286

......

PREHOSPITAL CARE Emerg Med J: first published as 10.1136/emj.2004.020636 on 23 March 2005. Downloaded from Debate For Debate…: A license to practise pre-hospital and retrieval medicine RMackenzie,DBevan

he provision of on scene medical support to from simple first aid and basic resuscitation to ambulance services in the UK is fragmented, high stakes critical care interventions. The Tdisorganised, and largely unregulated. development of modern ambulance services has Recent and evolving educational, professional, further polarised this activity. At one end of the and regulatory developments in medical practice spectrum, there clearly remains a need for basic now provide an opportunity to remedy this first response capabilities in rural areas. This has situation and ensure that ‘‘immediate care’’ is been recognised through initiatives such as the governed and regulated in the same way as any NHS Scotland Remote and Rural Areas Resource other specialist undertaking within the NHS. Initiative (which provides funding for standar- Immediate care has been defined as the dised training for remote and rural medical provision of skilled medical help at the scene of practitioners)12 and immediate care scheme an accident or medical emergency and during involvement in development of community transportation to hospital.1 Well before the based lay response systems. At the other end of development of modern ambulance services and the spectrum, there also remains a need for the recognition of accident and emergency specialist on scene and in transit medical (A&E) medicine as a specialty, general practi- support. The most common examples in our tioners (GPs) were required to deal with increas- experience are the patient with immediately life ing numbers of critically injured patients in the threatening asthma and respiratory failure who pre-hospital environment. Their response, in is remote from hospital, and the seriously injured most parts of the UK, was to form themselves vehicle occupant who is trapped at the scene. The into voluntary associations and create a frame- relative infrequency of such patients does not work within which their training, equipment, diminish their critical care needs or the impact and operational activity could be organised and that they have on NHS resources. There seems funded.1–3 These ‘‘immediate care schemes’’, in little doubt that the timely intervention of a stark contrast to the systems developed in the competent specialist with the full range of United States and elsewhere in Europe, were, critical care skills can have a major impact on and still are, funded almost entirely through such a patient’s journey, in terms of early charitable donations. diagnosis, meaningful interventions, triage, or In some parts of the country, hospital practi- advocacy.13–16 The care of such patients often tioners have also played a role in the provision of

requires difficult clinical decisions that are likely http://emj.bmj.com/ immediate care, either through ‘‘flying squads’’ to remain beyond the scope of most healthcare or mobile medical teams or by individual professionals employed by ambulance services membership of immediate care schemes.23 for the foreseeable future.17–20 We would argue Some hospitals continue to deploy mobile teams that many of these decisions and interventions at the request of ambulance services. are likely to also be beyond the scope of the Unfortunately, the provision of such services ‘‘occasional’’ or ‘‘fringe’’ immediate care doctor. continues to be unpredictable, and there are very Given the emergence of ‘‘intermediate’’ care wide variations in availability, funding, training, and confusion surrounding the medical practi- on October 1, 2021 by guest. Protected copyright. experience, and equipment.4–6 There also appears tioner’s contribution to pre-hospital care, we . . R Mackenzie, Consultant to be considerable uncertainty regarding the propose that the term ‘‘pre-hospital and retrieval . in Accident and composition, training, and role of hospital . Emergency Medicine medicine’’ be used as a more accurate description . mobile medical teams in incidents that are not . and Medical Director, of this area of specialist practice. In our current . MAGPAS, St Ives, declared as major incidents. practice, we frequently attend incidents in rural . Cambridgshire, UK . Regardless of their background, the core areas, provide on scene medical care, undertake . activities that define the clinical practice of . D Bevan, General procedural sedation or emergency anaesthesia at . immediate care have remained essentially the scene, and take responsibility for in transit . Practitioner and . Immediate Care Doctor unchanged over the last 40 years. They can be medical care for 30–60 minutes. We believe that . . MAGPAS, St Ives, defined by scrutinising the activity of individual this represents a specialist function within the . Cambridgeshire, UK . schemes and doctors and ambulance service Ambulance Service spectrum of activity. The . 2 7–11 . Correspondence to: medical advisors and directors. In our concept of ‘‘pre-hospital and retrieval medicine’’ . Dr R Mackenzie, experience, this practice includes direct clinical . Mid Anglia General . care at the scene and during retrieval to hospital Abbreviations: A&E, accident and emergency; BASICS, . Practitioner Accident . (in transit care), scene management, major British Association for Immediate Care; CCT, Certificate of . Service (MAGPAS), . St Ives, Cambridgeshire incident management, clinical leadership (for Completion of Training; DoH, Department of Health; GP, . general practitioner; GPwSI, General Practitioner with . PE27 5WF UK; roderick. example, medical director functions) and sup- . mackenzie@magpas. porting professional activities such as training Specialist Interest (GPwSI); JCPTGP, Joint Committee on . Postgraduate Training in General Practice; PHEC, Pre- . org.uk and education of ambulance service personnel. . hospital Emergency Care; PMETB, Postgraduate Medical . Accepted Doctors involved with immediate care have Education and Training Board; STA, Specialist Training . . 30 December 2004 historically undertaken a spectrum of activities Authority

www.emjonline.com For debate: A license to practise pre-hospital and retrieval medicine 287

...... being considered as a specialist endeavour rather BASICS accreditation standards to doctors who than an occasional pursuit is not new.12122 The deliver a clinical service (box 1). Organisations Emerg Med J: first published as 10.1136/emj.2004.020636 on 23 March 2005. Downloaded from glaring inconsistency between the requirement that employ doctors, such as the London Debate for a predominantly consultant led emergency Helicopter Emergency Medical Service (HEMS) department phase compared to a paramedic or and Great North Air Ambulance (GNAS), do not technician led pre-hospital phase for the same require applicants to hold and/or maintain critically ill or injured patient is now, however, BASICS accreditation. Similarly, A&E depart- more difficult to defend other than on historical ments who routinely send doctors to incident grounds. It is clearly recognised that time to scenes do not require them to be BASICS meaningful intervention related to injury pattern accredited. The accreditation standards them- is probably the most important determinant of selves are also widely regarded as primarily survival following traumatic injury.23–25 There is aimed at the occasional practitioner in rural no doubt that short scene times and rapid areas (for example, completion of a 3 day Pre- transfer to the appropriately staffed and prepared Hospital Emergency Care (PHEC) course). Those hospital should be the norm for most patients, organisations that have applied standards tend but what of those who cannot be transported to use the Dip IMC as a benchmark. This has (entrapment) or who have urgent pre-hospital been recommended as the minimum qualifica- critical care needs that cannot be met from tion for doctors regularly called out by ambu- current paramedic or emergency care practitioner lance services by both BASICS and the Royal education and training? In addition, trauma care College of Surgeons.12627 Despite this, the Dip systems are changing, with the recognition that a IMC is not a minimum requirement for BASICS balance has to be struck between local hospital accreditation and it has not become a mandated access and the concentration of multispecialist prerequisite for operational activity supporting expertise in regional centres.26 A regional trauma ambulance services. system further increases the need for on scene medical care, selection of the most appropriate THE FACULTY OF PRE-HOSPITAL CARE facility to meet each patient’s needs, and safe The Dip IMC is administered by the Royal retrieval to that facility. There is currently no College of Surgeons of Edinburgh and its system, training stream, or workforce in place Faculty of Pre-hospital Care. The faculty was across the UK to ensure that the needs of these formed in 1996 with the central aim of setting patients are met in a consistent or organised and maintaining standards of practice in pre- manner. hospital care. The Dip IMC has undergone extensive development and is now open to BASICS nursing and paramedic professionals. The British Association for Immediate Care Paradoxically, the current regulations for the (BASICS) was formed in 1977 with the aim of Dip IMC require ‘‘documented evidence of becoming the national co-ordinating body for clinical experience in the area of pre-hospital 28 those providing immediate care throughout the emergency care for a period of 1 year’’. Perhaps UK. It has been instrumental in the development as a result of this perceived restriction, a wide

range of short vocational courses such as PHEC, http://emj.bmj.com/ of the Resuscitation Council, the Diploma in 29 Immediate Medical Care (Dip IMC) and the Pre-hospital Trauma Life Support (PHTLS), Pre- hospital Paediatric Life Support,30 Safety at Faculty of Pre-hospital Care of the Royal College 31 3 Scene, and Major Incident Medical of Surgeons of Edinburgh. In 1998, BASICS 32 introduced a voluntary accreditation scheme for Management and Support have become regarded as sufficient in themselves to qualify its members. However, uptake has been poor, or accredit doctors for practice in pre-hospital and few ambulance services or immediate care care.

schemes have sought to enforce or even apply the on October 1, 2021 by guest. Protected copyright. A new Fellowship examination has recently been created, which is only open to doctors who Box 1 BASICS Accreditation have obtained the Dip IMC or its equivalent and have at least 4 years’ post-registration experi- Requirements for Doctors (from www. ence. It could therefore be taken 2 years after the basics.org.uk) Dip IMC. The concept of the FIMC as a specialist exit examination is implicit in the regulations N Full GMC registration and reflects the level of expertise and compe- N Evidence of professional development in the tence required for specialist practice. The regula- field of pre-hospital care tions state that experience must be in the N PHEC certificate or Immediate Care Course ‘‘specialist area of immediate medical care’’ and or Dip IMC or FIMC that the examination is ‘‘only open to those who have undertaken and successfully completed a N Evidence of operational activity in the pre- training programme approved by the Specialty hospital environment Advisory Board’’.28 These examination develop- N Recommendation from an accredited BASICS ments mirror, to some degree, the rigour applied member to the Examination of Special Competence in N Indemnity insurance is provided for Emergency Medicine of The College of Family N Individual member of BASICS Physicians of Canada,33 the Postgraduate N Undertaking to agree to BASICS accredita- Diploma in Community Emergency Medicine in tion requirements/code of practice New Zealand34 and the Diploma in Primary Emergency Care of the College of Family

www.emjonline.com 288 Mackenzie, Bevan

...... organisations (PCOs) and GPs to contract for Box 2 NES accreditation standard for enhanced services to meet local health needs. Emerg Med J: first published as 10.1136/emj.2004.020636 on 23 March 2005. Downloaded from Debate provision of immediate and first These enhanced services can include specialist response care (from reference 36) interests in addition to the essential traditional GP services. The contract documentation Practitioners will normally be expected to: includes a detailed national enhanced service (NES) specification for ‘‘provision of immediate (a) as a minimum, possess the Pre-Hospital care and first response care’’ (box 2).36 Although Emergency Care (PHEC) Certificate of the the NES represents an important step in recog- Royal College of Surgeons of Edinburgh or nising the role of General Practice in provision of other equivalent pre-hospital emergency immediate care, it does not differentiate first medicine qualification; response services from more specialist pre- (b) undertake a local orientation and famil- hospital critical care. The specification does, iarisation programme; however, make explicit the need for GPs to (c) undergo such advanced driving tuition as demonstrate competence. It states (under the required by the Ambulance Service; heading ‘‘accreditation’’) that GPs must satisfy (d) undertake such communications systems at appraisal and revalidation that they have the training as required locally; relevant ‘‘continuing medical experience, train- ing, and competence as is necessary for them to (e) undertake such refresher training as dic- be able to contract for the enhanced service’’. The tated by good clinical governance and the specification goes on to state that GPs should, as need to remain accredited; a minimum, have completed the PHEC course or (f) accept and obey the local statutory emer- its equivalent. The role of BASICS and the gency service command structures; Faculty of Pre-hospital Care as the standard (g) if the NES is operated locally through a setting and accreditation bodies is also endorsed. local immediate care scheme, accept its rules and operational standards; GENERAL PRACTITIONERS WITH SPECIAL (h) maintain appropriate communications INTERESTS with the tasking control room concerning In a parallel development, the Department of personal availability for call out; Health (DoH) General Practitioner with (i) be familiar with the scope and limitations Specialist Interest (GPwSI) project has encour- of paramedic practice; aged PCOs to support GPs and allied health (j) be willing to work in a team; professionals who wish to develop specialist (k) accept the ambulance service tasking interests and expertise in particular clinical policy. areas. While this development has been primarily aimed at improving access to outpatient services Practices or individuals that are contracted to (for example, ear, nose and throat), the DoH has provide such services should be able to demon- commissioned the Royal College of General strate competencies in all the above areas, and Practitioners (RCGP) to develop a framework

in addition should be able to show active for GPwSI appointments in ‘‘Emergency and http://emj.bmj.com/ participation in service development through Unscheduled Care’’.36 37 This framework includes CPD, audit, and critical case analysis. The pre-hospital and ‘‘scene of incident’’ care, and keeping of an individual log of incidents explicitly states that a process of accreditation attended and interventions is mandatory. should be undertaken by the ‘‘employer’’ orga- Accreditation may be achieved by meeting the nisation (acute trust, ambulance trust, or PCO). standards set by a mutually agreed third party This accreditation process should be related to such as a local immediate care scheme, British evidence of having achieved an agreed and Association for Immediate Care, or the Faculty defined set of competencies (although it is on October 1, 2021 by guest. Protected copyright. of Pre-Hospital Care. This should occur on an recognised that the competencies themselves annual basis and be summarised in an annual have not been defined). The framework docu- report. Such professional organisations should ments go on to state that ‘‘a diploma or similar be asked to review a doctor’s performance if formal qualification can provide a credible source there is any doubt or dispute over an indivi- of evidence of the acquisition of the required dual’s or practice’s status. competencies’’. The PHEC is described as an example of an ‘‘entry level’’ course.37 The GPwSI framework provides a much more robust mechanism for accreditation, appoint- Practitioners of South Africa.35 There is, however, ment, and funding of appropriately trained no formally constituted or recognised training specialist medical support to ambulance services programme in immediate care in the UK. than the NES provisions within the new GP contract. Applicants for such posts must show THE NEW GP CONTRACT proof of competency as a GP and provide In addition to the work of BASICS and the evidence of competence in the special interest Faculty of Pre-hospital Care, the new GP contract area sufficient to meet the requirements of the adds weight to the argument for recognition post.38 This mirrors established arrangements for of pre-hospital and retrieval medicine as a hospital subspecialty recognition: evidence of subspecialty activity undertaken only by those competency in the subspecialty is required in who are recognised as competent to do so. The addition to proof of competence as a consultant contract has made provision for primary care within a defined specialist area. Although the

www.emjonline.com For debate: A license to practise pre-hospital and retrieval medicine 289

...... N there are sufficient resources to achieve the Box 3 Key Principles and standards for programme’s learning outcomes; Emerg Med J: first published as 10.1136/emj.2004.020636 on 23 March 2005. Downloaded from postgraduate medical education N there are sufficient resources in the trust, Debate training programmes (Adapted from primary care organisation, practice or other reference 40) organisations where the trainee is being placed to allow the training to be undertaken The programme must: N effectively; N have defined, patient centred, learning out- there is provision of adequate resources to comes; be developed jointly with the dis- support trainees personal learning needs; ciplines concerned, the trainees, patients, N they have an appropriate working knowl- public and the service; edge and understanding of the regulatory N be based on the standards of professional framework in the UK. practice set out in Good Medical Practice; N include any generic learning outcomes required by the PMETB; NES funding arrangements could be applied to a N have explicit, published entry criteria and GPwSI, the NES specification is perhaps better selection processes that are valid, reliable, suited to GPs contracted to provide first response open and comply with current equal oppor- services. tunities legislation; N have arrangements to support trainees to LICENSING AND REVALIDATION train and work flexibly; Additional recent developments within medical regulation provide further impetus for develop- N have arrangements to support trainees who ment of pre-hospital and retrieval medicine as a have special needs; recognised subspecialty of both general and N be designed to support the needs of doctors hospital practice. From 2005, all doctors who who may enter training at a number of wish to practice medicine in the UK will be different levels with varying levels of knowl- required to hold a license to practice in addition edge and skills; to their registration. Although rarely explicitly N have processes in place for the regular stated, we believe that this license will be evaluation and review of the programme specialty specific. Central to the award of a and its outputs; license are the training and revalidation pro- N have processes for ensuring that trainees cesses. The evidence required to show compli- provide information on their supervision, ance with the principles of good clinical care (the training and clinical experience. first of the seven attributes of good medical practice examined by revalidation) is, by defini- The curriculum must: tion, speciality specific.39 Thus, if pre-hospital and retrieval medicine was recognised as a N include details of the intended learning specialist endeavour, neither a GP or a consul- outcomes and a syllabus of knowledge, skills,

tant in emergency medicine would have a license http://emj.bmj.com/ and professional attitudes and behaviours; to practice in this area unless they could N allow training and learning to be delivered demonstrate achievement and maintenance of flexibly in ways that are relevant and meet professional competence. Recognition of pre- trainees’ learning needs; hospital and retrieval medicine as a specialist N provide experiential learning through sys- endeavour will ensure that critically ill and tematic clinical training; injured patients obtain the same regulatory N involve trainees in the supervised delivery of protection in the pre-hospital environment as service; they would in any other healthcare setting. on October 1, 2021 by guest. Protected copyright. N provide for regular formal educational ses- sions that cover topics of value and topics of REFORM OF POSTGRADUATE MEDICAL interest to trainees; EDUCATION N include a systematic programme of valid and The drive for the development of an NHS reliable formative and summative assess- workforce that is fit for purpose has led to ments; fundamental reform of both undergraduate and postgraduate medical education and training.40 N provide opportunities and processes for self- All medical graduates of the future will complete directed learning, regular feedback, career a 2 year Foundation Programme, which will advice and counselling, extra support, and provide the appropriate background for entry remediation and retraining. into specialist and general practice training. On Those responsible for programmes must completion of this programme, doctors will be ensure that: able to apply directly to competency based specialist or general practice training pro- N there is a clear statement of responsibility for grammes within recognised training rotations, the different aspects of the programme; which will lead to a Certificate of Completion of N those who have responsibilities for teaching Training (CCT). The existing Specialist Training have the skills, attitudes and practices of a Authority (STA) will be absorbed into the new competent teacher and that trainees are Postgraduate Medical Education and Training properly supervised; Board (PMETB). For General Practitioners, it is intended that the Joint Committee on

www.emjonline.com 290 Mackenzie, Bevan

...... Emerg Med J: first published as 10.1136/emj.2004.020636 on 23 March 2005. Downloaded from Debate Completion of Foundation Programme and eligible to enter specialist or general practice training programme leading to CCT

Meet eligibility criteria for Dip IMC

Diploma in Immediate Medical Care

Competitive entry to PMETB approved training programme in Pre-Hospital and Retrieval Medicine

Competency based curriculum with training, supervised practice and assessment over 12 to 24 months depending on prior experience/competence

Fellowship in Immediate Medical Care

PMETB award Certificate of Completion of Sub-Speciality Training

GMC addition of sub-speciality to license

Specialist/Consultant in Pre-Hospital and Retrieval Medicine http://emj.bmj.com/ Appraisal/Revalidation (against competency framework)

Clinical practice of Pre-Hospital and Retrieval Medicine Direct Clinical Care/Leadership/ on October 1, 2021 by guest. Protected copyright. Education/Management

Figure 1 A framework for subspeciality training and registration for pre-hospital and retrieval medicine.

Postgraduate Training in General Practice currently recognised subspecialty. The process for (JCPTGP), the current equivalent of the STA, recognition of a new subspeciality in pre-hospital also becomes absorbed into the PMETB. The and retrieval medicine is likely to be similar to PMETB will therefore become the UK competent the existing arrangements.41 The PMETB will authority for accreditation of both general and require a competency based curriculum, frame- specialist practitioner training. work and training programme that meets its There are currently 55 recognised medical standards (box 3) and that has been agreed specialties and 29 subspecialties. We understand between the Faculty of Pre-hospital Care, the that an NHS consultant’s license to practice will Faculty of Accident and Emergency Medicine, be directly related to their recognised specialist the RCGP, and BASICS.42 There is no reason why and subspecialist accreditation on the GMC such subspecialty recognition, leading to a license Specialist Register. Within the specialty of to practice, cannot be included on the proposed accident and emergency medicine, paediatric General Practice Register in much the same way as accident and emergency medicine is the only for a consultant on the Specialist Register.

www.emjonline.com For debate: A license to practise pre-hospital and retrieval medicine 291

...... A POSSIBLE ROUTE TO SUBSPECIALTY ACCREDITATION BOX 4 The 10 themes in the MAGPAS Emerg Med J: first published as 10.1136/emj.2004.020636 on 23 March 2005. Downloaded from Doctors who wished to develop a subspecialty competency framework for specialist Debate practice in pre-hospital and retrieval medicine training in Pre-hospital and Retrieval would be required to undertake a training Medicine programme recognised by the PMETB (fig 1). Entry to the programme might follow the model 1. Operational environment and procedures proposed for competitive entry to 2. Resuscitation and clinical care general and specialist training programmes.40 The Dip IMC has been widely and repeatedly 3. Equipment and monitoring advocated as an appropriate benchmark for 4. Care of children immediate care practitioners and it, or its 5. Rescue and extrication equivalent, should also therefore be a pre- 6. Analgesia and procedural sedation requisite for entry to any training programme. 7. Pre-hospital emergency anaesthesia Given the need to have some pre-hospital emergency care experience prior to attempting 8. Special incident medical support the Dip IMC, an entry level vocational course 9. Major incident medical support such as PHEC or those delivered by BASICS 10. Retrieval and transfer Scotland could remain the minimum recom- mended basic training prior to undertaking supervised clinical experience. Unsupervised supervised practice.40–42 In developing such pro- clinical duties at this stage should be no more grammes, there is a critical distinction to be encouraged in pre-hospital care than they are made between the rural practitioner who has currently in general or specialist practice. occasional need to support the ambulance service Once accepted onto a training programme, the as a first responder (with skills equivalent to a doctor could be required to register with a modern paramedic) and the specialist practi- professional body such as the Faculty of Pre- tioner who is engaged or employed by ambu- hospital Care in order to undertake a review of lance services specifically for the purposes of their training and experience against a clearly defined competency framework. A tailored pro- providing specialist on scene, special incident, gramme of training and supervised experience and major incident medical support. The scope of lasting 12–24 months would then be agreed and clinical practice has been mentioned above and is progress through the programme monitored. neatly delineated by the 10 core competency Towards the end of the training programme, the themes in the current training programme utilised doctor could be required to complete the FIMC. On by Cambridgeshire’s immediate care scheme, 43 completion of the training programme and the exit MAGPAS (box 4). Work is currently underway examination, representation would then be made to develop these themes into a competency based to the PMETB for recognition of subspecialty curriculum and syllabus of knowledge, skills, and training. This may need to be linked to the professional attitudes and behaviours. underpinning CST in specialist or general practice We believe that there is an opportunity for the but it is not clear whether this would be necessary Faculty of Pre-hospital Care to set and maintain http://emj.bmj.com/ in reality as some doctors may have further the standards for both training and assessment training to complete before the award of a CCT. for such a programme, building on its existing Development of a subspecialist interest in pre- work with accreditation, the Dip IMC and the hospital and retrieval medicine would not be FIMC. Monitoring and evaluating the delivery of restricted to those at the beginning of their training would also become the remit of the medical careers. A fundamental tenet of PMETB. Actual delivery of training should probably remain a core activity of BASICS and Modernising Medical Careers is that systems should on October 1, 2021 by guest. Protected copyright. be in place to allow entry to recognised training BASICS Scotland together with ambulance programmes by doctors at various stages in their trusts, universities, immediate care schemes careers.40 In addition, a pre-hospital and retrieval and other faculty accredited course providers. medicine training programme need not be a full With regard to supervised practice, a number time endeavour and some flexibility would need of models currently exist in the UK, which are to be applied by the professional body (e.g. the well established in terms of organisation, Faculty of Pre-hospital Care) to ensure that prior training, and supervision and which could be learning and sessional, part-time and voluntary adapted to meet the needs of such a training experience can all be incorporated into training programme. Examples of these currently include programmes. This mirrors the approach taken by helicopter based services such as the Teeside the Faculty of Accident and Emergency based Great North Air Ambulance (www. Medicine, which already recognises some pre- greatnorthairambulance.co.uk) and London hospital activities for A&E training (e.g. within HEMS (www.hems-london.org.uk) as well as the military, with London HEMS and within land based services such as the MAGPAS some immediate care schemes). Emergency Medical Team (www.magpas.org.uk) and the West Midlands CARE Team (www.wmcareteam.com). COMPETENCY DRIVEN TRAINING AND ASSESSMENT Central to the concept of subspecialist accredita- ACALLFORACTION tion and practice is a competency based pro- Reform of emergency care has encouraged gramme with relevant training, assessment and radical thinking and innovative practices across

www.emjonline.com 292 Mackenzie, Bevan

...... the spectrum of emergency, unscheduled, and 9 Roberts K, Bleetman A. An email audit of prehospital doctor out of hours care demands. A new generation of activity in an area of the West Midlands. Emerg Med J Emerg Med J: first published as 10.1136/emj.2004.020636 on 23 March 2005. Downloaded from 2002;19:341–44. healthcare professionals are being given the Debate 10 Cooke MW. How much to do at the accident scene? BMJ education, training, and confidence to address 1999;319:1150. many of these demands. Among all this change, 11 Cooke MW, Allison K. Medical directors in the ambulance however, there is a tendency to underestimate service. Pre-hosp Immed Care 1998;2:128–9. the needs of critically ill or injured patients in the 12 RARARI. Remote and Rural Areas Resource Initiative. http:// community.rarari.org.uk. pre-hospital phase and undervalue the role of an 13 Baxt WG, Moody P. The impact of advanced prehospital appropriately trained and equipped physician in emergency care on the mortality of severely brain-injured their management. The daily operational activity patients. J Trauma 1987;4:365–9. of volunteer immediate care doctors around the 14 Deakin C, Davies G. Defining trauma patient subpopulations UK and their heavy involvement in ambulance for field stabilisation. Eur J Emerg Med 1994;1:31–33. 15 Oppe S, De Charro FT. The effect of medical care by a service development serves to remind us of the helicopter trauma team on the probability of survival and the continued need for access to such physicians in quality of life of hospitalised victims. Accid Anal Prev the ‘‘therapeutic vacuum’’ between injury or 2001;33:129–38. illness and meaningful intervention. Although 16 Lee A, Garner A, Fearnside M, et al. Level of prehospital care and risk of mortality in patients with and without severe blunt the language and terminology differ, develop- head injury. Injury 2003;34:815–19. ments within BASICS, the Faculty of Pre- 17 Baskett P, Chamberlain D, Clarke T, et al. The future role and hospital Care, the RCGP, the DoH, and the education of paramedic ambulance service personnel GMC reveal a clear recognition of the need for (Emerging Concepts). Joint Royal Colleges Ambulance competence and professional regulation in deliv- Liaison Committee, January 2000. www.jrcalc.org.uk. 18 Battersby D. The future of ambulance officer education ery of specialist pre-hospital care. and training in the UK. Pre-hosp Immed Care Patients have a right to expect that the same 1998;3:113–14. standards of professional medical regulation will 19 Woollard M, Ellis D. Prehospital care five years hence. Pre- apply in the pre-hospital phase of their journey hosp Immed Care 1999;3:102–7. 20 Ball L. Setting the scene for the paramedic in primary care: a as in the hospital phase. There are now oppor- review of the literature. Emer Med J, in press. tunities to develop a framework for a properly 21 Davies G. The future of Pre-hospital Medicine. In: Earlam R, trained and regulated medical workforce capable eds. Trauma care: HEMS London. London: Saldatore Ltd, of providing specialist medical support to ambu- 1997. lance services. The development of a rigorous, 22 Cooke MW. Immediate care: specialty or pastime? Injury 1994;25:347–8. accredited career stream in pre-hospital and 23 Cowley RA. The resuscitation and stabilization of major retrieval medicine would fill one of the few multiple trauma patients in a trauma center environment. Clin remaining gaps in the provision of emergency Med 1976;83:16–22. care in the UK. There is real opportunity for both 24 Trunkey D. Initial treatment of patients with extensive trauma. N Engl J Med 1991;324:1259–63. individual practitioners and the organisations 25 Sampalis J, Denis R, Lavoie A, et al. Trauma care responsible for regulating and applying stan- regionalization: a process-outcome evaluation. J Trauma dards to now collaborate and reach agreement on 1999;46:565–79. the scope of practice, competency framework and 26 Royal College of Surgeons of England and British licensing arrangements for the subspecialty of Orthopaedic Association. Better care of the severely injured. London: Royal College of Surgeons, 2003.

pre-hospital and retrieval medicine. 27 British Association for Immediate Care. BASICS clinical http://emj.bmj.com/ governance guidance document. Ipswich: BASICS, 2000. ACKNOWLEDGEMENTS 28 Faculty of Pre-hospital Care, Royal College of Surgeons of This work was supported by funds from the MAGPAS Edinburgh. Regulations relating to the Diploma and Research Programme. Fellowship in Immediate Medical Care. October 2003. www.rcsed.ac.uk. Competing interests: R Mackenzie is a member of BASICS 29 National Association of Emergency Medical Technicians. and the Faculty of Pre-hospital Care of the Royal College Pre-hospital Trauma Life Support. New York: CV Mosby, of Surgeons of Edinburgh. He is also an examiner for the 2003.

Dip IMC and the Deputy Associate Editor for Pre-hospital 30 Advanced Life Support Group. Pre-hospital paediatric life on October 1, 2021 by guest. Protected copyright. Care for the EMJ. D Bevan is a member of BASICS. the support. London: BMJ Publishing Group, 1999. opinions expressed are those of the authors and not of 31 Calland V. Safety at scene: manual for paramedics and either the Faculty of Pre-hospital Care or BASICS. immediate care doctors. London: Mosby Ltd, 2001. 32 Advanced Life Support Group. Major incident medical management and support: the practical approach at the REFERENCES scene. London: BMJ Publishing Group, 2001. 33 College of Family Physicians of Canada. Examination of 1 British Medical Association Board of Science and Education. Special Competence in Emergency Medicine. www.cfpc.ca. Immediate care schemes. London: BMA, 1993. 34 Faculty of Medical and Health Sciences, University of 2 In: Easton K, ed. Rescue emergency care. London: Auckland. Postgraduate Diploma in Community Emergency Heinemann, 1977. Medicine. www.health.auckland.ac.nz. 3 Hines K. BASICS Comes of Age 1977–1998: A short history 35 College of Family Practitioners of South Africa. Diploma in of immediate care. Ipswich: BASICS, 1998. Primary Emergency Care. www.collegemedsa.ac.za. 4 Brennan L, Sage FJ, Simpson A. Major incident planning in 36 Department of Health. National enhanced service for South East Thames Region: a survey of medical staff provision of immediate care and first response care and awareness and training. J Accid Emerg Med 1994;11:85–9. GPwSI framework guidelines. www.dh.gov.uk/ 5 Carley S, Mackway-Jones K. Are British hospitals ready for PolicyAndGuidance/OrganisationPolicy/PrimaryCare. the next major incident? Analysis of hospital major incident 37 Royal College of General Practitioners and Department of plans. BMJ 1996;313:1242–3. Health. Guidelines for the appointment of general 6 Graham CA, Hearns ST. Major incidents: training for practitioners with special interests in the delivery of clinical on site medical personnel. J Accid Emerg Med services: emergency and unscheduled care. London: DoH, 1999;16:336–38. 2002. 7 In: Greaves I, Porter K, eds. Pre-hospital medicine: principles 38 National Primary and Care Trust Development and practice. London: Arnold, 1999. Programme. Practitioners with special interests: A step 8 In: Søreide E, Grande CM, eds. Pre-hospital trauma care. by step guide to setting up a general practitioner with a New York: Martin Dekker Inc, 2001. special interest (GPwSI) service. London: NHS

www.emjonline.com For debate: A license to practise pre-hospital and retrieval medicine 293

...... Modernisation Agency, 2003, www.natpact.nhs.uk/ 41 Specialist Training Authority of the Medical Royal Colleges.

special_interests. Process for recognition of sub-specialty training. Emerg Med J: first published as 10.1136/emj.2004.020636 on 23 March 2005. Downloaded from 39 General Medical Council. Registration, licensing and www.sta-mrc.org.uk. revalidation arrangements. www.gmc-uk.org. 42 Postgraduate Medical Education and Training Board. Debate 40 Departments of Health of the United Kingdom. Modernising Certification for doctors. www.pmetb.org.uk. medical careers: the next steps. London: Department of 43 MAGPAS. Specialist pre-hospital Emergency Medical Team Health, 2004. www.mmc.nhs.uk. training programme. www.magpas.org.uk.

PREHOSPITAL CARE Commentary from RCGP TAmbury

his is a timely call for the standardisation of commissioning of enhanced services by primary the training for and the provision of care organisations (PCOs). Such commissioning Timmediate care. The current situation – that will drive standards of care upwards by making such a fundamental service consists of a plethora training for, and ongoing competence in, imme- of providers and skills funded, in the main, diate care conform to a set minimum standard. through charitable means – is scandalous. However, PCOs are not restricted to commission- Standardised training leading to a quality ing these services from GPs. Indeed, the flex- assured service is in the best interests of patient ibility of the enhanced service framework is that safety. it should allow the development of teams of The Royal College of General Practitioners skilled practitioners, including GPs, in the way (RCGP) stance is that there must always be a alluded to above. role for doctors in the provision or immediate General practitioners with a specialist interest and unscheduled care, and that all practitioners (GPwSI) are, first and foremost, GPs. Guidance involved in such care be appropriately trained to to PCOs and other prospective employers regard- national standards. The authors’ call for regula- ing the level of skills acquired by GPwSI is tion leading to the ‘‘timely intervention of a designed to ensure that the GP, while working competent specialist’’ is one the College wel- from a generalist position, has attained, and comes. takes steps to maintain, specialist experience and Mackenzie and Bevan speak of raising the skills. It is likely that appraisal and revalidation standard of the pre-hospital environment to that will lead to a robust system of ensuring that this http://emj.bmj.com/ of at least A&E by citing the latter’s predomi- does indeed occur. There are as yet no definitive nantly consultant led status. While true, con- plans for a GP register to be set up, let alone sub- sultant led does not necessarily mean doctor led. specialist registers below this. There are now several nurse consultants across Therefore, rather than call for the creation of a the UK, and training is underway to deliver sub-specialty that maintains the status quo, consultant emergency care practitioners (ECP). patients would be better served if a pre-hospital To imply that paramedic or technician led care

and retrieval medicine speciality was much more on October 1, 2021 by guest. Protected copyright. may be sub-standard is offensive and also flies in the face of current workforce planning. ambitious. The Faculty of Pre-Hospital Care The pre-hospital environment needs a team of should oversee the development of a multi- competent clinicians providing a pool of skills skilled, multi-disciplinary team of clinicians – and experience. Rather than reinforcing existing medical, nursing and paramedical – to provide professional silos by creating a doctor led Faculty care in this setting, working to do so not only of Pre-Hospital and Retrieval medicine, the with the RCGP, Faculty of Accident and authors would do better to call for the develop- Emergency Medicine, and BASICS, but also ment of a multi-disciplinary system, with shared nursing and ambulance authorities. training measured against national standards, and workforce planning, to ensure that patients’ ACKNOWLEDGEMENT needs are well served. Thanks to I Maconochie, A&E Consultant, St Mary’s There is also confusion about provision of Hospital, London, for discussing an early draft. such care under the new GMS contract by Competing interests: none declared

www.emjonline.com 294 Royal College of Anaesthetists

......

PREHOSPITAL CARE Emerg Med J: first published as 10.1136/emj.2004.020636 on 23 March 2005. Downloaded from Debate Commentary from the RCA Royal College of Anaesthetists

imely pre-hospital interventions by doctors, There are several challenges that emerge from which cannot be undertaken by paramedics, the proposal to form a subspecialty of pre- Tmay improve the outcome for some patients; hospital and retrieval medicine. The need for a however, we should recognise that this assertion doctor on scene is comparatively rare (precise lacks robust scientific evidence. In comparison data would be valuable) and acquiring the with several other European countries, the appropriate skills and experience may be difficult involvement of doctors in pre-hospital care in outside of helicopter emergency medical services the UK is variable; in some regions, pre-hospital that cover a large population. Having acquired involvement is negligible. In many areas, the the skills necessary for pre-hospital practice, it is response to ambulance personnel requesting difficult to see how adequate ongoing experience medical assistance at the scene of a motor could be achieved unless the individual has the vehicle crash, for example, comprises a mobile opportunity to practice in another setting—that medical team dispatched from the nearest is, in hospital. How does the general practitioner hospital. The doctor on this team may be a with a pre-hospital interest acquire and maintain trainee in emergency medicine or anaesthesia skills in advanced airway management? Are who has received little or no training in pre- primary care trusts (PCTs) prepared to fund a hospital care. pre-hospital programme of training and super- Doctors who commit to providing pre-hospital vised experience lasting for up to 2 years? Will care should be trained appropriately. In line with the PCTs have resources to fund increasing other medical specialities, such training should involvement of doctors in pre-hospital practice? be competency based and subject to revalidation. With appropriate training, pre-hospital practi- In an attempt to improve and standardise pre- tioners could become involved in the transfer of hospital care by doctors in the UK, Mackenzie critically ill patients between hospitals. These and Bevan propose the establishment of the new practitioners are more likely to be those with an sub-specialty of pre-hospital and retrieval med- in hospital primary specialty, such as emergency icine. It is suggested that the curriculum for this medicine. Regionalisation of specialist services subspecialty would be agreed by the Faculty of such as trauma will necessitate more patient Pre-hospital Care of the Royal College of transfers from the receiving hospital to the Surgeons of Edinburgh, the Faculty of Accident regional centre. The receiving hospitals often and Emergency Medicine (FAEM), the Royal struggle to release skilled personnel (usually College of General Practitioners (RCGP), and the anaesthetists) to undertake prolonged transfers. British Association for Immediate Care By taking on this transfer work, the pre-hospital (BASICS). As rapid sequence induction of specialist would have the opportunity to main- http://emj.bmj.com/ anaesthesia and tracheal intubation is consid- tain skills at the same time as creating a more ered to be one of the key pre-hospital interven- viable business case for PCTs. tions that can be undertaken by a properly Timely pre-hospital interventions by doctors, trained doctor, but not a paramedic, it would which cannot be undertaken by paramedics, may seem sensible to include the Royal College of improve the outcome for some patients; how- Anaesthetists (RCA) in these discussions. ever, we should recognise that this assertion Recently, collaboration between the RCA and lacks robust scientific evidence. If a subspecialty on October 1, 2021 by guest. Protected copyright. FAEM has resulted in the development of an of pre-hospital and retrieval medicine were to be emergency airway course, which introduces developed, audit and research would be one of its emergency physicians and anaesthetists to the important functions. skills and decision making needed for rapid Competing interests: none declared sequence induction and intubation.1 This course will be relevant to the pre-hospital practitioner. If pre-hospital practitioners are to acquire and REFERENCE maintain advanced airway skills they will benefit 1 Nolan J, Clancy M. Airway management in the emergency from the co-operation of anaesthetists. department. Br J Anaesth 2002;88:9–11.

www.emjonline.com Commentary from BASMeD 295

......

PREHOSPITAL CARE Emerg Med J: first published as 10.1136/emj.2004.020636 on 23 March 2005. Downloaded from Commentary from BASMeD Debate JScott

am grateful to have the opportunity to provide medical directors, we would expect benefits from a commentary on this paper, responding on such a development, and if benefits were Ibehalf of the membership of the British demonstrated, then it is hoped that funding Ambulance Services Medical Directors Group and support would follow. (BASMeD). The principles of a competency based frame- There is clear support from the membership work are to be applauded. However, the aca- for the idea and principles in the paper. BASMeD demic support should not be narrow but as particularly welcomes the opportunity that this widely based as possible, being intercollegiate. paper provides to stimulate the debate, but There is a need to break down professional would like to emphasise that the paper should barriers, and this proposal must not be allowed not be seen as an endpoint. The need for a sub- to create divisions or fragmentation. As medical specialty and linkage to ambulance trusts is directors, we work across many professional overwhelming, but in striving for that goal, any groups, particularly in the rapidly developing or change must not alienate those doctors providing evolving ambulance provision. If this proposal is real and additional clinical care for patients, to succeed, we need to think beyond the concepts often before the ambulance response arrives. of the major incident or serious incident, and There is a particular need to establish clinical include the whole range of resuscitation skills standards (individual competencies/proficien- coupled with the more minimalist interventions cies) with regulation of those who aspire to required in the provision of out of hours, practise to those standards. There is certainly a telemetric, or virtual medical support to ambu- need to ensure that examination points are lance trusts and their staff. There should be consistent and that there is equity of clinical professional links established to those staff standard throughout the body of doctors provid- providing other aspects of ambulance response, ing services to support ambulance work. be that paramedics, nurses, or doctors. Who should regulate this sub-specialty? There So what, if any, are the downsides? The title of is presently a vacuum that must be filled before the sub-specialty strikes a discordant note. yet more fragmentation occurs. Medical directors Colleagues in BASMeD were unhappy with the of ambulance services with a governance "hat", use of the word ‘‘retrieval’’. Only one alternative require, probably more than any other group, name was suggested: ‘‘early emergency inter- the creation of a sub-specialty, not only for ventional care’’. The present title of the sub- their own clinical practice, but as managers of specialty is not supported. a publicly funded clinical service. The sub-

The paper challenges us and does indeed open http://emj.bmj.com/ specialty must not detract from the voluntary the debate. Let us not close the door just because aspects of the existing immediate care groups, but should ensure consistent standards of care, it seems to touch a nerve; BASMeD must engage facilitating much needed education, research, in this debate or be left behind, and that would and audit across lines or disciplines of service harm patient care. BASMeD supports the debate provision. and congratulates those who have set the fox To that end, the sub-specialty is essential to among the chickens; let us now together build a develop governance, but there has to be a coop for the future, providing a way of life for on October 1, 2021 by guest. Protected copyright. pragmatism that recognises the real world of both foxes and chickens. targets placed on all health economies. As Competing interests: none declared

www.emjonline.com 296 Carlin

......

PREHOSPITAL CARE Emerg Med J: first published as 10.1136/emj.2004.020636 on 23 March 2005. Downloaded from Debate Commentary from BASICS Scotland BCarlin

here is unanimous agreement that there is a standards referred to in this paper, particularly need to further improve pre-hospital emer- the FIMC, were rigidly applied, it would be Tgency care (immediate care) training, but impossible for rural practitioners to meet them. strong disagreement that the core activities that The likely consequence is a fear of litigation that define the clinical practice of immediate care would stop rural practitioners practising immedi- have remained unchanged over the past ate care altogether. It is felt by BASICS Scotland 40 years. In Scotland, and other areas of the that this would be extremely detrimental to UK, the standard and availability of training has patient care in Scotland and other rural areas. increased dramatically in the past 10 years. More The reality of life for rural practitioners is that recently, there has been a significant improve- training is mostly based on advanced life support ment in the provision of equipment. As a principles. Because of geography and time con- consequence, a broader range of interventions straints, any more elaborate training would be can be undertaken by a large number of totally impractical. practitioners with more skill, more knowledge, It is also felt that if a specialty is to be better equipment, and within a well defined developed, then more opportunities should be system of care. created for our ambulance and nursing collea- We would question the number of situations gues to gain further qualifications in this area. requiring skills greater than those of the The proposals as suggested are too doctor immediate care trained general practitioner. centred. This is especially true in urban areas, where time It is felt that the paper did not produce any to hospital is short and prolonged entrapment evidence to justify the argument that there is a rare. It has to be remembered that as well as the need for a significant amount of training beyond immediate care training, such practitioners have that currently taught on immediate care courses. already had a minimum of 9 years of medical We would like to see any evidence of which we training before they enter independent general are not aware that justifies the increase in practice. This delivers a level of expertise well training and the time that would be required to above standard UK paramedic training for most undertake such training to develop enough pre- conditions. hospital and retrieval medicine specialists to The reality of the delivery of pre-hospital care in Scotland is that because of the large propor- provide a service across the UK. Just what tion of rural areas, many general practitioners exactly are the additional critical care skills that and rural nurses are actively involved. These will have a major impact in terms of early practitioners have a large number of demands on diagnosis, meaningful interventions, triage, or http://emj.bmj.com/ the limited amount of time they have available advocacy? for education and training. If many of the Competing interests: none declared on October 1, 2021 by guest. Protected copyright.

PREHOSPITAL CARE Commentary from BAIC DZideman

hank you for requesting a commentary long recognised the need for the ‘‘licensing’’ of directly from the British Association for practitioners and introduced an accreditation TImmediate Care (BASICS). BASICS is always programme that has been running for over delighted to consider any proposal that improves 6 years. The programme encompasses a wide the delivery of immediate care in the UK. range of practitioners. It recognises that the In this article, the authors have provided a vast PHEC course is a minimum standard and we array of proposals, culminating in a licensing have always encouraged regular responders to system for practitioners of immediate care based undertake the Diploma examination. Further- on an examination system. Our association has more, it recognises experience. We have always

www.emjonline.com Commentary from BAIC 297

...... discouraged the use of untrained staff to work in development and implementation of a compe- the pre-hospital environment. Unfortunately, tency based accreditation system. This would Emerg Med J: first published as 10.1136/emj.2004.020636 on 23 March 2005. Downloaded from there seems to be a persistent misconception allow individual practitioners to develop their Debate that hospital A&E staff, many of whom hold skills along the line that was of particular high academic qualifications, can simply and interest to them and of relevance to their own instantly adapt their practice to the out of individual practice. If enough practitioners regis- hospital environment. This misconception must tered on a competency based system in a be corrected, and only trained and accredited particular area, then cover could be sustained, individuals be sent to a pre-hospital incident. tasking would be appropriate, and there could be BASICS, in using its accreditation process, has development of team practice together with team also recognised the large number of practitioners training. Individuals with a declining skill base needed to provide even the most rudimentary could be supported through sparse times, and immediate care assistance. We have repeatedly local schemes would become empowered to undertaken recruitment drives to encourage make treatment and management recommenda- those interested in immediate care to register, tions based on hard evidence of good practice train, and become accredited. We do have to rather than an aging examination certificate. concede that there are vast areas of the UK, both This approach does not hinder the few who wish urban and rural, that do not have this type of to make a primary career of pre-hospital medi- voluntary emergency medical cover, and rely cine, who should follow a pathway similar to totally on the skills of the ambulance service that described by the authors in the manuscript, paramedics and technicians. BASICS has had to thereby becoming the true ‘‘consultant’’ in this recognise that, although an examination based field. accreditation process would be ideal, this could Finally, our association has, on a number of result in a large number of very experienced occasions, examined the terminology of the title practitioners becoming non-operational. Instead, of this sub-specialty. We have remained with the we have continued to encourage those interested term ‘‘immediate care’’, as we believe that this in immediate care practice to train, to update, most accurately describes the work that our and to honestly assess their level of participation. membership undertakes. Although there was It is essential that immediate care practitioners some confusion with ‘‘intermediate care’’, this should only practise within the boundaries of now seems to have passed, following some their training/experience. This does lead to a careful explanation of the differences. The variation in the level of accreditation, but we terminology proposed by the authors of ‘‘Pre- have to recognise that immediate care is such a Hospital and Retrieval Medicine’’ would seem to huge subject, covering a vast geographic envir- onment, that it would be foolhardy to expect a limit the scope of practice and is also open to large number of highly trained, experienced misinterpretation. However, we do support the individuals to be instantly and constantly avail- proposal of a specialty recognised for its true able throughout the UK. worth and value in saving and preserving life in If immediate care is going to progress, then this complex, unpredictable, and difficult envir- our association, apart from supporting the onment. http://emj.bmj.com/ examination system, would wish to see the Competing interests: none declared on October 1, 2021 by guest. Protected copyright. PREHOSPITAL CARE Commentary from FAEM AMcGowan

rs MacKenzie and Bevan are to be con- accurately identifies the importance of the new gratulated for producing a thoughtful and Postgraduate Medical Education Training Board Dthought provoking article. They present a and the supervision of a new style of medical very strong case for further strengthening train- education with competencies at its centre. ing and quality assurance of training in pre- The paper is inaccurate, however, in stating hospital and retrieval medicine. that license to practise will be specialty specific. The Faculty of Accident and Emergency This is not the case. The license to practise will Medicine fully accepts the need for ongoing be a license to practise as a doctor, not as a improvement in this area and would be very glad specialist. of the opportunity to work together with other The changes in supervision of medical educa- relevant bodies to this end. tion occur at the same time as changes in the We are in a time of substantial change in the provision of healthcare. Reconfiguration of hos- provision of healthcare in the UK. The paper pital services seems inevitable. Implicit in this

www.emjonline.com 298 McGowan

...... will be an extra burden of patient transfer from anaesthesia, or a variety of other treatments for one hospital to another. The burden of providing a single casualty or major incident. It is difficult Emerg Med J: first published as 10.1136/emj.2004.020636 on 23 March 2005. Downloaded from Debate this service is likely to fall on anaesthetic, critical to see how this situation will change in the short care, and emergency medical services. The to medium term. Pre-hospital care must remain implications of the proposals in this paper for an integral part of specialist training in emer- these services need further exploration. gency medicine. The scale of pre-hospital care is enormous. This paper clearly identifies the need for Almost every day, an ambulance service some- rigorous standards, clear curricula, and robust where in the country will ask for a doctor’s help. assessment processes in ensuring the necessary We should also remember that pre-hospital care competencies for practice in this area. It seems to will include work with voluntary aid societies, me to make a better case for strengthening care at equestrian, sporting, and motoring existing curricula and structures than it does for events, and membership of mountain and cave the establishment of a new specialty. rescue teams. The Faculty of Accident and Emergency Voluntary immediate care schemes offer Medicine would, however, be very pleased to invaluable support to ambulance services, but enter into dialogue with the Faculty of Pre- provision of cover for the whole country is Hospital Care and other relevant bodies in not available, and in the absence of such further exploring this important issue. comprehensive cover, any emergency depart- ment may be asked to provide analgesia, Competing interests: none declared

PREHOSPITAL CARE Commentary from the Royal College of Surgeons of Edinburgh B Steggles, K Porter, R Fairhurst http://emj.bmj.com/ he consultation paper by Drs Mackenzie and It is anticipated that passing the Diploma in Bevan is timely, and complements the Immediate Medical Care will be the main criteria Tpreliminary work already undertaken by for entry into what will be up to a 4 year training the Faculty of Pre-Hospital Care and the Royal programme, with the Fellowship in Immediate College of Surgeons of Edinburgh to establish Medical Care being equivalent to the exit immediate medical care as a recognised medical examination in other specialties. specialty. We are also in discussion with ‘‘Skills for on October 1, 2021 by guest. Protected copyright. This is a complex procedure, and will require Health’’ and other relevant agencies to determine the co-operation and support of the relevant expected competencies in the pre-hospital arena, stakeholders, academic bodies, and politicians to and the work by MacKenzie and Bevan supports gain inclusion into the European Specialties this initiative. Medical Order. Competing interests: none declared

www.emjonline.com