64677 Ambulance Trust ReportV3:63630 AnnualMon 27/1/11 16:34 Page A
Review of approval and monitoring 2007–10
UK ambulance service pre-registration programmes 64677 Ambulance Trust ReportV3:63630 AnnualMon 27/1/11 16:34 Page B
Contents
Introduction 2 About us (the Health Professions Council) 2 Our main functions 2 Brief overview of the approval and monitoring processes 2 About this document 3
Review of approval activities 5 Background to the programme of visits 5 Preparation for the programme of visits 6 Outcomes of visits 6 The evidence base 6 The impact on resources and timeframes for the approval process 7 Feedback from ambulance services 10 Time taken to complete approval process 11 Communication and information 11 Pre-visit stage 12 The visit 14 The post-visit stage 14 Education provider feedback conclusions 15 Standards of education and training 15 Standards of proficiency 19 Standards of proficiency: further analysis 21 Conclusions on SOPs data 24 Conclusions from the review of visits 24 IHCD as a curriculum-setting body 25 64677 Ambulance Trust ReportV3:63630 AnnualMon 27/1/11 16:34 Page 1
Review of annual monitoring activities 26 The history leading to the annual monitoring of pre-registration education and training delivered by UK ambulance services 26 Brief overview of the annual monitoring process 26 Outcomes from the UK ambulance service annual monitoring process 27 Evidence base 27 The impact on resources and timeframes for the annual monitoring process 27 Standards of education and training 29 Analysis of Visitor comments 30 Summation of trends 30 Conclusions from annual monitoring activities 31 Conclusions from review of the approval and monitoring activities 31 Distinctiveness of each programme 32 Application of standards and approval and monitoring processes 32
Appendix A – Final outcomes from approval process 33
Appendix B – Ambulance Service Feedback Form 34
Appendix C – SOPs numbering 37
Appendix D – Final outcomes from annual monitoring 49
List of graphs 50 64677 Ambulance Trust ReportV3:63630 AnnualMon 27/1/11 16:34 Page 2
Introduction
About us (the Health Our main functions Professions Council) To protect the public, we: We are the Health Professions Council (HPC) – set standards for registrants’ education and we were set up to protect the public. To and training, professional skills, conduct, do this, we keep a register of professionals performance, ethics and health; who meet our standards for their training, professional skills, behaviour and health. – keep a register of professionals who meet those standards; Professionals on our Register are called ‘registrants’. We currently regulate members of – approve programmes which 15 professions. professionals must complete to register with us; and – Arts therapists – take action when professionals on our – Biomedical scientists Register do not meet our standards. – Chiropodists / podiatrists The Health Professions Order 2001 says that – Clinical scientists we must set standards which are necessary for safe and effective practice. This is why our – Dietitians standards are set at a ‘threshold’ level (the – Hearing aid dispensers minimum level of safe and effective practice to protect the public). – Occupational therapists Brief overview of the approval – Operating department practitioners and monitoring processes – Orthoptists We visit all the programmes we approve to – Paramedics make sure that:
– Physiotherapists – the education programme meets or continues to meet our standards of – Practitioner psychologists education and training (SETs); – Prosthetists / orthotists – those who complete the programme are – Radiographers able to meet or continue to meet our standards of proficiency (SOPs) for their – Speech and language therapists part of the Register; and
We may regulate other professions in the – all programmes and education providers future. For an up-to-date list of the professions are assessed fairly and consistently. we regulate, please visit our website at www.hpc-uk.org
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Introduction
When we carry out an approval visit, we are About this document represented by what we refer to as the HPC Panel. The HPC Panel is normally made up of This report details the work conducted to two Visitors, at least one of whom is from the review the programme of visits and annual same part of the Register as the profession to monitoring activities for pre-registration which the programme relates, and an HPC education and training delivered by UK public representative from the Education Department. ambulance services. It is the role of the Education Department The review focused on the series of approval representative to support both the Visitors and visits undertaken by the Education Department the education provider. Throughout the visit, to UK public ambulance services. The review we will ask questions of the staff, students, also focused on the outcomes of the annual senior managers and practice-placement monitoring activities and the implications for providers. We relate all our discussions back to the future approval and monitoring of pre- our standards. At the end of the approval visit, registration education and training delivered by the Visitors will make a recommendation as to UK ambulance services. whether, or to what extent, the programme meets or continues to meet our standards. In particular the review focused on: Their recommendation is sent to our Education – the methodolgy the HPC applied in and Training Committee (ETC) which makes deciding to undertake a programme of the final decision. visits to UK public ambulance services; If we approve an education programme, it is – how the HPC plan for the visit normally given ‘open-ended approval’ and is programme was formulated; then subject to monitoring. Annual monitoring is a retrospective, documentary, process. We – the impact of the implementation of the consider whether a programme continues to approval visit on the ambulance services meet our standards of education and training and the HPC; (SETs) and deliver the standards of proficiency – (SOPs). We try to build on the education the outcomes of the approval visits and provider’s own documents and processes for any trends identified from this; monitoring to remove the need for regular – how the HPC plan for the amended visits. The annual monitoring process operates annual monitoring process was in conjunction with the major change and formulated; and approval processes. Information on these processes can be found in the supplementary – the outcomes of the annual monitoring information documents available on our activities, any identifiable trends and the website. implications for the future approval and monitoring of pre-registration education and training delivered by UK ambulance services.
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Introduction
The paper draws on:
– a qualitative review of Education Department records of the amended approval process used for the programme of visits and a structured interview with the lead Education Officer for the project;
– quantitative data, drawn from Education Department records, describing some of the key features of the implementation of the approval process;
– a quantitative and, to a limited extent, qualitative review of the reports produced after each visit;
– a qualitative review of Education Department records of the amended annual monitoring process used for pre- registration education and training delivered by UK ambulance services;
– structured interviews with members of the Education Department who have been leading operationally on the annual monitoring of those education and training services; and
– a quantitative and, to a limited extent, qualitative review of the reports produced after the amended annual monitoring assessment.
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Review of approval activities
Background to the programme In the 2005–06 academic year all UK public of visits ambulance services submitted an audit which was assessed by Visitors. Of the 34 audits At the meeting held in February 2004, the submitted, only three resulted in a Education and Training Committee decided to recommendation that an approval visit was conduct approval visits to all approved required. A paper to the Education and programmes which had not been subject to a Training Committee on 5 September 2006 visit since the publication of the Quality reported the outcomes of annual monitoring Assurance Agency’s Subject Benchmark for the UK public ambulance services. This Statement for each profession. This led to a paper stated that the distinctiveness of the period of activity for the Education Department arrangements for delivery and assessment of in which programmes that had not received a the IHCD programmes at each ambulance visit were contacted and visits arranged. service warranted site-specific visits. The Benchmark Statement for paramedic programmes was published in 2004. Owing to the continuing uncertainty about the future of the IHCD programmes and the recent In the paramedic profession, many of the merger of English ambulance services, the HPC-approved programmes are delivered by Committee directed the Education Department UK public ambulance services and follow the to contact all UK public ambulance services to Institute of Health and Care Development determine whether they intended to continue (IHCD – part of Edexcel) rules for delivery and to deliver an IHCD programme. Where a assessment of the programme. At the time, it service indicated that it intended to continue to was anticipated that a visit was required to deliver a programme, the Education approve the IHCD model of training generally Department was directed to organise an rather than visits to specific sites of delivery. appropriate visit. At this time it was anticipated Information available indicated that the IHCD that, following site visits, a visit to the IHCD model was due to be phased out as the would also be needed to address profession made the transition to higher generic issues. education. Additionally, the ambulance service in England was subject to restructuring in July On 12 June 2007 the findings of the initial 2006 with the merger of services into a smaller contact exercise with the UK public ambulance number of larger NHS Trusts. services were reported to the Education and Training Committee. That report stated that, Given the uncertainty surrounding the future of although there was a clear intention to move the programmes, alongside the significant paramedic training into higher education, the resource impact of 34 visits being added to the time required for the transition meant that schedule, the decision was made that the UK IHCD programmes would continue to run until public ambulance services had first to be at least 2008. The Committee decided that entered into the annual monitoring audit approval visits should take place at all UK process before visits would be undertaken. ambulance services other than those which This process enabled the department to confirmed that they would cease to enrol prioritise visits appropriately in the schedule for students after 1 September 2008. the following academic year.
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Preparation for the programme Appendix A summarises the approval of visits outcomes reached in the case of each of the 15 UK public ambulance services. It was recognised that the IHCD model delivered by ambulance services was As South Central Ambulance Service NHS significantly different from the majority of Trust indicated that they did not intend to approved programmes that are based in continue delivering a programme after higher education institutes. 1 September 2008, only 14 visits were conducted. As a result, the Education Department commenced work to review and amend the The evidence base approval process to ensure it was appropriate for the visits. This work commenced by The evidence used to review the visits was holding a meeting with a group of experienced gathered from the Visitor reports, the HPC paramedic Visitors. At this meeting each experience of a key member of the Education standard was discussed to determine what Department responsible for planning and types of evidence for the SETs an ambulance overseeing the implementation of the approval service might be able to provide. This process, and from feedback sought from the information was then used to tailor 14 ambulance services who were subject to correspondence and other documents and approval visits. prepare an appropriate agenda for each visit. Visitor reports It was also decided that wherever possible, the HPC panel would comprise two Visitor reports are produced after an approval paramedic Visitors and a third Visitor visit has been conducted. A report makes from a different profession. recommendations about whether a programme should receive open-ended A programme of visits was then arranged. approval or re-approval of that status. The The first visit took place on 11 March 2008 Visitors’ recommendations are based on and the last visit took place on whether a programme meets all of the 20 January 2009. standards of education and training.
Outcomes of visits Visitors can make one of three recommendations. All the Visitors’ reports have been produced and considered by the Education and Training 1. To approve / reapprove the programme. Committee. The majority of the programmes were granted continued approval. There were 2. To approve / reapprove the programme four programmes that had approval withdrawn. subject to conditions being met.
Outcomes of all visits, departmental records 3. To not approve / withdraw approval from and feedback from the ambulance services a programme. involved meant that there was now sufficient When it is recommended that conditions are data to begin identifying trends. All the Visitors’ applied to a programme, these are detailed in reports can be found online in the Education the Visitors’ report. They always relate to Department section of the HPC website. specific standards of education and training and are supported by reasons.
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Agreed conditions can be met by the Six ambulance services responded to this education provider submitting further feedback request. Of the six respondents, documentation to the Visitors. The Visitors five services received reconfirmation of open- must be satisfied that the documentation ended approval and one trust had approval submitted in response to the conditions withdrawn. A copy of the feedback form can demonstrates how the programme meets the be found at Appendix B. SET. Education providers are given two opportunities to meet conditions prior to a final The impact on resources recommendation being made to the and timeframes for the Education and Training Committee. approval process
Ambulance Service Feedback Form From an operational perspective, the work A feedback form was distributed in November undertaken to visit each of the programmes 2009 to all ambulance services involved in the was significant. Graphs 1, 2 and 3 show the approval process. The form was designed to lengths of some of the stages of the approval gather experiences of the approval process process. Graph 1 illustrates the length of the and asked for feedback on a range of pre-visit, whole approval process from the date on visit and post-visit issues. which a visit request was received to the date the Education and Training Committee made Issues explored included: the final decision.
– the appropriateness of publications and communications to inform the service of the purpose and requirements of a visit;
– the appropriateness of the suggested agenda and the groups of people to be met at the visit;
– the documentation required prior to the visit;
– the role and remit of the HPC and the visiting panel at the visit; and
– the appropriateness of the report and its usefulness in clarifying the requirements for conditions to be met.
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Graph 1 Time between visit request received and final decision by Education and Training Committee
35
30
25
20
15
Duration in months in Duration 10
5
0 NHS Trust Care Trust Care Social Care Trust Social Care Service NHS Trust Service NHS Trust Service NHS Trust Service NHS Trust Service NHS Trust Service NHS Trust Service NHS Trust Service NHS Trust Service NHS Trust Service NHS Trust Service Health and London Ambulance Yorkshire Ambulance Yorkshire North East Ambulance North West Ambulance North West Isle of Wight NHS Primary Welsh Ambulance Service Welsh East Midlands Ambulance Great Western Ambulance Great West Midlands Ambulance West South Western Ambulance East of England Ambulance Northern Ambulance Ireland Scottish Ambulance College South East Coast Ambulance
Ambulance service
The approval process for most programmes is This extended duration can be attributed to a normally completed within six to nine months. variety of reasons, including: It is apparent that the duration of the process – was significantly longer for ambulance service education providers suggesting the programmes. This is representative of the latest possible dates for their visit to be complexity of each of the approval visits and undertaken to maximise the time to the associated impact of time spent working present documentation; on these visits. In some cases the process has – extenuating circumstances leading to taken in excess of two and a half years from rescheduled visits; the date the visit request was received. – documentation deadlines being missed leading to cancelled visits;
– the time taken to produce reports; or
– the time required for education providers to meet conditions.
Graph 2 shows the time taken to produce Visitors’ reports after each of the visits.
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Graph 2 Time between visit date and report sent to education provider
3.5
3.0
2.5
2.0
1.5 Duration in months in Duration 1.0
0.5
0.0 NHS Trust Care Trust Care Social Care Trust Social Care Service NHS Trust Service NHS Trust Service NHS Trust Service NHS Trust Service NHS Trust Service NHS Trust Service NHS Trust Service NHS Trust Service NHS Trust Service NHS Trust Service Health and London Ambulance Yorkshire Ambulance Yorkshire North East Ambulance North West Ambulance North West Isle of Wight NHS Primary Welsh Ambulance Service Welsh East Midlands Ambulance Great Western Ambulance Great West Midlands Ambulance West South Western Ambulance East of England Ambulance Northern Ambulance Ireland Scottish Ambulance College South East Coast Ambulance
Ambulance service
All the reports took one month or more to Another resource-intensive period in the produce and in some cases more than three approval process is the post-visit stage. months. This is much longer than usual in Graph 3 shows the duration of the comparison to other programmes: overall 69 post-visit stage from the visit date through per cent of reports are submitted to education to the date the Education and Training providers within 28 days of the visit date as Committee made the final decision for indicated in the Education annual report 2009. each programme. The length of time taken can be attributed to the complexity of some of the cases and the numbers of conditions required.
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Graph 3 Time between visit date and Education and Training Committee decision
20
15
10 Duration in months in Duration 5
0 NHS Trust Care Trust Care Social Care Trust Social Care Service NHS Trust Service NHS Trust Service NHS Trust Service NHS Trust Service NHS Trust Service NHS Trust Service NHS Trust Service NHS Trust Service NHS Trust Service NHS Trust Service Health and London Ambulance Yorkshire Ambulance Yorkshire North East Ambulance North West Ambulance North West Isle of Wight NHS Primary Welsh Ambulance Service Welsh East Midlands Ambulance Great Western Ambulance Great West Midlands Ambulance West South Western Ambulance East of England Ambulance Northern Ambulance Ireland Scottish Ambulance College South East Coast Ambulance
Ambulance service
Previous education annual reports for 2008 In some cases, education providers submitted and 2009 have indicated that the post-visit observations on the Visitors’ report to contest process is completed, in the majority of cases issues of accuracy and also to request (67% in 2008, 76% in 2009) within four extended deadlines or split deadlines for months of the visit date. Only eleven per cent meeting conditions. of cases in the 2006–07 academic year Extended or split deadlines were granted by required more than six months to meet the Education and Training Committee. These conditions. In all but one case, the post-visit were cases where specific conditions could process for the ambulance service visits not be met within the normal time frame owing exceeded six months. The one case in which to extenuating circumstances, such as a the post-visit process was resolved in less than particular service waiting for publication of six months was a result of a decision by the curriculum information by the IHCD. Education and Training Committee to withdraw approval without the education provider Feedback from submitting a response to the conditions. ambulance services In some cases, the length of the post-visit process was affected by the time it took to Information regarding the ambulance services produce reports. However, in the majority of satisfaction with the approval process was cases it was the result of the time the sought in the feedback and the results are ambulance services required to respond to discussed below. the conditions placed on continued approval.
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Time taken to complete Communication and information approval process The services agreed that communication and Of the six ambulance services to respond to information in the pre-visit stage was delivered the feedback request, four found the time in a timely manner. This suggests the time and taken to be satisfactory. The two services that resource committed to adapting the approval were dissatisfied cited the feedback from process and communicating with services Visitors as the part of the process with which was sufficient. they were most dissatisfied. Graph 4 Responses to the feedback The time taken by Visitors to decide whether questionnaire regarding timeliness of an IHCD programme had met the conditions communication from HPC throughout set was longer than the time usually taken in each stage of the approval process relation to other programmes. The complex issues arising from each visit affected the Communication duration of the decision-making process for the post-visit stage. In particular, it took longer Pre-visit
than usual to consider the documentation Visit submitted. Respondents acknowledged the challenges faced as this was the first time the Post-visit
approval process was being applied to 0123456
ambulance service programmes. These issues Yes No are explored further in this report.
We also sought feedback on the three stages Most services also agreed information and of the approval process – the pre-visit, visit communication was delivered in a timely and post-visit stages. The tables and manner at the visit itself. Our decision to information which follow detail the responses include an additional Visitor from another from the services. profession may have assisted this process and ensured consistency in the application of standards.
One ambulance service disagreed and two specific issues were seen as contributing to this. Firstly, the service cited the lack of collaboration from the HPC in comparison to that from a panel at another HPC approval event the respondent had observed. Secondly, the respondent indicated that the panel appeared unprepared and seemed to have not read the documentation submitted prior to the visit. This particular programme was one of the first to be visited. The final outcome of the visit was the reconfirmation of approval of the programme.
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The panel, although fully trained, did include The majority of respondents found the paramedic Visitors who had not previously publication Approval process – supplementary undertaken an approval visit. It is therefore information for education providers to be likely that the combination of these factors may useful. However, one service found the have influenced the experience of the information difficult to understand. ambulance service in this instance. The Respondents were asked whether they felt planning, communication and implementation well-informed of the HPC’s purpose in of the approval process aimed to apply a fair conducting an approval visit. Five services felt and equitable process. The lessons learnt from they were well-informed and one did not. That this early visit were fed into future visits and service did not understand why the HPC were this is reflected in the responses of the other visiting individual ambulance services instead ambulance services. of the IHCD body itself. The evidence within this report supports the view that all the Most services found communication was programmes were based on the IHCD effective and information was delivered in a curriculum, but delivered in differing ways. timely manner in the post-visit stage. Some This same viewpoint was held by the noted the time taken to receive the Visitors’ Education and Training Committee and was report, and the decision from the Visitors’ a key factor in deciding to visit individual regarding responses to conditions, exceeded sites of delivery. the timeframes communicated in HPC publications and at the visit itself. However, The majority of respondents felt well-informed the programmes of these services during the organisation of the visit. The data were reapproved. suggests the significant resources committed by the HPC to communicate key messages Pre-visit stage were expended successfully. This view is supported by the fact that all respondents To further explore the application of the were satisfied with the information and approval process, ambulance services also communication received at the pre-visit stage responded to more detailed aspects of the of the process. pre-visit, visit and post-visit stages. All ambulance services were satisfied with the Graph 5 Responses to pre-visit stage agenda for the visit and were content that it feedback questions was negotiable and could accommodate other
Pre-visit stakeholder requirements. The agenda was tailored for the purposes of these visits and Q1. ensured the meetings were appropriate and Q2. Q3. could be accommodated by each service. We Q4. also used terminology which reflected the Q5. professional titles used within the programmes. Q6. 0123456
Yes No
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Five services felt they understood who the The remaining two respondents were not clear HPC needed to meet. Confusion arose with about the documentation requirements. one service regarding this issue. In this One indicated that they were unprepared for particular case, the ambulance service had the specific documentation requirements. representatives fulfilling multiple roles within the Particular reference was made to the approval programme and therefore, they had to attend process being traditionally applied to different meetings at the visit. This is not stakeholders within higher education who are unusual when conducting visits to education better placed to meet the documentary programmes for other professions. It is often requirements. The final outcome for this the case that members of the programme programme was to have approval withdrawn. team are also present at meetings with senior The challenges highlighted by this particular team members. The most confusion centred service regarding documentation were on the roles and titles used within ambulance identified by the HPC as challenges common services and further clarification of these roles to all sites of delivery. These challenges have was sought at the visit itself. already been addressed within this report.
The submission of documentation is a key The second service suggested the publication milestone in the pre-visit approval process. Approval process – supplementary information Four of the services indicated they were clear for education providers could be interpreted in about these requirements. Of these, one noted different ways. This issue was recognised by that the HPC did not account for additional the HPC at the beginning of the approval mapping documentation which was supplied process and requires attention since we by them. That documentation related to how approve programmes which vary significantly the programme met the requirements of other in terms of methodology and delivery. The stakeholders. The HPC appoints Visitors to publications which detail our standards and assess how the programme meets the SETs approval and monitoring processes are and will consider evidence relating specifically designed to communicate with a range of to these. The regulatory role of the HPC and education providers who operate in a variety of that of other external bodies (eg The Quality settings. As mentioned previously, significant Assurance Agency for Higher Education, resources were committed to ensuring that professional bodies, funding bodies) may not issues of terminology and process were have been communicated effectively in clarified. this instance.
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The visit The post-visit stage
Graph 6 Responses to visit stage Graph 7 Responses to post-visit stage feedback questions feedback questions
Visit Post-visit
Q7. Q10.
Q8. Q11.
Q9. Q12.
0123456 012345
Yes No Yes No
Most services agreed that the role and remit of Most services agreed the Visitors’ reports were the HPC were made clear at the visit. clear and easy to understand. One disagreed All services agreed that the roles and remits of and cited the practice of listing each standard the Education Department representative and of proficiency (SOP) not met under SET 4.1 as the Visitors was also made clear. One service the reason. The listing of particular SOPs not disagreed and commented that the HPC panel being met for conditions relating to SET 4 is did not engage in collaborative discussion with not a standard practice but is applied where it the rest of the members of the joint panel. The is deemed useful for the education provider to HPC panel need to arrive at decisions address the condition. Individual SOPs were independent of any other stakeholders. Private listed in 12 of the 14 reports. In the two cases meetings are held at the visit and a separate where the SOPs were not listed, both Visitors’ report is produced to ensure this. As programmes were approved. However, seven this was a new process, this may have been other programmes also received approval perceived as not being collaborative. with SOPs listed.
Feedback was sought on whether the Most services understood exactly what was post-visit procedures were made clear to the required of them in order to address the ambulance services. Due to the complexity conditions set for the programme. Two and number of conditions, feedback to the services did not understand the requirements panel was limited to information about to meet conditions. One respondent did state operational timeframes for the post-visit stage. they required further clarification to gain a full One service commented that although the understanding of the conditions set. This was post-visit timeframes were communicated, an expected response given this was the first they were not adhered to (28-day turnaround HPC Visitors’ report each service received. for report and Visitor feedback). In practice it The Education Department provided additional was these post-visit procedures and the support to services to clarify the conditions traditional timeframes which proved most set. The extra time taken to produce reports challenging to the HPC, Visitors and the may have assisted services’ understanding of ambulance service. the conditions still to be met. Telephone and email support may also have proved useful. These measures, although not normal to the post-visit stage, were necessary.
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Education provider – identifying the groups of people who feedback conclusions were to be present at the visit itself; and
The feedback indicates that this was a – the time taken to receive Visitor challenging process for the services to engage feedback on responses to conditions. with. Although they were not familiar with such Despite these challenges, the view widely held a process being applied to their programmes, by the services that responded to the request the majority of services were satisfied with the for feedback was that the HPC and approach adopted by the HPC. Common Visitors were contactable, approachable challenges highlighted from their feedback and well-informed. included:
– gaining a clear understanding of why Standards of education visits were taking place; and training
– gaining a clear understanding of how the As mentioned previously, the time spent approval process was applied and the producing reports during this programme of potential outcomes; visits was greater than usual. This was due to the high number of conditions applied. Graph – understanding the terminology used by 4 shows the number of conditions applied to the HPC in publications, each programme. correspondence and Visitor reports;
Graph 8 Number of conditions applied to each programme
60
50
40
30
20 Number of conditions of Number
10
0 Care Trust Care Welsh Ambulance Welsh Service NHS Trust Service NHS Trust Service NHS Trust Service NHS Trust Service NHS Trust Service NHS Trust Service NHS Trust Service NHS Trust Service NHS Trust Service NHS Trust Service NHS Trust London Ambulance Yorkshire Ambulance Yorkshire North East Ambulance North West Ambulance North West Isle of Wight NHS Primary East Midlands Ambulance Great Western Ambulance Great West Midlands Ambulance West South Western Ambulance East of England Ambulance Scottish Ambulance College Health and Social Care Trust Health and Social Care South East Coast Ambulance North Ireland Ambulance Service North Ireland
Ambulance service
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There is considerable variation between the Many programmes had more than 30 number of conditions applied across the conditions, but less than 40. Programmes programmes. In some instances, the number within this range of conditions reached a final of conditions is significantly higher than outcome within a wide variance of time from commonly found in cases of visits to 14.8 to 20.6 months taken to complete the programmes that already have approval. In approval process. A selection of programmes contrast, a number of the programmes have had more than ten conditions, but less than less than 20 conditions applied to ongoing 30. These programmes took between 15.2 approval, which is relatively typical of a and 24.7 months to reach a final outcome and programme visited for the first time by the complete the approval process. Again, this HPC, following the publication of the QAA supports the view that the number of Benchmark Statement. The variance between conditions does not necessarily relate to an the number of conditions supports the view extended duration for the approval process. that the individual ambulance services However, these do further highlight the implemented the IHCD model of paramedic complexities of each ambulance service and education in distinctive ways and therefore a programme visited, and further support the delivery site visit was required. decision to visit each site separately.
Notably, in the case of the programme which One consequence to the number of conditions received the highest number of conditions applied to each programme is that it made it (over 50), an eventual decision for withdrawal challenging to provide useful informal feedback of approval was reached by the Education and at the end of the approval visit. In many cases, Training Committee. The two programmes it was decided that it would be inappropriate to which received 40–50 conditions also list the proposed conditions that were being subsequently had approval withdrawn. placed on continued approval. This made the production of the Visitors’ report more crucial These three programmes took varying times to for the ambulance services, as it was the first complete the approval process (8.5–30.6 opportunity to determine the full nature of the months). Therefore, the high number of outcome related to the approval visit and conditions applied did not necessarily relate to begin the work of responding to proposed the length of the approval process. conditions. These programmes tended to have extenuating circumstances related to key Graphs 9, 10 and 11 provide more detail on programme team members as the main the nature of the conditions that were applied cause for the extended duration. to the ongoing approval of the programmes.
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Graph 9 Conditions applied by standard of education and training
3 1 2 4 11 11 7 9 6 7 3 6 8 7
17 9 11 20 14 7 8 13 19 5 6 16 5 1 2 5 7 6 1 4 5 7 3 4 2 5 2 2 13 4 6 6 7 3 3 4 4 3 4 1 7 2 4 0 3 736 5 1 4 4 3 1 2 1 Care Trust Care Welsh Ambulance Welsh Service NHS Trust Service NHS Trust Service NHS Trust Service NHS Trust Service NHS Trust Service NHS Trust Service NHS Trust Service NHS Trust Service NHS Trust Service NHS Trust Service NHS Trust London Ambulance Yorkshire Ambulance Yorkshire North East Ambulance North West Ambulance North West Isle of Wight NHS Primary East Midlands Ambulance Great Western Ambulance Great West Midlands Ambulance West South Western Ambulance East of England Ambulance Scottish Ambulance College Health and Social Care Trust Health and Social Care South East Coast Ambulance North Ireland Ambulance Service North Ireland
Ambulance service
SET 2 SET 3 SET 4 SET 5 SET 6
This graph illustrates which areas of the SETs The range and duration of placement were subject to conditions at each of the experience is commonly an area for further ambulance services. There is significant development in the programmes. Each variance between each programme in terms of ambulance service has responded individually application of conditions to a particular type of to the conditions, but the IHCD have also standard. For example, in relation to SET three recently amended the Rules that dictate how (management and resource standards), one training is delivered, to increase the required programme received no conditions whilst other range and duration of placement education. programmes received up to 13. For one programme that reached a final The most significant proportion of conditions decision for withdrawal of approval, there were that applied to each programme generally fell a significant number of conditions applied to all under SET five (practice placement standards). areas of the standards. However, conditions This is relatively typical of all programmes of for SET 5 came in highest for three other study subject to approval visits and is a programmes which also reached a final recorded trend in previous annual reports. decision for withdrawal of approval. There are Some programmes, such as the one delivered no clear trends for significant conditions across by the London Ambulance Service NHS Trust, all other SETs. stand out as exceptions to this, having received just one condition related to the practice placements and proportionally receiving more conditions related to assessment standards.
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The following graph provides an illustration of – Documentary based – there is the nature of the conditions applied. evidence to show that the standard is The conditions have been broken into met, but documentation requires three categories: updating to reflect this evidence; and
– Resource based – requires changes to – Curriculum or assessment based – resource allocation for the programme requires review of the curriculum or for the standard to be met; assessment procedures to ensure the standard is met.
Graph 10 Types of condition applied
11
13 12 20 9 9 6 10 9 13 8 9 10 8 1 9 3 2 10 11 13 5 20 3 9 2 3 16 16 14 13 4 16 14 6 3 11 9 10 5 3 4 Care Trust Care Welsh Ambulance Welsh Service NHS Trust Service NHS Trust Service NHS Trust Service NHS Trust Service NHS Trust Service NHS Trust Service NHS Trust Service NHS Trust Service NHS Trust Service NHS Trust Service NHS Trust London Ambulance Yorkshire Ambulance Yorkshire North East Ambulance North West Ambulance North West Isle of Wight NHS Primary East Midlands Ambulance Great Western Ambulance Great West Midlands Ambulance West South Western Ambulance East of England Ambulance Scottish Ambulance College Health and Social Care Trust Health and Social Care South East Coast Ambulance North Ireland Ambulance Service North Ireland
Ambulance service
Documentation Resources Curriculum / assessment
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As is common in many approval visits, a trend across all programmes (excluding East emerges which shows that Visitors have Midlands Ambulance Service NHS Trust and received verbal confirmation or demonstration North West Ambulance Service NHS Trust). that a standard is met, but do not receive There is a general trend, demonstrated in documentary evidence to support this. In 11 previous Education annual reports, of out of the 14 cases, this type of condition is conditions being imposed where significant most common. This type of condition is numbers of standards of proficiency have not indicative that, in terms of student experience been adequately mapped against learning or attainment of the standards of proficiency, outcomes for the programme. the standard is in effect met, but not adequately documented. Standards of proficiency
Resource based conditions appear in relatively Graph 11 shows the number of times high proportion in the four programmes which conditions were applied which required reached a final outcome of withdrawal of education providers to articulate particular approval. However, other programmes which standards of proficiency (SOPs). The received a similar number of resource-related distribution of conditions related to individual conditions secured continued approval. SOPs illustrates variance across the ambulance services. Curriculum or assessment based conditions also appear in a relatively high proportion
Graph 11 Number of instances where conditions were applied to SOPs and their delivery in a programme
10
8
6
4
2 Conditions applied across all programmes all across applied Conditions 0 1a.1 1a.2 1a.3 1a.4 1a.5 1a.6 1a.7 1a.8 1b.1 1b.2 1b.3 1b.4 2a.1 2a.2 2a.3 2a.4 2b.1 2b.2 2b.3 2b.4 2b.5 2c.1 2c.2 3a.1 3a.2 3a.3
SOPs
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In relation to this variance, there is no standard of proficiency common to all of the 14 programmes which required greater description. There are, however, four standards which were outlined in conditions placed on ten of the 14 programmes. The highest occurrences are to the SOPs 2b.1, 2c.1, 2c.2 and 3a.1. It is important to note that this analysis does not take into account the individual standards under each SOP heading.
Further analysis was undertaken under each of the SOP headings, to ascertain whether these instances were related to specific individual standards within the SOPs, or whether a significant variance of individual standards within these could be found.
The standards of proficiency which required conditions in 50% or more of the visited programmes are:
SOP heading number SOP wording 1a.1 be able to practise within the legal and ethical boundaries of their profession 1a.6 be able to practise as an autonomous professional, exercising their own professional judgement 1b.3 be able to demonstrate effective and appropriate skills in communicating information, advice, instruction and professional opinion to colleagues, service users, their relatives and carers 2b.1 be able to use research, reasoning and problem-solving skills to determine appropriate actions 2b.3 to be able to formulate specific and appropriate management plans including the setting of timescales 2c.1 be able to monitor and review the ongoing effectiveness of planned activity and modify it accordingly 2c.2 be able to audit, reflect on and review practice 3a.1 know and understand the key concepts of the bodies of knowledge which are relevant to their profession specific practice
In the majority of cases, it is apparent that the above SOPs fall into a category of professional skills rather than technical competencies.
Each ambulance service responded individually to the conditions, but the IHCD also amended the rules that dictate how training is delivered to include the addition of Module J, which is entitled “Professional Paramedic Practice” and includes explicit delivery of learning outcomes related to professional skills, rather than technical competencies. Some ambulance services made the decision in responding to the conditions to incorporate the IHCD Module J, whilst others took a different approach by either including a service-designed module J or amending the programme in other ways. Again, this reflects the significant variance between the individual programmes.
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Standards of proficiency: further analysis
The tables below provide further analysis of the SOPs which were most commonly identified across the Visitor reports. Each table is grouped according to the three overarching areas of practice as illustrated in the HPC standards of proficiency for paramedics. These are then further classified according to the applicable sub-areas of practice. For the purposes of further analysis, each individual standard SOP is allocated a specific number in order to identify each easily. A copy of this numbering system can be found in Appendix C.
Expectations of a health professional
– 1a – Professional autonomy and accountability
1a.1 Sub Level 1a.6 Sub Level 1b.3 Sub Level 1a.1.i 4 1a.6.i 5 1b.3.i 6 1a.1.ii 6 1a.6.ii 6 1b.3.ii 8 1a.1.iii 5 1a.6.iii 5 1b.3.iii 8 1a.1.iv 6 1a.6.iv 6 1b.3.iv 8 1a.1.v 2 1a.6.v 6 1b.3.v 7 1b.3.vi 7 1b.3.vii 7 1b.3.viii 7
Where SOP 1a.1 and 1a.6 appeared in Visitors reports’, their individual standards (excluding 1a.1.v) were referenced in at least half. All sub-standards for SOP 1b.3 were referenced in at least six Visitors’ reports. Three individual standards were present in all eight reports in which SOP 1b.3 was referenced. These SOPs detail professional skills which are generically applied to all professions regulated by the HPC. However, SOP 1b.3.viii is specific to the paramedic profession and requires paramedics to be able to identify anxiety and stress in patients, carers and others and recognise the potential impact upon communication.
These results suggest that most areas of practice in SOPs 1a.1, 1a.6 and 1b.3 were not clearly described in the programme documentation. Common factors influencing this trend could potentially relate to the design and delivery of the individual programme and also the articulation of these professional skills within the IHCD curriculum. However, these results are not conclusive and only suggestive, and would indicate that there was a variance in design and delivery of programmes across each service.
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The skills required for the application of practice
– 2b – Formulation and delivery of plans and strategies for meeting health and social care needs
– 2c – Critical evaluation of the impact of, or response to, the registrant’s actions
2b.1 Sub Level 2b.3 Sub Level 2c.1 Sub Level 2c.2 Sub Level 2b.1.i 10 2b.3.i 7 2c.1.i 9 2c.2.i 10 2b.1.ii 9 2b.3.ii 7 2c.1.ii 6 2c.2.ii 9 2b.1.iii 10 2c.1.iii 8 2c.2.iii 9 2b.1.iv 8 2c.1.iv 5 2c.2.iv 9 2b.1.v 10 2c.2.v 10 2c.2.vi 8
SOP 2b.1 individual standards are generic to all professions regulated by the HPC. Three of the individual standards were not met in all ten reports. The remaining two individual standards were referenced in at least eight reports.
2b.3.i is generic to all professions and 2b.3.ii is specific to the paramedic profession. Once again the data illustrates that this SOP was applied in its entirety to half the programmes visited.
The distribution is varied with regards to SOP 2c.1. Individual standard 2c.1.i was referenced nine times and 2c.1.iii was referenced eight times. These individual standards both relate to professional skills for the gathering of evidence to influence practice, which are generic across all professions.
Similar to the trends identified in SOP 2b.1, the individual standards for SOP 2c.2 were found in most reports. This SOP, generic to all professions, requires registrants to “be able to audit, reflect on and review practice”.
Again, the distribution of data suggests the IHCD curriculum upon which these programmes were based may not have clearly described the proficiencies encompassed by this SOP. Alternatively, the ambulance services may not have clearly demonstrated how this SOP was delivered from the programme documentation submitted.
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Knowledge, understanding and skills
– 3a – know and understand the key concepts of the bodies of knowledge which are relevant to their profession-specific practice.
3a.1 Sub Level 3a.1.viii Sub Level 3a.1.ix Sub Level 3a.1.i 0 3a.1.viii.a 9 3a.1.ix.a 3 3a.1.ii 7 3a.1.viii.b 9 3a.1.ix.b 2 3a.1.iii 2 3a.1.viii.c 8 3a.1.ix.c 4 3a.1.iv 3 3a.1.ix.d 8 3a.1.v 1 3a.1.ix.e 7 3a.1.vi 4 3a.1.vii 1 3a.1.viii 9 3a.1.ix 8 3a.1.x 2
SOP 3a.1 relates to technical competencies a registrant must possess. Most competencies within this SOP are specific to the paramedic profession. Standard 3a.1.viiii was referenced nine times and 3a.1.ix was referenced eight times. SOP 3a.1.viiii relates to the understanding of various aspects of behavioural science. The data suggests the psychological and social aspects underpinning the knowledge, understanding and skills delivered on most programmes was not demonstrated clearly.
SOP 3a.1.ix concerns the understanding of various aspects of clinical science. Of the five individual standards related to this SOP, two sub-standards were referenced at least seven times with SOP 3a.1.ix.d referenced eight times. These two sub-level SOPs detail:
– the principles of evaluation and research methodologies which enable the integration of theoretical perspectives and research evidence into the design and implementation of effective paramedic practice; and
– the theories supporting problem solving and clinical reasoning.
This data suggests each services’ approach to delivering both generic professional skills and profession specific competencies differed and the documentation produced for each visit varied accordingly. The variance found across all the individual standards relating to this SOP strongly suggests its delivery was dependant on factors concerning the site of delivery.
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Conclusions on SOPs data The data also suggests that the technical competencies which related to the profession Further analysis conducted into the most specific understanding of aspects of common SOPs contained within the Visitor behavioural and clinical science were not reports highlight many issues. Firstly, the data articulated clearly. continues to suggest that the IHCD curriculum guidance, upon which these programmes It is important to note at this stage that the were traditionally based, may have not data above does not correlate directly to articulated the standards of proficiency related whether or not individuals who have to generic professional skills and profession completed one of these programmes have specific technical competencies. However, the attained the standards of proficiency, only that variance of SOPs applied to programmes at the programme documentation did not clearly the first, second and, where applicable, third indicate how learning outcomes were linked to levels indicate each service delivered their these standards of proficiency. programme in their own way. The factors influencing the common trends and also the Conclusions from the review variance within each SOP could be further of visits explored. In particular, a gap analysis could be conducted within the IHCD curriculum to It is clear from the data and analysis in this ascertain if any elements relating to the report that the normal time frames for the professional skills and technical competencies approval process were exceeded for the identified in the Visitors’ reports could be programme of visits to ambulance trust attributed to the curriculum itself. However, this services. This appears to have been the type of research is outside the scope and result of: purpose of this report. The SOPs data – the differences between the type of suggests the model of education adopted education and training delivered by within each ambulance service differed ambulance services and other significantly and therefore, the decision to education programmes; and visit each site and programme accordingly was appropriate. – the individual complexity of conducting the approval process Analysis has also highlighted all the at particular services. professional skills which were common to the Visitor reports relate to generic professional These factors were acknowledged and skills applicable to registrants of all professions confirmed by the ambulance services as part regulated by the HPC. This suggests that of feedback sought from each delivery site on these aspects of practice, which may be found the implementation of the approvals process. within the education programmes of other Furthermore, the feedback clearly professions, are continuing to be developed demonstrated satisfaction from those services and embedded within models of paramedic which responded with the process which was education. This is certainly not conclusive adopted in light of these issues. The reflections given the size of the data set, however it is still received from the ambulance services confirm worth noting as the HPC continues to engage the additional resource allocated by the with paramedic education. Education Department to implement the approval process was appropriate, and contributed to the successful implementation of the approval process.
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The data and analysis supports the view that In the case of programmes that have received the approval process is robust and flexible and a final outcome of continued approval, it is can be applied to programmes which use a difficult to state that they are only comprised of variety of educational models. There are areas elements from the IHCD curriculum. In many for further development, relating particularly to cases, the programmes incorporate elements the communication activities at the post-visit derived from: stage, which have been highlighted in this report and will prove useful to future – the IHCD curriculum; undertakings of a similar nature. – the College of Paramedics’ curriculum The final outcomes from each approval visit guidance document; indicate that there is significant variance – ambulance service-specific initiatives; or between each site of delivery and this supports the decision to visit each site. Trends have – procedures from higher education emerged in relation to the conditions applied to partner institutions. continued approval, but within the sample In effect, this has meant that whilst many of the size it is difficult to determine their programmes still contain the programme title statistical relevance. “IHCD paramedic award”, it is challenging to Trends have also emerged in relation to the define these programmes as being solely IHCD SOPs applied to the programmes. Particular models of education and training. Curriculum SOPs relating to professional skills, applicable guidance documents form an important part of to all professions regulated by the HPC and an education provider’s reference tools in the technical competencies specific to the development and implementation of an paramedic profession were consistently approved programme of study. However, as applied across most programmes. The data the standards of education and training and suggests there is also significant variance in the standards of proficiency are the threshold how programmes evidenced these SOPs. standards required for approval of a These trends further support the importance of programme, curriculum guidance documents continually assessing the site of delivery of are not critical to the decision-making process paramedic programmes. to grant approval to a programme. This means that education providers must be mindful of IHCD as a curriculum-setting body the curriculum guidance available to a profession, but that each education provider The range of responses to conditions also must make an individual decision about the demonstrates that the IHCD curriculum has most appropriate way to meet HPC standards. been an important element to the programmes that have been visited, but also that Accordingly, in conducting visits to each site of ambulance services have made different delivery, this has effectively reviewed all the decisions about how closely to follow IHCD ambulance services and no specific visit is guidance, in the process of meeting conditions required to review the IHCD as a curriculum placed on continued approval. This reflects the authority. Despite the distinctive nature of each status of the IHCD curriculum in these visit, further analysis of the conditions programmes as being similar to that of other highlighted common areas, within the curriculum guidance documents for the IHCD curriculum, which may not have professions regulated by the HPC. been clearly articulated.
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The history leading to the annual The Education Department adapted the annual monitoring of pre-registration monitoring process to reflect this and asked education and training delivered UK ambulance services delivering pre- by UK ambulance services registered education and training to submit additional documentation. As a result of the review of approval visits, the Education and Training Committee agreed on When we carry out an annual monitoring audit, a variation to the normal annual monitoring it is normally reviewed by two HPC Visitors. process for all pre-registration education and At least one Visitor will be from the relevant training delivered by UK ambulance services, profession and all Visitors undergo a conflict of to allow additional areas of these programmes interest process. The documentation is to be monitored. reviewed by the Visitors, along with previous reports from the approval, annual monitoring Brief overview of the annual and major change processes. monitoring process The Visitors make recommendations to the Education and Training Committee. They either When we approve an education programme it outline that there is sufficient evidence to show obtains what we refer to as 'open-ended that the programme continues to meet the approval' and is then subject to our monitoring standards or outline that there is insufficient processes. Annual monitoring is a evidence to show how the programme retrospective documentary process where we continues to meet our standards. The Visitors consider whether a programme continues to can ask the education provider for further meet our standards of education and training documentation before making a (SETs) and continues to effectively deliver and recommendation to Education and Training assess the standards of proficiency (SOPs). Committee. If the Education and Training From the review of the programme of visits to Committee agrees that there is insufficient pre-registration education and training, evidence to show how the programme delivered by UK ambulance services, the continues to meet our standards, a visit Education and Training Committee decided would be required to gather that evidence that the annual monitoring process should be and, if required, to place conditions on adapted to reflect the outcomes of the review. ongoing approval. In particular the three areas highlighted for In the amended UK ambulance service annual further monitoring were: monitoring review, the Visitors were asked to – implementing and embedding make a recommendation on both the standard professional skills into the delivery of the annual monitoring submission that all HPC programme; approved programmes go through, and also a separate recommendation on the additional – implementing the range of appropriate annual monitoring requirements previously placements; and outlined. For ongoing approval to be – the availability of resources and recommended the Visitors need to be content confirming the ongoing provision. that both elements were evidenced.
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Outcomes from the UK It is important to also note that the East of ambulance service annual England Ambulance Service NHS Trust monitoring process submitted a major change to the HPC in September 2009, which initiated an approval All the Visitor reports have been produced and visit as an increase to student numbers was approved by the Education and Training planned. The visit took place in March 2010 Committee and all pre-registration education and took account of all standards of education and training programmes delivered by and training. As is normally the case, when a UK ambulance services were granted programme is subject to the full scrutiny of an continued approval. approval visit, it is removed from the next two cycles of the annual monitoring process. All the reports can be found online in the education section of our website and in the The impact on resources and Education and Training Committee papers. Appendix D summarises the outcomes timeframes for the annual reached in the case of the eight UK ambulance monitoring process services who deliver pre-registration education From an operational perspective, the work to and training. monitor each UK ambulance service Evidence base programme required an increased resource provision at various stages of the annual The evidence used to review the annual monitoring process. However, the overall monitoring process for pre-registration duration of the annual monitoring process was education and training delivered by UK not significantly extended. ambulance services was gathered from Visitor Graph 12 Duration between annual reports produced from the review of eight monitoring submission being received and annual monitoring audits, Education education provider informed of outcome Department records and from the experience of Education Department representatives 5 responsible for planning and overseeing the 4 implementation of the annual monitoring process. Ten pre-registration education and 3
training programmes are currently being 2
delivered by UK ambulance services, however Duration in months in Duration within the annual monitoring process, it is 1 usual to review full time and part time 0 programmes within the same audit and for these to be represented in the same report. The graphs that follow within this report Social Care Trust Social Care Welsh Ambulance Welsh Service NHS Trust Service NHS Trust Service NHS Trust Service NHS Trust Service NHS Trust
therefore only represent the eight UK Service Health and Services NHS Trust London Ambulance Yorkshire Ambulance Yorkshire
ambulance services and the eight audits Ambulance North West East Midlands Ambulance South Western Ambulance South Western
(as full and part time are usually submitted Ambulance Northern Ireland Scottish Ambulance College as one audit). Ambulance service
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East Midlands Ambulance Service NHS Trust Graph 13 Duration between ambulance submitted ten weeks earlier than the other UK service annual monitoring audits ambulance services and as such, this has received and review at assessment day affected this submissions overall duration.
Graph 12 illustrates the individual durations for 4 the UK ambulance services to complete the full 3 annual monitoring process, from the date on
which the submission was received to the date 2 the ambulance service was informed of the 1 outcome. The average duration for the full audits of Numbers annual monitoring process for pre-registration education and training delivered by UK 0 ambulance services was 3.3 months. The average duration for the full annual monitoring four months between one process for all other HPC approved education months three and two months between two and and training for the academic year 2009 –10 and between three less than one month was also 3.3 months. Duration between receipt of audit and assessment day 217 annual monitoring audits were reviewed in the academic year 2009–10. On average the Education Department was able to submit an The main factor that caused the UK audit to an annual monitoring assessment day ambulance service annual monitoring process within five weeks of receipt. UK ambulance to be delayed was that the Education service programmes went to an assessment Department undertook a second unplanned day on average within six weeks of receipt. assessment day. This was needed for a variety Although this is not a significant delay, it had of reasons including: originally been planned that all eight UK ambulance service audits would be reviewed in – the comprehensive nature of the one assessment day, and that the time to submissions and some of the review the UK ambulance service audits at an documentation not relating to the assessment day would be significantly less standards of education and training; than five weeks. On 15 June 2010, five UK – documentation being inaccurately ambulance service audits were reviewed. referenced with Visitors unable to find A second assessment day was required what the education provider had stated and this was undertaken on 3 August 2010. as being submitted; Graph 13 reflects this split between the two assessment days. – apparent confusion about the retrospective nature of annual monitoring, with documents being submitted well outside of the required time frames, including information regarding changes that had been looked at during the approval visit and those which had taken place since; and
– the submission of major changes within the documentation.
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The outcomes from the UK ambulance service Graph 14 Standards of education annual monitoring assessment days differ in and training that required comparison to the outcomes from all the other additional documentation annual monitoring assessment days in the 2009–10 academic year. Seventy-five per cent of the UK ambulance service annual 111 monitoring audits required additional 11 1 documentation. This compares to twenty-five 1 1 per cent of audits requiring additional documentation for all other pre-registration 2 education and training going through the 11 annual monitoring process that year. The requirement to seek additional documentation does have a small impact on the resource provision within the Education Department, as Social Care Trust Social Care Welsh Ambulance Welsh Service NHS Trust Service NHS Trust Service NHS Trust some post assessment day action is required. Service NHS Trust Service NHS Trust Service Health and Services NHS Trust London Ambulance All the UK ambulance services that were Ambulance Yorkshire North West Ambulance North West East Midlands Ambulance asked for additional documentation South Western Ambulance Northern Ireland Ambulance Northern Ireland Scottish Ambulance College provided this on time and in line with our Ambulance service operational requirements. Six of the eight UK ambulance services were Standards of education required to submit additional documentation and training linked to the management and resourcing of If Visitors request further documentation they the programmes. From the issues identified, frame requests around specific standards of all but one was based around SET 3.2, which education and training. Graph 14 gives an refers to the effective management of the indication of the areas where the Visitors programme. The recurring issue around SET requested further information. 3.2 was that the Visitors were not provided with evidence that the programmes continued to be effectively managed because incomplete annual monitoring submissions were submitted. In particular, several programmes did not include internal quality documents and external examiner reports and some included information relating to different programmes. In one submission, the Visitors noted a change to the programme leadership, by reviewing an external examiner’s report.
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Two of the UK ambulance services required Two main areas were raised by the Visitors additional documentation linked to the within the eight UK ambulance service annual curriculum. In one submission the Visitors monitoring reports. Three of the reports had required additional documentation to clarify comments around issues with confidentiality. issues around the implementation and The Visitors noted that education providers embedding of professional skills into the had submitted information about individual delivery of the programme (the first additional students, including results and individual requirement in the amended ambulance comments in minutes. The second issue raised service annual monitoring assessment). in the Visitors’ comments in 75 per cent of the reports was around the comprehensive nature Three UK ambulance services required of the submissions, as discussed previously. additional documentation linked to assessment. From the issues identified two Summation of trends were specific to standard 6.1 (which is linked to assessment strategy and meeting the Analysis of the UK ambulance trust annual standards of proficiency). In one submission, monitoring Visitors’ reports shows that UK a comment in the external examiner’s report ambulance services did not understand the indicated a lack of clarity around the purpose of the annual monitoring process. In assessment strategy. The Visitors therefore particular, a number of UK ambulance services asked for additional documentation to clarify submitted audits which addressed many areas the assessment design and procedure. of their programme rather than focusing on the Another area addressed under assessment last two years of delivery. related to a change in external examiner. The However, analysis also shows that whilst this Visitors required clarification that the external engagement with the annual monitoring examiner was on the appropriate part of the process was consistent across many of the Register. In one review the Visitors noted ambulance services, where additional changes to the practical assessment documentation was required, each programme guidelines and required further information. was asked to submit additional documentation Analysis of Visitor comments for individual programme-specific reasons. All UK ambulance services running pre- As part of the annual monitoring process the registration education and training have Visitors have the opportunity to add comments successfully completed the HPC annual to a Visitor’s report. A comment would not monitoring for 2009–10. require any direct response from the education provider, however, it gives the Visitors the opportunity to offer advice on areas the education provider may want to consider addressing for future annual monitoring submissions.
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Conclusions from annual The report concludes that: monitoring activities – each programme is distinct; It is clear from the data and analysis in this – UK ambulance services are able to report, that the annual monitoring activities of conform to the requirements of annual pre-registration education and training monitoring (though at the next audit delivered by UK ambulance services has taken cycle for ambulance services it will be longer than usually expected. This appears to sensible to ensure that copies of the have been the result of: annual monitoring supplementary – the need to undertake a second UK information are enclosed in initial ambulance service annual monitoring correspondence); assessment day due to the individual – all UK ambulance services programmes complexity and comprehensive nature of have been granted continued approval audit submissions; and by the Education and Training – ambulance services not always Committee; and understanding the retrospective – no further amended annual monitoring nature of annual monitoring. process will be required and the UK All UK ambulance service pre-registration ambulance service programmes are able education and training programmes have been to fit into the normal annual monitoring able to provide additional documentation when schedule. required and have been able to do this within operational deadlines. Additionally, all Conclusions from review of the programmes have been able to meet the approval and monitoring activities additional requirements for annual monitoring requested by the Education and Training The review of the approval and monitoring Committee. Data and analysis also indicates activities conducted for pre-registration that the outcomes of the annual monitoring education and training delivered by UK activities of pre-registration education and ambulance services highlights trends which training delivered by UK ambulance services have been discussed consistently thoughout do not significantly differ from those of other this report. HPC pre-registration education and training.
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Distinctiveness of Application of standards and each programme approval and monitoring processes The review of the approval and monitoring activities demonstrates that approved The outcomes from each process support the programmes delivered by UK ambulance view that the HPC standards and approval and services are each designed and delivered in monitoring processes are robust, flexible and different ways. The review of approval visits can be successfully applied to programmes identified significant variance between each with different models of education. Feedback programme and the decision to visit each site from ambulance service representatives clearly was supported. The issues arising from each highlights the difficulties experienced in monitoring submission were in most cases attempting to engage with our standards and specific to each programme and additional processes. As this was the first time these documentation was required to address processes were applied, further support was individual programme specific issues. provided by the HPC where necessary. The impact to expected time frames has also been Each programme has demonstrated its discussed resulting from this. Any future distinctive nature and analysis of Visitor reports impact should be reduced as these across all programmes further supports this. programmes continue to engage with these Although common trends were identified, each standards and processes. programme has demonstrated how our standards were met in different ways. The Programmes which were approved and have review also supports the HPC position that the completed the annual monitoring process have IHCD act as a curriculum setting body and that demonstrated how standards were met and each ambulance service programme delivers continue to be met. The programmes this curriculum uniquely. approved by the HPC will continue to be subject to our routine approval and monitoring processes.
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Appendix A – Final outcomes from approval process
Service Programme Modes of study Status East Midlands Ambulance IHCD Paramedic Award FT and PT Reconfirmed Service NHS Trust approval East of England Ambulance Certificate of Higher PT Reconfirmed Service NHS Trust Education in Emergency approval Medical Care (incorporating the IHCD paramedic award) Great Western Ambulance IHCD Paramedic Award FT Closed Service NHS Trust Isle of Wight NHS IHCD Paramedic Award FT Approval withdrawn Primary Care Trust London Ambulance IHCD Paramedic Award Block Release Reconfirmed Service NHS Trust approval North East Ambulance IHCD Paramedic FT Approval withdrawn Service NHS Trust Programme North West Ambulance IHCD Paramedic Award Block Release Reconfirmed Service NHS Trust approval Northern Ireland Ambulance Paramedic-in-training FT Reconfirmed Service Health and Social approval Care Trust Scottish Ambulance College IHCD Paramedic Award FT Reconfirmed approval South Central Ambulance IHCD Paramedic Award PT Closed Service NHS Trust South East Coast Early Registration FT Approval withdrawn Ambulance Service Programme NHS Trust (IHCD Modules) South Western Ambulance IHCD Paramedic Award FT Reconfirmed Service NHS Trust approval Welsh Ambulance IHCD Paramedic Award FT Reconfirmed Service NHS Trust approval West Midlands Ambulance IHCD Paramedic FT Approval withdrawn Service NHS Trust Yorkshire Ambulance IHCD Paramedic Award FT and PT Reconfirmed Service NHS Trust approval
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Appendix B – Ambulance Service Feedback Form
Ambulance Service Feedback Form
Education Provider: ______
Name: ______
Position: ______
The Education Department undertook approval visits to paramedic pre-registration education and training programmes delivered by UK ambulance services in the 2007– 08 academic year. This questionnaire is designed to gather your feedback on the approval process adopted for these visits. Your thoughts, experiences and feedback on the process will be used to report to our Education and Training Committee in March 2010. The report produced will not reference specific names or bodies, just trends found across the data gathered from this form. Also your responses will have no affect on the outcome of the approval process conducted for your programme.
Approval Process: Pre-visit, Visit and Post-Visit
Pre-Visit
Q1 – Did you find our publication the ‘Approval process – supplementary information for education providers’ useful to prepare for your visit?
Yes No
If no, please use the box below to provide further comments:
______
Q2 – Did you feel well informed regarding the HPC’s purpose for conducting an approval visit?
Yes No
If no, please use the box below to provide further comments:
______
Q3 – Did you feel well informed during the organisation of the visit?
Yes No
If no, please use the box below to provide further comments:
______
Q4 – Did you feel the suggested agenda for the visit was easy to accommodate and negotiate?
Yes No
If no, please use the box below to provide further comments:
______
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Appendix B – Ambulance Service Feedback Form
Q5 – Was it clear what groups/people the HPC needed to meet with as part of the suggested agenda?
Yes No
If no, please use the box below to provide further comments:
______
Q6 – Was it clear what documentation we needed from you once a visit date had been suggested?
Yes No
If no, please use the box below to provide further comments:
______
Visit
Q7 – At the visit was the role and remit of the HPC made clear?
Yes No
If no, please use the box below to provide further comments:
______
Q8 – At the visit was the role of the Visitors and the HPC executive made clear?
Yes No
If no, please use the box below to provide further comments:
______
Post-Visit
Q9 – During the approval process were the post visit procedures made clear to you?
Yes No
If no, please use the box below to provide further comments:
______
Q10 – Was the function and format of the Visitors’ report clear and easy to understand?
Yes No
If no, please use the box below to provide further comments:
______
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Appendix B – Ambulance Service Feedback Form
Q11 – Did you understand exactly what was required of you in order to address the conditions set as outlined in the Visitors’ report?
Yes No
If no, please use the box below to provide further comments:
______
Q12– Did you find the time taken to complete the process satisfactory (from submission date of visit request form to receipt of official outcome of the approval process)?
Yes No
If no, please use the box below to provide further comments:
______
Overall
Q13 – Did you find communication and information was delivered in a timely manner throughout the approval process?
Pre-Visit Yes No
Visit Yes No
Post-Visit Yes No
If no, please use the box below to provide further comments:
______
Q14 – Do you have any further comments regarding the approval process?
______
Thank you for completing this form.
Please return electronic forms to us at [email protected]
Alternatively if you would like to complete the form by hand please send completed forms to:
Education Department Health Professions Council Park House 184 Kennington Park Road London SE11 4BU
Please send all completed forms back to us by 18 December 2009.
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Appendix C – SOPs numbering 3a 3a.1 structure and structure function of the human to their relevant body, practice, together with a knowledge of health, and disease, disorder understand the key concepts of the bodies of knowledge to relevant which are their profession-specific practice dysfunction 3a.1 know and 3a Knowledge, 2a 2a.2 understand the 3a.1.i and use appropriate assessment techniques appropriate information appropriate Registrant clinical The skills required for The skills required the application of Knowledge, understanding 2a.2 be able to select practicescientists must and skills 2a Identification and 1a 1a.1 2a.1 be able to gather 2a.1 to act in the best interests of service interests users at all times within the legal and ethical boundaries of their profession autonomy and accountability assessment of health needs. and social care understanding and skills health professional Standard of Standard proficiencyExpectations of a Number of Standard Number proficiency of Standard Number proficiency Understand the need 1.a.1.i 1a Professional 1a Professional 1a.1be able to practise
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Appendix C – SOPs numbering and the research process and the research appropriate techniques appropriate and equipment the evaluation of efficacy treatment ranges, including calling for specialist help where available Standard of Standard proficiencyunderstand what is of them by required Number the Health Professions Council 1.a.1ii of Standard be able to undertake Number 2a.2.i a thorough, and record proficiency sensitive and detailed of Standard of the be aware assessment, using Number 3a.1.ii principles and applications of scientific proficiency including enquiry, understand the need to and so far as respect, 1.a.1 iiipossible uphold, the values rights, dignity, and autonomy of every service user including in the their role be able to conduct a diagnostic and therapeutic process 2.a.2.iiand in maintaining and detailed thorough health and wellbeing physical examination of the patient using observation, palpation, of the role recognise auscultation and other 3a.1.iii assessment skills to and to guide the inform clinical reasoning in other professions formualtion of a health and social care all age diagnosis across
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Appendix C – SOPs numbering science: intervention to conduct assessment and onservation in order to establish patient management strategies systems physiology, especially physiology, the dynamic relationships and of human structure function and the musculoskeletal, cardiovascular, cardiorespiratory, digestive and nervous aspects of biological 2a.4 human anatomy and 3a.1.vi.a 2a.3 understand the following 3a.1.vi functional abilities of patients to, approaches assessment and 2a.4 be able to analyse 2a.3 be able to undertake 1a.3 1a.2 1a.3 understand the manner as appropriate Standard of Standard proficiency UK of current be aware legislation applicable to 1.a.1 iv Number work of their profession be able to use of Standard observation to gather Number 2.a.2.iii information about the proficiency of understand the Standard basis of, theoretical Number 3a.1.iv and the variety of proficiency be able to practise in with current accordance legislation governing the 1.a.1 v use of prescription-only medicines by paramedics understand the need to 2.a.2.iv consider the assessment 1a.2 be able to practise of both the health and needs of social care patients and carers know human anatomy 3a.1.v and physiology, to understand sufficient and effects the nature of injury or illness, and importance of and be able to maintain confidentiality and critically evaluate the information collected in a non-discriminatory or arrange investigations
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Appendix C – SOPs numbering behavioural change changes from interpret the norm human lifespan cognitive, emotional and of social measures maturation through paramedic practice may cause physiological and development across the development across lifespan 2b how the application of 3a.1.vi.b 2b.1 and human growth 3a.1.vi.c determine appropriate actions determine appropriate to the critical research evaluation of practice stages of normal development, including 2b Formulation and 2b.1 be able to use solving skills to problem 1a.6 the value of recognise 2b.1.i the main sequential 3a.1.vi.d 1a.4 1a.5 proficiency1a.4 understand the consent proficiency needs. and social care health the problem proficiency be able to initiate and of problems resolution be able to exercise personal initiative 1a.6.ii methodologies research of a range be aware 2b.1.iii physiological relevant parameters and how to 3a.1.vi.f Standard of Standard Number 1a. 5 be able to exercise of Standard Number of Standard Number be able to assess a situation, determine the and severity of the nature and call upon the problem 1a.6.i knowledge and required experience to deal with be able to engage in evidence-based practice, evaluate practice 2b.1.ii and systematically, participate in audit procedures normal and altered anatomy and physiology 3a.1.vi.e the human throughout lifespan 1a. 6 be able to practise as an autonomous exercising professional, their own professional judgement importance of and be able to obtain informed delivery of plans and strategies for meeting a professional duty of carea professional and reasoning research,
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Appendix C – SOPs numbering applied to paramedic aspects of physical science pre-hospital care pre-hospital determine a diagnosis 2b.2 understand the following 3a.1.vii 2b.2 be able to draw on level of skill in the use information technology to their appropriate practice physical sciences can inform the understanding and analysis of information used to appropriate knowledge appropriate and skills in order to make and skills in order judgements professional 1a.8 be able to demonstrate a 2b.2 ii the means by which 3a.1.vii.b 1a.8 understand the obligation to maintain fitness to practise know the limits of their practice and when to seek 1a.6.iii to another advice or refer professional be able to demonstrate a 2b.1.ivtheir decisions logical and systematic be able to use a range of to problem approach 1a.6.v disease and trauma 3a.1.vi.g or situations circumstances solving the 1a.7 recognise and how to processes need for effective self-management of apply this knowledge to workload and be able to 1a.7 own practice practise accordingly be able to change their 2b.2 i developments practice as needed to take account of new the planning of patient’s principles and theories 3a.1.vii.a of physics, biomechanics, and electronics ergonomics that can be integrated skills and self-awareness to manage self-awareness clinical challenges in unfamiliar effectively proficiency proficiency proficiency Standard of Standard Number that they arerecognise for personally responsible of Standard 1a.6.ivand must be able to justify Number be able to evaluate and other research of Standard evidence to inform their 2b.1.v Number the factors influencing 3a.1.vi.h human function individual variations in
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Appendix C – SOPs numbering application of techniques measurement based on biomechanics or electrophysiology 2b.3 the principles and 3a.1.vii.c specific and appropriate specific and appropriate management plans including the setting 2b.3 be able to formulate of timescales or socio-economic factors lifestyle that may impact on the individual’s health the interaction and affect between the patient and paramedic illness needs of different groups groups needs of different for distinguished by, example, physical, psychological, cultural environmental, practise safely and effectively within their effectively scope of practice proficiency proficiency proficiency understand the need to 1a.8.i Standard of Standard Number of Standard Number of Standard understand the importance of maintaining their own health Number 1a.8.iii demonstrate sensitivity to understand the need to 2b.3 ii the factors which shape psychological and socail 3a.1.viii.a factors that influence an individual in health and understand the need to maintain high standards 1a.8.iiof personal conduct understand the to adapt requirement 2b.3 i practice to meet the understand the following 3a.1.viii aspects of behavioural science
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Appendix C – SOPs numbering sociology can inform an understanding of physical and mental health, illness and health in the context of care paramedic practice and the incorporation of this knowledge into paramedic practice developing and maintaining effective relationships 2b.4 how psychology and 3a.1.viii.b 2b.4 be able to conduct positioned (and if necessary immobilised) for safe and effective interventions science aspects of clinical appropriate diagnostic or appropriate skilfully monitoring procedures, monitoring procedures, therapy or treatment, other actions safely and 1b.1 service users are ensure 2b.4.ii understand the following 3a.1.ix proficiency proficiency proficiency Standard of Standard understand both the need 1a.8.iv Number of Standard Number of Standard Number environment 1b.1be able to work, and carers their relatives where appropriate, in appropriate, where partnership with other support professionals, service users, and staff, to keep skills and knowledge up to date and the importance of learning career-long be able to maintain a high of professional standard 1a.8.v by adopting effectiveness strategies for physical and pschological slef-care, critical self-awareness, understand the need to and by being able to maintain a safe working 2b.4.i maintain the safety of both service users, and those involved in their how aspects of care 3a.1.viii.c sociology are psychology and fundamental to the role of the paramedic in
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Appendix C – SOPs numbering functional assessment and and the scientific treatment physiological, pharmacological, evaluation of effectiveness practice effective paramedic effective 2b.5 basis of the theorectical 3a.1.ix.c 2b.5 be able to maintain records appropriately records in accordance with in accordance applicable legislation, and guidelinesprotocols evidence and research into the design and implementation of member of a team proficiencyunderstand the need to build and sustain 1b.1.i relationships professional as both an independent practitioner and collaboratively as a know the indications and 2.b.4.iii using specific paramedic proficiency techniques, including their contra-indications of pathological changes 3a.1.ix.a needs and goals modifications of conditions features commonly encoutered clinical and related proficiency by paramedics be able to make 1b.1.iii appropriate referrals appropriate treatments and treatments interventions to meet their behavioural and understand the need to engage service users and 1b.1.ii in planning and carers evaluating diagnostics, be able to modify and 2.b.4.iv adapt practice to emergency situations the changes that can 3a.1.ix.b paramedic from result practice, including Standard of Standard Number of Standard Number of Standard Number understand the range and 1b.1.ivlimitations of operational between relationships paramedics and other professionalshealthcare be able to keep accurate, 2b.5.i and legible records principles of evaluation the need to recognise 3a.1.ix.d and handle these records all other clinical information and research enable the integration of perspectives theoretical methodologies which
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Appendix C – SOPs numbering 3a.2 pharmacokinetics to approaches different practice, and how to the needs of an or individual, groups communities situations pharmocology, including pharmocology, pharmacodynamics and 3a.2 know how 2c understand relevant 3a.1.x 2c.1 2c Critical evaluation of 2c.1 be able to monitor 1b.2 1b.3 recognise the principles recognise and practices of other 1b.1.v professionals healthcare systems and healthcare and how they interact with of a paramedic the role 1b.2 be able to contribute understand the need to 2b.5.iimulti-disciplinary team use only accepted terminology in making records the theories supporting 3a.1.ix.e actions registrant’s clinical reasoning solving and problem 1b.3 be able to demonstrate effective skills in and appropriate communicating information, advice, instruction and opinion to professional colleagues, service users, and carers their relatives the ongoing and review of planned effectiveness accordingly activity and modify it and expressed are principles professional translated into action a number of through select or modify to meet approaches proficiency proficiency proficiency Standard of Standard Number of Standard Number of Standard Number be able to communicate in English to the standard 1b.3 iequivalent to level 7 of the International English System, Language Testing with no element below 6.5 be able to gather information, including qualitative and quantitative 2c.1.i of evaluate the responses data, that helps to service users to their care know how to select or 3a.2 i meet the needs of to modify approaches when and carers, in emergency presented patients, their relatives effectively to work effectively undertaken as part of a to, the response the impact of, or
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Appendix C – SOPs numbering 3a.3 need to establish and maintain a safe practice environment 3a.3 understand the accordance with these accordance improvement programmes improvement between and use forms of appropriate verbal and non-verbal communication with service users and others monitor and evaluate the quality of practice and the value of contributing to quality assurance and the generation of data for proficiencyunderstand how communications skills the assessment of affect service users and how the 1b.3 iimeans of communication should be modified to and take account address of factors such as age, physical ability and be able to evaluate learning ability intervention plans using outcome recognised be able to select, move the and revise measures proficiency 2c.1.ii plans as necessary in 1b.3 iii service user conjunction with the know the theory and the need to recognise principles of paramedic 3a.2 ii practice 2c.1.iii proficiency Standard of Standard Number of Standard Number of Standard Number be aware of characteristicsbe aware 1b.3 ivand consequences of non-verbal communication and how this can be age, by culture, affected religious gender, ethnicity, be able to make reasoned 2c.1.ivbeliefs and socio-economic status continue, modify or cease decisions to initiate, of applicable be aware 3a.3 i techniques or procedures, or the use of treatment the decisions and record and reasoning legislation, and any health and safety in force and procedures at the workplace, such safety policies relevant appropriately as incident reporting, and be able to act in
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Appendix C – SOPs numbering environments for practice, environments which minimise risks to them, and treating others, including the and control use of hazard in a safe manner with health accordance particularly infection control techniques and safety legislation 2c.2 be able to establish safe 3a.3 iv reflect on and review on and review reflect practice 2c.2 be able to audit, relationships with service relationships users should be based on and trust, mutual respect and be able to maintain of care high standards even in situations of service users, those Standard of Standard understand the need to service users provide Number 1b.3.v(or people acting on their behalf) with the information necessary to enable them to make informed decisions of Standard be able to make of effectiveness judgements on the 2c.1.v Number procedures possible wherever be able to work safely, of Standard that recognise 3a.3 ii Number including being able to 1b.3 vii select appropriate and risk control hazard personal incompatibility management, reduction or elimination techniques communication be able to identify anxiety 1b.3. viii in patients, and stress and others carers the potential recognise impact upon understand the principles 2c.2.i and of quality control understand and be able quality assurance 3a.3 v to apply appropriate moving and handling proficiency proficiency proficiency understand the need to use an appropriate 1b.3 vi to assist interpreter patients whose first language is not English, be able to use quality 2c.1.vi and quality control assurance techniques, action be able to select including restorative 3a.3 iii equipment protective personal appropriate and use it correctly
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Appendix C – SOPs numbering audit and review in quality audit and review management, including quality quality control, assurance and the use of outcome appropriate and purpose of sterile fields and the paramedic’s maintaining them for and responsibility role participate in quality assurance programmes, 2c.2.iv measures appropriate where understand the value of on practice and reflection 2c.2.v the the need to record outcome of such reflection the value of recognise and case conferences 2c.2.vi other methods of review 1b.4 of of the role be aware 2c.2.ii understand the nature 3a.3 vi proficiency1b. 4 understand the proficiencyusers proficiency need for effective need for effective communication of the care throughout the service user Standard of Standard Number of Standard the need to use recognise 1b.4.iinterpersonal skills to encourage the active Number participation of service be able to maintain an of Standard 2c.2.ii audit trail and effective Number continual work towards improvement
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Appendix D – Final outcomes from annual monitoring
Ambulance trust Program name Mode of study Status East Midlands Ambulance IHCD Paramedic Award FT and PT Continues to meet Service NHS Trust the standards London Ambulance Service IHCD Paramedic Award Block Continues to meet NHS Trust the standards North West Ambulance IHCD Paramedic Award Block Continues to meet Service NHS Trust the standards Northern Ireland Ambulance Paramedic-in-training FT Continues to meet Service Health and the standards Social Care Trust Scottish Ambulance IHCD Paramedic Award FT Continues to meet College the standards South Western Ambulance IHCD Paramedic Award FT Continues to meet Service NHS Trust the standards Welsh Ambulance Services IHCD Paramedic Award FT Continues to meet NHS Trust the standards Yorkshire Ambulance IHCD Paramedic Award FT and PT Continues to meet Service NHS Trust the standards
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List of graphs
Graph 1 Time between visit request received and final decision by Education and Training Committee 8
Graph 2 Time between visit date and report sent to education provider 9
Graph 3 Time between visit date and Education and Training Committee decision 10
Graph 4 Responses to the feedback questionnaire regarding timelines of communication from HPC throughout each stage of the approval process 11
Graph 5 Responses to pre-visit stage feedback questions 12
Graph 6 Responses to visit stage feedback questions 14
Graph 7 Responses to post-visit stage feedback questions 14
Graph 8 Number of conditions applied to each programme 15
Graph 9 Conditions applied by standard of education and training 17
Graph 10 Types of condition applied 18
Graph 11 Number of instances where conditions were applied to SOPs and their delivery in a programme 19
Graph 12 Duration between annual monitoring submission being received and education provider informed of outcome 27
Graph 13 Duration between ambulance trust annual monitoring audits received and review at assessment day 28
Graph 14 Standards of education and training that required additional documentation 29
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