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Competence and curriculum framework for the emergency care practitioner

29 September 2006

Dear Sir

Our comments on the curriculum framework proposed for emergency care practitioners follow our detailed responses to the consultations on the development of curriculum frameworks for similar extended roles for non medically qualified practitioners, including the surgical care practitioner (16.6.05) and the medical care practitioner (10.2.06).

We acknowledge that there are a number of non medically qualified practitioners currently undertaking similar roles to those envisaged for emergency care practitioners. We recognise that such roles should be formalised and could be developed further. However, we have major concerns about the proposed development of this grade not least because we believe some crucial questions remain unanswered.

Our members’ main concerns about the proposals for the extended role include:

• Assumptions behind the workforce and workload planning have not been fully discussed or debated
• There has been no full evaluation of the effectiveness of the new roles
• The regulatory framework has not been fully established
• The curriculum has not been fully formulated or validated
• Training will be in direct competition with medical trainees
• The new roles will require supervision by medical practitioners, the supervisory, assessment and mentoring functions of which have yet to be clarified
• The public has not been fully informed of the grades, competencies and functions of the new role
• Lines of accountability and responsibility for patient care have not been clarified
• Implications of the proposals for a physician delivered service have not been clarified

To date we have yet to receive assurances from the Department of Health that the concerns we have previously expressed concerning other types of medical care practitioners are being addressed. There is a need for evidence on medical care practitioners which includes an evaluation of the medical care practitioner as a concept; we believe this should include an evidence base to support the projected number of practitioners that will be trained. We recognise that a number of non medically qualified practitioners with extended roles are already employed in NHS trusts. We would nonetheless welcome evidence of their effectiveness from current healthcare practitioners and those interested in healthcare training as well as evidence that shows a real demand for additional posts.

We believe that to ensure that the competencies and limitations of the emergency care practitioner, and similar roles, are known by other healthcare practitioners it will be important to gain the acceptance of the role by the medical profession, other healthcare professionals and patients. We do not believe that the consultation process for the development of the competence and curriculum framework for the emergency care practitioner has fully engaged with medical professionals and are concerned that stakeholders have not been consulted adequately. We therefore call for further consultation with the medical profession, patients and the public on the way forward for this group of practitioners to ensure that the future delivery of healthcare and development of a service with care practitioners fulfils patient need.

Our more detailed comments to this consultation are attached.

Yours sincerely
Sally Watson
Director of Representational and Political Activities

Competence and curriculum framework for the emergency care practitioner

Curriculum framework for the ECP as the basis for the development of educational programmes
We recognise the skills of non medically qualified practitioners differ from those of medically qualified practitioners and that a diversity of skills can enhance patient care however, we believe that skills should complement rather than compete with those of medically qualified practitioners.

The skills of doctors in training are not currently being used to best effect. Some tasks that could be more appropriately performed by healthcare professionals are being undertaken by doctors, in particular doctors in training. It is right that enhanced roles for non medically qualified practitioners be investigated however tasks undertaken should be properly identified, defined and procedures in place for supervision and support. Their role within the healthcare team should be properly defined.

We are concerned that medical students and doctors in training will compete for the same education and training opportunities as emergency care practitioners (both those in training and trained) and that this competition will further limit training opportunities. We are concerned that deskilling of the medical workforce may result as doctors in training have difficulty in achieving required levels of competency in medical procedures. It is reasonable to suggest therefore that the similarities in the two roles raise concerns about fulfilling the aim of a physician delivered service.

Entry routes to the ECP programme
There is a need to demonstrate that the new roles of care practitioners are required in the current health service. There is a need for an evaluation of the emergency care practitioner as a concept; we believe this should include an evidence base to support the projected number of practitioners that will be trained. Workforce planning is essential not least due to the current reports of unemployment amongst junior doctors in training and the reduction in the number of specialist nurses employed. The BMA has called for medical training to be reformed, but not at the price of an exodus of junior doctors from the NHS [go to note 1]. The Royal College of Nurses have also recently reported concern about loss of skills through specialist nurses being targeted to reduce mounting NHS debts [go to note 2].

We believe that all emergency care practitioners should be required to attain nationally agreed standards of competency which will allow them to practice competently in all aspects of their role. We seek assurances that all emergency care practitioners will undergo the same rigorous training to ensure they provide a consistent standard of care and that other healthcare professionals and patients will be able to easily recognise the training level of the practitioner caring for them.

If the purpose of the emergency care practitioner role is to create medical generalists then we believe that trainees will have neither sufficient time during their proposed training to gain in-depth knowledge not the broad-base medical degree required to practice to a competent and safe standard. The roles will invariably become specialists within a limited clinical sphere of expertise as is the case with community matrons for example.

Doctors are required to undertake rigorous medical training for five years or more prior to registration with the GMC and then undertake at least four further years of post graduate training. Medical students incur significant levels of debt [go to note 3] and we believe that the proposed entry route for the emergency care practitioner may seem more attractive than that for doctors. This may have serious implications for the long term provision of healthcare by practitioners caring for them.

The core competencies at qualification
We note that the role of the emergency care practitioner includes reference to care being ‘patient-focussed, in the least intensive and most convenient and appropriate place for the patient’. We believe that it is of greater importance is for appropriate care delivered by an emergency care practitioner who is within their competencies and within the boundaries of patient safety.

Of further concern is the suggestion that emergency care practitioners could provide an alternative model of delivering unscheduled care out of hours or provide an alternative model of delivering prison healthcare and custody suite health care. We are extremely concerned that such specialist services would be provided by non medically qualified practitioners. We believe that non medically qualified practitioners should not practice in these environments without properly identified, defined procedures and that medically qualified practitioners should provide direct supervision at all times.

We are also concerned that the emergency care practitioners will be able to prescribe drugs. We believe that access to a prescribing formulary by non medically qualified practitioners should be limited. In our view it is only with the considerable training which medical professionals undertake that the depth and breadth of knowledge to understand how different drugs interact with each other and within the context of differing pathologies can be understood. Training levels should be appropriate to the drugs that professionals have access to and should be subject to similar levels of supervision and audit as medical professionals. There should be a requirement for practitioners to demonstrate on-going competent evidence based prescribing together with the knowledge that practitioners are accountable for the consequences of their prescribing decisions.

Core clinical skills which the ECP needs to demonstrate
Medically qualified practitioners have undergone the highest levels of medical education and training, which enables them to respond to the unexpected and to recognise when they have reached the limits of their expertise. Without the breadth of knowledge that doctors have, we are concerned that emergency care practitioners will not always be able to diagnose illness accurately, know how to deal with the full range of problems that can occur during a patient’s treatment, know when and how such problems may interact with each other and know when to refer. We are concerned that patients will be treated by practitioners who do not have sufficient medical knowledge or skills to treat them as they have not undergone the intensive medical training necessary to practise safely.

The most important characteristics of a medically qualified practitioner is their ability to make a decision about what is the most appropriate medical response to a condition, to know how to respond to the unexpected and to have a clear idea of the limitations of their experience and hence when to call on the expertise of others. Medical practitioners develop these skills over several years during their medical training. We believe that it is the achievement of the appropriate level of competency that is significant and not the time spent training however, the time spent training must be of sufficient length and standard to provide skills for safe and effective practice.

We do not believe that the required competencies for emergency care practitioners can be achieved through the proposed training programme of 300 hours of theory and 700 hours of clinical experience. We would welcome further information about how these figures were arrived at and what additional support will be in place should the proposed training be inadequate for trainees to reach the required levels competency. We are concerned that trainees will be expected to make ‘best use of the opportunities available without imposing upon patients’. There are existing models of professional learning and development which should be used to ensure that trainees develop learning opportunities from clinical practice effectively and acquire the necessary competencies without compromising patients.

We note that emergency care practitioners will be required to ‘undertake physical examinations based on a whole systems approach, taking full and appropriate patient history using a medical model’. It is our understanding that such a requirement is that of a medically qualified practitioner who is registered with the GMC. We do not believe that six months training will equip emergency care practitioners with the necessary skills and level of competency to function proficiently or safely within the healthcare setting.

We note with interest the national audit figures for the ECP Leads Network. Whilst 76 per cent of cases were dealt with by an emergency care practitioner may have been ‘unaided’ we would ask for further information on the proportion of those cases that were diagnosed fully and correctly. We would also question the time spent with patients. The framework suggests that the role will ‘improve capacity and efficiency across the emergency care network’, with reference to this and that ‘similar roles spend 39 minutes interacting with a patient’, we would ask for evidence as to how this is measured for the purposes of cost versus clinical effectiveness. We would welcome publicly available data of a full evaluation of the effectiveness of emergency care practitioner pilot schemes.

Core clinical conditions which the ECP will meet in practice and the level of competence required
The competencies set out in the framework suggest a broad based educational curriculum similar to that of undergraduate and postgraduate medical education. This would seem at variance with the intention to establish a grade and fulfil a need which is different from medically qualified practitioners.

Arrangements for teaching and supervision
We would welcome evidence that current healthcare practitioners working in all the clinical settings described in the framework are able to, and want to take on the clinical management responsibility for emergency care practitioners. There appears to be a lack of clarity as to who will be responsible for the management, appraisal and professional development of the new roles in the various clinical settings described in the framework.

We are concerned that the lines of both professional and clinical responsibility have yet to be fully defined. We believe that emergency care practitioners should be accountable to their regulatory body and their supervising medically qualified practitioner. There should be clear management structure to support both the emergency care practitioner and the supervising medical practitioner. It is not acceptable for the level of autonomy and supervision to be described as ‘broadly defined’. We believe that supervision should be defined as ‘under close supervision of a named medically qualified practitioner’.

There is a need for medically qualified practitioners to determine the clinical roles and responsibilities of emergency care practitioners in training and practice. We reiterate that procedures should not be undertaken without appropriate medical supervision. It is essential that the medically qualified practitioner retains ultimate clinical responsibility for patients in their care, however, emergency care practitioners should be accountable for their own practice.

The knowledge base proposed for emergency care practitioners appears to indicate that there may be scope to further expand the role in the future. We are concerned that in the future, procedures may be undertaken outside the remit of the original proposals and welcome assurances that this is not the intention.

We would welcome a commitment within the curriculum framework for non medically qualified practitioners in extended roles be supported in a fully funded programme of continuing professional development throughout their training and development.

Underpinning all our comments on the arrangements for the teaching and supervision of emergency care practitioners is for the training of medical students and doctors in training to remain uncompromised.

Methods of assessment, pre and post registration and national support structures
Education and training for emergency care practitioners must be subject to rigorous and nationally agreed quality standards and recognised qualification and levels of competency. We understand that there may be differences in the development of similar roles between England and Wales, Scotland and Northern Ireland however there need to be mechanisms in place for recognising common competencies to ensure transferability of skills at an agreed standard.

We believe that mechanisms need to be in place to asses the competencies of emergency care practitioners and believe that there should be appropriate training provided for trainees who fail to meet the required assessment criteria. We believe that there should be limits set for the number of times a practitioner can retake assessment components where there has been a previous failure to meet the required assessment criteria. There should be further consultation on who will undertake assessment and what impact there will be on patient care.

Title for the new role
The BMA is concerned about the proposed titles of non medically qualified roles, including those referred to as ‘emergency care practitioners’. We believe that such post holders should be called ‘assistants’ which more clearly identifies the role as non medically qualified and is in line with international practice, most notably in America. We note that the working title of medical care practitioners has been replaced by ‘physician assistant’ in the recent publication [go to note 4] ‘the competence and curriculum framework for the physician assistant’ (28.9.06). We seek assurances that the title ‘physician assistant’ will be used as a working title nationally and until such time as there will confirmation by the regulator following consultation about the title with medical professionals, patients and the public.

It should be noted that patients are required to give informed consent for any procedure to be undertaken. We recognise that informed consent is not always possible in an emergency medical situation; however, it should always be made clear to a patient that emergency care practitioners are not medically qualified and patients should have the right to treatment by a medically qualified practitioner if they wish. Patients should know when they are being treated by a doctor and when they are not.

We are concerned that patients and the public are not and will not be aware of the level of experience of emergency care practitioners and believe that further consultation should be undertaken with the public, patients and medical professionals about the role, function and competency of the new roles.

Proposed regulation of the new role
We note that there is currently no statutory regulation of the grade. We are concerned that registration will be voluntary with the onus on the emergency care practitioner to provide evidence of continuing professional development and re-assessment. We would welcome further consultation on the assessment, accreditation and standard setting by the regulatory body for the role.

We believe there is a need to ensure that emergency care practitioners, as with other healthcare professionals, retain the required competencies of their role and adhere to the required standards set out in the curriculum framework. We believe that there should be a requirement for all practitioners to demonstrate ongoing attainment of the required competencies set out in the curriculum framework.

References
1 BMA calls for training programme delay to halt skills drain (26.9.06). Read more here.
2 Specialist nurses must not be soft targets in deficits crisis say RCN and Bowel Cancer UK (27.9.06) Royal College of Nurses. Read more here.
3 Medical student debt tops £22,000 (BMA annual medical student finance survey shows that students in the fifth year of medical school have an average debt of £20,172) BMA Press Release (19 December 2005).
4 The Competence and Curriculum Framework for the Physician Assistant Department of Health (27.9.06) Gateway reference 7043. Read more here.
Read more here.