What is Pre-Hospital Emergency Medicine?

The term ‘pre-hospital care’ covers a wide range of medical conditions, medical interventions, clinical providers and physical locations. Medical conditions range from minor illness and injury to life threatening emergencies. Pre-hospital interventions therefore also range from simple first aid to advanced emergency care and pre-hospital emergency anaesthesia. Care providers may be lay first responders, ambulance professionals, nurses or physicians of varying backgrounds.

All of this activity can take place in urban, rural or remote settings and is generally mixed with wider out-of-hospital and unscheduled care. The complexity
of unscheduled and urgent care provision is illustrated in figure 1.1. Another useful way to conceptualise this breadth of clinical providers is to use the levels of practice originally described in the Skills for Health Career Framework (figure 1.2). The Career Framework describes the level of autonomy, responsibility and clinical decision-making expected of a healthcare provider operating at a particular level.

PHEM subspecialist practice relates to the Emergency Response, Primary Scene Transfer and Secondary Emergency Transfer functions highlighted in figure 1.1 at the level of the consultant (level 8) practitioner illustrated in figure 1.2. PHEM primarily relates to that area of medical care required for seriously ill or injured patients before they reach hospital (on-scene) or during emergency transfer to hospital (in-transit). It represents a unique area of medical practice which requires the focused application of a defined range of knowledge and skills to a level not normally available outside hospital.

There is a long-established tradition of provision of voluntary and charitable emergency pre-hospital care in the UK. Building on the success of these individuals and services, the aspiration of the Intercollegiate Board for Training in Pre-hospital Emergency Medicine is that each NHS Ambulance Service should now have consistent, immediate access to deployable PHEM subspecialist services 24 hours a day.

Figure 1.1 Conceptual model of effective urgent care. Adapted from: Direction of Travel for Urgent Care: a discussion document. Department of Health, October 2006.

Figure 1.2 Skills for Health Career Framework.

The Intercollegiate Board for Training in Pre-hospital Emergency Medicine estimates that ten whole-time equivalent (WTE) PHEM subspecialist consultants would be required per region to fulfil the need and achieve the aspirations of the subspecialty. However, many regions encompass large populations and/or geographical areas and distinct PHEM services may be justified in several parts of the UK (perhaps more closely aligned to Major Trauma Centre outreach and retrieval services or Air Ambulance Services than to regional NHS Ambulance Services). Workforce estimates are based on 200 to 250 WTE consultants in PHEM across the UK. Given that all will have at least a 50% commitment to their base specialty, this equates to a head count of 600 to 750 subspecialty trained clinicians nationally. Since the inception of the subspecialty, numbers of training posts and LEPs have gradually increased. Over 100 clinicians have successfully completed training and 10 regional training programmes have been fully established. There continues to be oversubscription of recruitment and high demand for PHEM subspecialists – as evidenced by the ongoing expansion of service providers and post-training survey results showing continued engagement in consultant-level PHEM clinical practice.

The development of this cadre of subspecialty trained clinicians has not diminished or de-emphasised the importance of individuals (including non-specialist medical practitioners and allied health professionals such as paramedics and nurses) continuing to provide clinical service at different levels of the Skills for Health Framework. Instead, the subspecialty has proven to be a mechanism by which this area of medical activity can be aligned with other areas of specialist medical practice and existing practitioners can be better supported. The Intercollegiate Board for Training in Pre-hospital Emergency Medicine also believes that addressing the key drivers for the development of the subspecialty will result in stronger medical leadership within all areas of pre- hospital clinical practice and help to develop services and standards across all levels of pre-hospital care.

The NHS Ambulance Services in the UK primarily deploy Health and Care Professions Council-registered paramedics. Specialist, Advanced and Consultant paramedics with a defined additional range of pre-hospital critical care knowledge and skills (often referred to as critical care paramedics) have also been trained in many regions. Multi-professional teams are already essential for the provision of good hospital clinical and critical care and the combination of doctors, nurses and paramedics working closely together in pre-hospital care has been associated with effective operational services and good outcomes. The strengthening of education and training for doctors also supports the development of specialist paramedic practitioners and enhances the delivery of PHEM by doctor-paramedic teams.