Emergency Medical Services in New Zealand - Clinical Education - Post NAOTS (1999-2008)

Post NAOTS (1999-2008)

Following closure of the National Training School and disbanding of the New Zealand Ambulance Board which had previously published the National Authorised Patient Care Procedures each service took on responsibility for its own clinical education and standing orders (patient care procedures) which would further aggravate regional differences and ultimately, help lead a return to nationalised clinical education.

In 1999 a program of "Intermediate Care Upskilling" was introduced by St John (initially in the Auckland District ) to equip selected ICOs with adrenaline, morphine, naloxone and (at the time) metoclopramide. This distinct training package was not part of any formal qualification . St John also merged the two Post-Proficiency modules back into one education program at some point during this time so that an officer became qualified in both portions of Intermediate Aid concurrently . Wellington Free Ambulance chose to adhere to the original Post-Proficiency module design thus retaining two distinct practice levels (cardiac and IV/cardiac). They also developed their own upskilling program known as "advanced life support" consisting of two modules, A and B; module A contained cardiac arrest drugs (at the time adrenaline, atropine and lignocaine) while Module B provided intravenous pain relief along with naloxone and metoclopramide .

To coincide with introduction of the various upskilling packages in the early 2000s there was a move away from the once nationally consistent qualification titles (Ambulance Officer, Intermediate Care Officer, Advanced Care Officer (Paramedic)) that existed under the National Training School to the introduction of new titles into each of the services. St John renamed Intermediate Care Officer to "Paramedic" and Paramedic (ACO) to "Advanced Paramedic" in 2001 along with a new national uniform . Wellington Free Ambulance chose to rename all staff qualified at National Certificate (Proficiency) or Intermediate Aid to "Paramedic" and their Paramedics (ACOs) to "Intensive Care Paramedic" . There is anecdotal suggestion that the renaming of staff who did not hold the full National Diploma/Advanced Aid to "Paramedic" was due in part to the high media profile of programs such as Third Watch and Rescue 911 which glorified and glamorised the role of "Paramedic" thus giving the public an expectation that they, as on TV, should be attended to by a "Paramedic". It has also been recorded that the move to rename Intermediate Care Officer to "Paramedic" on the part of St John was somewhat motivated by their desire to expedite contract negotiations with the Ministry of Health and ACC which required a certain number of "Paramedics" however it can be logically assumed that the contract did not actually define what a "Paramedic" was, as the original definition of a Paramedic in New Zealand was somebody qualified to National Diploma/Advanced Care level .

With the demise of NAOTS; Auckland Institute of Technology, having been awarded University status and renamed Auckland University of Technology, developed the Bachelor of Health Science (Paramedic) degree while Victoria University (Melbourne) partnered with Wellington Free Ambulance to create a tertiary Paramedic degree administered through Whitireia Community Polytechnic. In 2003 St John began to require completion of the Bachelor of Health Science (Paramedic) for those staff who wished to moved to the Advanced Life Support (Advanced Aid) qualification level . Wellington Free introduced an "Intern Paramedic" position in 2004 to accommodate staff who would completing the Degree while also working on the road at the same time .

By the late 2000s there was a need to once again bring reform to clinical education; and although not as marked as those introduced during the time of the National Training School the following issues needed urgent attention

• Introduction of tertiary degrees and the apparent double standard this created compared to more technically focussed vocational qualifications centred around a narrow scope of knowledge ; coupled to this the ongoing viability of NZQA Unit Standards as a realistic platform to deliver comprehensive paramedic education (many felt they had outlived their useful life for higher practice levels)
• Moves by comparative jurisdictions in Australia totally towards tertiary education only
• The lack of a distinct qualification for the intermediate tier practitioner; originally the Certificate in Intermediate Aid was awarded upon completion of the ICO course however with the introduction of the National Certificate and Diploma in 1995 there was no longer a distinct external qualification for this level and this was even more true for the "upskilled" provider as this was an internally run course
• The need for structured ongoing clinical education once a qualification had been gained
• The very low completion rate of the National Certificate by volunteers (19%) when considering the goal of NAOTS had been to qualify all Ambulance Officers to the "basic" level (originally Proficiency but later National Certificate)
• Increasing complexity of ambulance practice beyond "scoop and run" and early Paramedic practice focussing mainly on early defibrillation/cardiac arrest and trauma care
• Increasing chronic disease,
• Impracticality of delivering all patients to a hospital emergency department, particulary in the face of increasing chronic disease or mental health problems which are not ideally handled in an acute presentation to ED.
• Increasing public expectation (see above)
• Inconsistency between service providers' levels of practice and the requirements of a newly introduced Ambulance Sector Standard which defined three levels of practice (discussed below)
• The long held view (since 1993) that Paramedics should be registered health practitioners in their own right .

The 2007 Health Select Committee report into the provision of ambulance services and the resulting National Ambulance Service Strategy included requirements to "achieve national consistency" in ambulance education and scope of practice (clinical competency) . St John had during this time developed a draft "Operations Competency Framework" which would become the foundation of more recent developments ; specifically the replacement of the National Certificate, the requirement for all the various intermediate level officers to transition to a new "Paramedic" level which would approximate the "Upskilled Paramedic (ALS-A/ALS-B)" levels and become a Degree course, the development