patient.’

The Ambulance Response Programme therefore sought to provide a more clinically appropriate response by targeting the right resource to the right patient. For non-life-threatening calls, ambulance call handlers were given up to an additional 3 minutes to determine what was wrong with the patient and therefore decide an appropriate response.

Phase 2 involved the introduction of a new code set that has four key categories, rather than two, which better reflects the wide range of needs patients have when they dial 999. In the old system almost 50% of calls to ambulance services are classified as Red 1 or Red 2, requiring a response within 8 minutes. However, this does not accurately reflect the type and urgency of care needed by patients (Turner et al, 2017). Under the new system there will now be four revised call categories:

  • Category 1 is for life-threatening calls. These are for people needing treatment for life-threatening illnesses or injuries and will be responded to in an average of 7 minutes
  • Category 2 is for emergency calls. These are potentially serious conditions that may require rapid assessment, urgent on-scene intervention and/or urgent transport. These will be responded to in an average of 18 minutes
  • Category 3 is for urgent calls. These are non-life-threatening problems involving patients needing treatment to relieve suffering. Often they can be managed at the scene and 90% of these patients will be responded to within 120 minutes
  • Category 4 is for less urgent calls. These are for non-urgent problems requiring assessment either face-to-face or by telephone and 90% of these patients will be responded to within 180 minutes.

The final initiative involved a review of the current ambulance system, Ambulance Quality Indicators (AQI), and the development of a revised set of indicators linked to the revised call categories.

Evaluating the programme

A formal trial of Phase 1 began in October 2015 and a trial of the Phase 2 revised call categories began in three services in April 2016. An evaluation of Phases 1 and 2 was published by researchers at Sheffield University (Turner et al, 2017). Benger said:

‘We are very fortunate in the Ambulance Response Programme to have very good stakeholder engagement and excellent independent academic scrutiny from Sheffield University.

‘They have analysed the data we’ve collected from more than 14 million 999 calls. Of those 14 million patients, no patient came to harm as a result of the Ambulance Response Programme.’

The review revealed that under the new dispatch on disposition system, early recognition of life-threatening conditions, such as cardiac arrest, will increase. The knock-on effect is up to an additional 250 lives saved each year. By sending an appropriate response, more vehicles will be freed up to attend emergencies, and patients will be conveyed to the appropriate place.

According to Benger, when call handlers were given more time, rather than impeding or reducing the speed of response for the sickest patients, speed and performance actually improved.

‘The ambulance services became a lot more efficient,’ said Benger. ‘Taking the entirety of both dispatch on disposition and the new coding set together, we were releasing 15 000–16 000 additional resources each week that could respond to a 999 call, when that was not previously the case. And that’s principally from putting an end to duplicate responses.’

Evaluation of Phase 2 on its own, however, is more complicated. The use of time-based standards as a key performance measure have been used by ambulance services throughout the world, despite a lack of evidence that they actually lead to good clinical care. As Phase 2 has only been operational for a short period of time, it is not possible to say whether the new model is better, only that it is ‘different’ (Turner et al, 2017). However, the three services reviewed indicated a period of operational stability during a period of high demand, even when response time performance continued to deteriorate in services operating the current national model.

It is thought that the more flexible approach to call assessment, resource dispatch, and response intervals brought on by the combination of dispatch on disposition and the
new code set, may reduce further deterioration in performance and maintain a consistent service. However, as highlighted by the researchers at Sheffield University, a system of ongoing review and refinement is needed to optimise delivery (Turner et al, 2017).

Implementing the programme

All ambulance services are now using dispatch on disposition, and the new call categories are intended to be fully implemented by winter 2017. This will hopefully reduce pressures on A&Es during their busiest time period.

‘We wanted to make ambulance services as efficient as they could be but that we didn’t lose sight of some of the core aims: prioritising the sickest patients, making sure we incentivise clinically and operationally efficient behaviours, and trying to reduce the long waits for patients,’ said Benger.

‘When I first started in my job, I noticed that when you gathered ambulance chief executives together in a room, they would spend about 90% of the time talking about ambulance response times and 10% about clinical outcomes. I’d like to reverse that.’

As demand for urgent and emergency care sees year-on-year increases, services have to adapt to reduce pressure and ensure patients are able to get the care they need. It is hoped the new ambulance standards will go some way to making this a reality.

References

Keogh B. Ambulance Response Programme—letter to Secretary of State [Internet]. Leeds: NHS England; 2017. Available from http://tinyurl.com/ybfgxmfx

NHS England. What next for England’s ambulance services? Leeds: NHS England; 2017a. Available from http://tinyurl.com/yb7vzk8g

NHS England. New ambulance standards announced. Leeds: NHS England; 2017b. Available from http://tinyurl.com/yc6ywmqs

Turner J, Jacques R, Crum A, Coster J, Stone T, Nicholl J. Ambulance Response Programme: Evaluation of Phase 1 and Phase 2. Final Report. Sheffield: School of Health and Related Research, University of Sheffield; 2017.

Taken from Journal of Paramedic Practice, published October 2017.

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Hunt challenges the NHS to deliver digital services by 2018

Adobe Spark (6)The Health Secretary, Jeremy Hunt, has challenged the NHS to deliver digital services nationwide by 2018 to coincide with the NHS’ 70th anniversary next year.

Hunt used September’s Health and Care Innovation Expo in Manchester to highlight the opportunity of technology in creating ‘The patient power decade’. The Health Secretary painted a pixelated portrait of a future shift in power within the NHS from doctor to patient, with the patient ‘Using technology to put themselves in the driving seat of their own healthcare destiny.’

Hunt stated that by the end of 2018, patients will be able to use an integrated smartphone app to access services such as NHS 111, book a GP appointment and even have the ability to view healthcare records online.

Currently, according to NHS Digital, 680,000 patients are viewing their medical records online every month.

In this keynote speech, he further acknowledged how ‘People should be able to access their own medical records 24/7, show their full medical history to anyone they choose and book basic services like GP appointments or repeat prescriptions online.’

Mr Hunt also stated that the app could be used to order repeat prescriptions, access support for managing long-term conditions, or express preferences on organ donation, data sharing, and end-of-life.

Hunt emphasised how the ‘master-servant relationship’ between doctors and patients that has existed for three millennia will be ‘turned on its head’, and patients will use the information that becomes available at their fingertips, ‘to exert real control in a way that will transform the prospects of everyone.’

Overcoming hurdles

If the NHS is to successfully deliver digital health services, there are a number of potential hurdles to overcome. Firstly, there are concerns over the accessibility of services for those unfamiliar with smartphone technology, or from those of disadvantaged backgrounds who cannot afford to buy a smartphone. For this reason, Hunt stressed how the new services will be for everyone:

‘If the NHS is not there for everyone, it is nothing,’ he said. ‘We recognise that not everyone is comfortable using a smartphone. So we will always make sure that when we introduce new services, there is a face-to-face or telephone alternative, for people who do not use smartphones.’

While many older people struggle with online technology, it is worth pointing out this is not always for want of trying. Hunt outlined how 400 000 people have already been trained to help get them online, and over the next 3 years, a further 20 000 digital inclusion hubs will be rolled out. Additionally, wifi will be introduced across primary care this year and secondary care next year, which is hoped will help support people accessing online resources.

Secondly, in lieu of the NHS cyber attacks earlier this year, Hunt conceded that a lot needs to be done to win back the public’s trust:

‘We have to recognise that we still have a lot to do to earn the public’s trust that their patient data is safe with us,’ he said.

As part of this, the Government announced its response to the National Data Guardian and Care Quality Commission report on data security in July. Among the initiatives are 10 new data security standards, a £21 million investment to protect trauma centres from cyber attack and new national support for unsupported Microsoft systems that were part of the original problem that caused the cyber attacks.

The role of mobile technology in delivering health services was also highlighted in a keynote speech from Professor Sir Bruce Keogh, medical director of the NHS. He said we run our social lives, financial lives, travel lives and retail lives online, so why not our health? Keogh welcomed the idea of being able to book GP appointments, get blood results or see X-rays online. However, he also recognised that it brings with it some challenges.

The first challenge is digital therapy, particularly in the area of mental health. According to Keogh, this will involve activities patients can do on their mobile phone that will improve their health, such as talking therapies, so that they do not have to visit a psychologist, psychiatrist or your GP. The NHS will have to work out how it assesses these, but importantly it needs to work out the payment mechanisms behind them so that they are available for everyone on the NHS.

The second challenge concerns what happens when people can get advice and treatment outside normal geographical boundaries. Currently, the way the NHS is structured means a GP is determined by where a patient lives. However, Keogh highlighted how already many are visiting GPs outside the area where they live. He therefore questioned what happens as more people start to access health care not just beyond their local area but beyond their regional area and possibly internationally. He stressed the need to work out who pays for what, the duties of Government and arm’s length bodies with respect to ensuring the safety of those transactions, and the legal implications. The issue is how this can be made part of the NHS, rather than creating a two-tier ‘pay for it if you can’ service.

Looking to the future

Pilot schemes are already underway, with ongoing evaluation before the digital service is introduced nationally. According to Hunt, initial results from pilots in north London, Leeds, London and Suffolk, show that when NHS 111 services are transferred online it is safe. He also pointed out that if digital health services are introduced in the right way, it will save the NHS money. He said: ‘The 6% of people who use the 111 app, rather than speaking to the call handler, save the NHS money. That’s more resources for doctors and nurse.’

Looking to the future, Hunt confirmed that the Government are trying to build the safest, highest quality health system in the world. The role of technology, therefore, is one that he believes is of the utmost importance in making this a reality:

‘As we grapple with the challenges of resources, challenges to improve patient safety, challenges to improve quality and challenges to improve changing consumer expectation, technology can be our friend if we recognise it as a means to an end and not an end in itself, and that end is safer, healthier patients,’ he said.

Taken from British Journal of Healthcare Management, published October 2017.

Sir Bruce Keogh admits health system is ‘creaking’ and ‘under pressure’

Prof Sir Bruce Keogh, medical director of the NHS, has admitted the National Health Service is ‘creaking’ and ‘under pressure’, at a conference held at the King’s Fund on 19 December.

The Urgent and Emergency Care Conference, hosted by the King’s Fund, provided an update on progress with the Urgent and Emergency Care Review, as well as exploring the immediate challenges facing urgent and emergency care services.

Prof Chris Ham, chief executive of the King’s Fund, opened the event by asking delegates: what kind of urgent and emergency care system do we need in the future? Ham proposed that we need a much more joined up and integrated system than the one that is currently in place.

Prof Sir Bruce Keogh delivered the keynote speech on the future of urgent and emergency services in England, placing an emphasis on the long-term vision for transforming urgent and emergency care. Keogh explained that over the past year there has been a steady and relentless growth in the number of A&E attendances, and in light of reports of additional pressures placed on services during the Winter months, he admitted:

‘The system is creaking. A&Es are having to address increasing demand, the ambulance services are struggling in many parts and we have a number of issues to deal with, which we are tackling.’

Keogh acknowledged that responsive services need to be provided closer to home and that highly specialised centres must be made available. It is only through this way that we can ensure patients in life-critical conditions receive the right level of treatment at the right place.

Keogh outlined that the current urgent care system is complex and confusing, and so a simple and intuitive system is needed if patients are to access the right care, at the right place, at the right time. The introduction of urgent care networks, as a means to dissolve boundaries between hospitals and community services, and join up pathways of care, will be integral to ensuring this is possible.

Dr Robert Varnam, head of General Practice Development for NHS England, followed with a talk on the contribution of primary care in the provision of urgent and emergency care. Varnam stressed the need to develop more responsive and joined-up approaches from general practice, noting that only by seeing the whole system can the needs of patients be properly met. He also stressed the importance of primary care colleagues collaborating with the urgent care pathway, and the need to think about access in primary care. Varnam questioned what the point in quick access is if what you get access to doesn’t address need.

Dr Clifford Mann, president of the College of Emergency Medicine, gave the final talk before delegates broke for coffee on the next steps for emergency medicine. Following on from the publication of the College of Emergency Medicine’s CEM10, which outlined 10 priorities for resolving the crisis in emergency departments, Mann gave an overview of the College’s STEPs to rebuilding emergency medicine. These consist of staffing, tariffs and terms, exit block, and primary services.

After coffee, procedings were separated into two streams: one on urgent care, the other on emergency care. Within the urgent care stream, Richard Hunt, chair of the London Ambulance Service NHS Trust, delivered the first talk on supporting the development of ambulance services as out-of-hospital providers. This was given on behalf of the Association of Ambulance Chief Executives (AACE).

After giving a background to the AACE, Hunt outlined the potential role of ambulance services in transforming urgent and emergency care. Through the development of the paramedic workforce—to include more specialist and advance paramedic roles—it is hoped that ambulances could be used as mobile urgent treatment services capable of dealing with complete episodes of care without transport to hospital. Improving the range of clinical assessment and decision-making skills of paramedics so that they can manage patients closer to home, and the introduction of independent prescribing for paramedics could help achieve this.

This was followed by a panel discussion on providing a highly responsive urgent care service outside of hospital. Panellists included: Dr Chaand Nagpaul, chair of the General Practitioners Committee, British Medical Association; Adam Duncan, chief operating officer, London Central and West Unscheduled Care Collaborative; Dr Simon Abrams, GP and chair, Urgent Health UK, Federation of Social Enterprise Out of Hours Providers; and Ashok Soni OBE, clinical network lead, Lambeth Clinical Commissioning Group and president, Royal Pharmaceutical Society.

Key issues discussed in this session included: improving access for patients to ensure they can easily navigate the system; developing and implementing plans to meet predictable surges in demand; the role of GPs in urgent care now and under new plans for two types of urgent care networks: strategic and operational; and aligning 999 and NHS 111.

After lunch, Rob Webster, chief executive of NHS Confederation, spoke on new models for urgent and emergency care. Webster offered a system perspective on challenges and opportunities for urgent and emergency care networks, outlining that urgent and emergency care networks provide increased access to a simplified urgent and emergency care system, and better integration between urgent and emergency care services.

Examining existing evidence on networks, Webster looked at functions for network models, including strategic leadership for urgent and emergency care; to coordinate operational implementation at a local level; and to address fragmentation within the urgent and emergency care pathway.

This was followed by a panel discussion, where speakers gave an overview of existing networks and coordination at local level. Dr Nav Chana, chairman of the National Association of Primary Care, gave an interesting talk where he argued primary care should be defined by its function not its membership.

Stephen Dalton, chief executive of the Mental Health Network, delivered a talk on mental health and crisis care. Explaining that mental health service users have double the A&E attendance rate of the general population, Dalton gave an overview of the Mental Health Crisis Care Concordat, whose vision is for services to work together to deliver a high-quality response when people—of all ages—with mental health problems urgently need help.

Solveig Sansom, head of commissioning for integration, South Devon and Torbay Clinical Commissioning Group spoke on the Newton Abbott Frailty Hub, an initiative aiming to increase the number of patients who are proactively case-managed at home. Utilising a joined-up approach for frail elderly care, its predicted outcomes include a reduction in long-term care placements, as well as a reduction in emergency admissions from care homes.

The closing session of the day saw Adrian Masters, managing director, sector development for Monitor, speak on implementing a new payment approach to support improved delivery of urgent and emergency care. Masters highlighted that payment needs to change to support the service reforms and that Monitor are working with their partners on a wider programme of work on payment, which offers a coordinated and consistent payment approach across all parts of the urgent and emergency care network.

The final talk was given by Prof Keith Willett, director for acute episodes of care, NHS England, on progress made with phase two of the Urgent and Emergency Care Review. Outlining the next steps in delivering change following the review, Willett explained how emergency care networks will connect all services together into a cohesive network so that the system is more than just the sum of its parts. NHS England is now at the stage of moving from design to delivery; however, it faces a number of significant challenges, including payment system reform, information sharing, workforce and skills shift.

Taken from Journal of Paramedic Practice, published 9 January 2015.

The waiting game: resolving the crisis

Last month saw the highest number of patients who waited more than 4 hours in Type 1 A&E units (major A&E) before they were treated since figures began in 2010 (Campbell, 2014).

Figures from NHS England revealed that for the week ending 7 December, 35 373 patients waited more than 4 hours from arrival to admission, transfer or discharge at Type 1 A&E units (NHS England, 2014a). Of the total number of attendances, only 87.7% were treated in 4 hours or less. This is below the target set by the Government of 95%. This also marks a 66% increase on figures from the same week last year (NHS England, 2013). For the week ending 12 December, this rose to 44 153, which represented a drop in the number of patients treated within 4 hours to 84.7% (NHS England, 2014b).

The number of patients spending between 4 and 12 hours on a trolley from decision to admit to admission was similarly high: 7 760 patients for the week ending 7 December and 10 126 for the week ending 14 December, respectively (NHS England, 2014a; 2014b). This is more than double the numbers of 2013 (NHS England, 2013).

Following a decision made by health secretary Jeremy Hunt not to publish performance figures over the festive period, so as to give staff a break, data published on 6 January revealed that only 92.6% of patients were seen in 4 hours from October to December (Triggle, 2015b). This performance is the worst quarterly result in a decade.

It is undoubted that A&E departments are facing difficult times. At a King’s Fund conference in December, Prof Sir Bruce Keogh admitted that the health system is ‘creaking’ and ‘under pressure’ as a result of the strain brought on by increased attendances during winter months. The need for radical change within the urgent care system, therefore, has never been so apparent.

In England, an extra £700 million has been set aside to help the NHS, through the provision of additional staff. However, Dr Clifford Mann, president of the College of Emergency Medicine, has raised concerns that it has not gone through to all the places it should (Triggle, 2015a).

With major incidents being declared at a number of hospitals, new measures need to be implemented if targets are to be met. Keogh’s vision for a new urgent and emergency care system outlined in the Urgent and Emergency Care Review could present an answer, but it is expected to take 3–5 years to enact the major transformational changes. Although the Keogh Review wants to avoid risky ‘big bang’ change, that change is needed now. It is, therefore, a neverending waiting game.

References

Campbell D (2014) Record A&E waits show NHS is cracking under pressure—doctors’ chief. The Guardian. http://tinyurl.com/llm54sy (accessed 5 January 2015)

NHS England (2013) A&E weekly activity statistics, NHS and independent sector organisations in England. Week ending 8/12/2013. NHS England, London

NHS England (2014a) A&E weekly activity statistics, NHS and independent sector organisations in England. Week ending 7/12/2014. NHS England, London

NHS England (2014b) A&E weekly activity statistics, NHS and independent sector organisations in England. Week ending 14/12/2014. NHS England, London

Triggle N (2015a) A&E performance in England ‘likely to hit new low’. BBC. http://www.bbc.co.uk/news/health-30679949 (accessed 5 January 2015)

Triggle N (2015b) A&E waiting in England worst for a decade. BBC. http://www.bbc.co.uk/news/health-30679949 (accessed 6 January 2015)

Taken from Journal of Paramedic Practice, published 9 January 2015.

NHS Confederation calls for a sustainable and high-quality urgent and emergency care system

A response by the NHS Confederation to Sir Bruce Keogh’s review of urgent and emergency care has called for an end to ‘sticking plaster solutions’ and the need for a sustainable and high-quality urgent and emergency care system that can meet the needs of patients.

The report, entitled Ripping off the Sticking Plaster, urges joint work between primary care, acute, ambulance, mental health, social care and community services.

One of the key recommendations from the report calls for getting the best from the urgent and emergency care system and workforce. This would involve improving the education, information, engagement and support available to staff.

Sir Bruce Keogh’s report said fewer patients attended by ambulance crews should be taken to hospital in order that pressures on A&E departments are reduced. The NHS must therefore improve training and investment in its staff, such as the development of more community-based ambulance services, through enhancing paramedic practitioner roles.

This would enable paramedics to take more responsibility for decisions to treat patients on scene and not feel the need to err on the side of caution and transfer patients to hospital.

Chief of the NHS Confederation, Rob Webster, said: ‘We know patients will go “where the lights are on” and instead of blaming patients for going to the wrong place, we need to build a system around patients and to give them the care they need, when they need it.

‘Looking at emergency care in isolation, or just as a hospital problem, without an appreciation or understanding of what is going on across the rest of the NHS and social care will not solve the long-term issues.

‘This will require primary care, acute, ambulance, mental health, social care and community services to work together in networks

‘We need to build on the existing good practice which is out there, but change needs to happen, and fast.’

Taken from Journal of Paramedic Practice, published 26 March 2014.

2013: the year in review

As paramedics across the country are recovering from the busiest shift of the year, the Journal of Paramedic Practice thought it would look back over 2013 and consider some of the notable events that occurred, both good and bad.

The beginning of 2013 will be remembered by most for the tragic loss of Roland Furber, President of the College of Paramedics, who passed away on 4 February. Roland and his late wife Carol were known for the huge contribution they made to the paramedic profession and the establishment of the professional body, which was then the British Paramedic Association (BPA). As the inaugural chief executive of the BPA, Roland made an enormous impact on the founding of the profession.

February also saw the release of the final report of the Mid Staffordshire NHS Foundation Trust Inquiry chaired by Robert Francis QC, which though not directly affecting paramedics, raised a number of important questions concerning the care of those who are older and more vulnerable. Perhaps more than anything it highlighted the need for a cultural change within the NHS, where patients are placed at the centre.

One of the most notable events of the past year was the long-awaited publication of the UK Ambulance Services Clinical Practice Guidelines 2013, which was issued following lengthy development with JRCALC and National Ambulance Service Medical Directors. The first major re-write since 2006, it features a number of significant changes in terms of guidance for clinical care. Work is already underway scoping future editions and updates, as can be seen in the obstetrics and gynaecology update published in this issue.

April saw the new health and care system in England become fully operational, with its ambitious aims to deliver the content laid out in the Health and Social Care Act 2012.

August saw the publication of the end of study report for the Paramedic Evidence Based Project (PEEP). Commissioned as a result of the growing interest in the delivery of paramedic education and training, the project called for the introduction of a national education and training framework for paramedics.

Perhaps the biggest piece of news came with Sir Bruce Keogh’s report on the first stage of his review into urgent and emergency care, published 13 November, which presented a significant step in the progression of the paramedic profession. Sir Bruce’s call for the development of 999 ambulance services so that they become mobile urgent treatment services, illustrated an appreciation of the skillset of paramedics and their potential in the delivery of pre-hospital care.

Finally, 2013 marked the five-year anniversary of the Journal of Paramedic Practice, which was launched in October 2008. On behalf of the journal I would like to thank the editorial board, the consultant editors, all those who have contributed to the journal, helping to make it an informative learning resource, and most of all, you the readers, without which this publication would not be possible. I look forward to another exciting year and wish you all the best for 2014.

Taken from Journal of Paramedic Practice, published 10 January 2014.

NHS medical director proposes increased role for ambulance services

The National Medical Director of NHS England, Sir Bruce Keogh, has proposed an increased role for ambulance services in the provision of emergency and urgent care in England.

Sir Bruce Keogh’s report on the first stage of his review of urgent and emergency care, published 13 November 2013, has called for the development of 999 ambulance services so that they become mobile urgent treatment services, noting that paramedics now have the skills and equipment that would only be done by doctors 10 years ago.

In a letter to Health Secretary Jeremy Hunt and NHS England Chair Sir Malcolm Grant, Sir Bruce says:

‘Our vision is simple. Firstly, for those people with urgent but non life-threatening needs we must provide highly responsive, effective and personalised services outside of hospital. These services should deliver care in or as close to people’s homes as possible, minimising disruption and inconvenience for patients and their families.’

Both the College of Paramedics (CoP) and the Association of Ambulance Chief Executives (AACE) have welcomed the report, and emphasised that increasing demands on ambulance services highlights the need for further investment into the training and education of paramedics.

Prof Andy Newton, chair of the College of Paramedics, said:

‘Key roles, like that of the specialist paramedic roles in urgent care, now urgently need support with further investment and critically the development of prescribing for paramedics, another key area highlighted in this NHS England report.’

Association of Ambulance Chief Executives managing director, Martin Flaherty OBE, said:

‘This will require further investment in the training and education of paramedics and other ambulance staff together with a review of the overall capacity of ambulance services. This will ensure that they have the resources needed to resolve the patient’s issue without taking them to hospital.’

The report also suggests that a two-tier A&E system should be introduced. The biggest 40–70 units would be called ‘Major Emergency Centres’ and designated to deal with heart attacks, strokes and other serious injury, while the remaining 70–100 A&Es would be ‘Emergency Centres’ and deal with less serious conditions.

Taken from Journal of Paramedic Practice, published 26 November 2013.