From Pinnacle: An Ambulance Service Without a Medical Director?

The acceleration of advanced paramedic degrees and doctorates in the UK has led to the point where a UK ambulance service no longer employs a physician as its medical director.

Jason Killens, chief executive of Welsh Ambulance Services, presented a talk Thursday morning August 15, 2024 at the Pinnacle EMS conference in Marco Island, FL, that outlined this transformative model and how it works.

There are 14 publicly funded ambulance trusts across the UK, said Killens. English ambulance services are commissioned by integrated Care Boards. The Welsh Ambulance Service University NHS Trust (WAST) is likewise commissioned by health boards responsible for setting care standards, funding and allocation.

WAST was formed in 1998, bringing together previously regional ambulance services. It’s had a “checkered history” according to Killens and in 2015 was “borderline” in quality measures. Performance challenges triggered a major turnaround and WAST is now in a position of system leadership and supporting the wider healthcare system, said Killens.

Paramedics in the UK earn baseline 3-year higher education degrees in addition to patient care skills to enter the profession. Following two years of observation, paramedics can enroll in post-registration experience to become advanced paramedic practitioners—other specialties include palliative care paramedic, high-acuity response paramedic, research paramedic and members of hazardous area response teams.

Paramedic Leadership Within WAST

An executive director of paramedicine sits on the WAST board and oversees assistant directors of clinical delivery, clinical development and research and innovation. Associate medical directors of acute care and community care advise on clinical practice matters. While physicians are advised there are none in leadership posts or in board positions.

A nurse also sits on the board as WAST employs roughly 300 nurses, said Killens.

Following the recent retirement of Dr. Brendan Lloyd from the post of medical director of WAST, the members of the trust’s board voted to remove the medical director role from the board. WAST is not mandated to have a medical director on its board, said Killens.

Board voting rights held by the executive medical director shifted to the director of paramedicine.

“Brendan’s retirement presented an opportunity to re-consider the leadership structure of our clinical directorate,” Killens stated at the time. “It is an opportunity to place greater focus on the further development of our paramedic workforce and to establish the necessary seniority and influence to enable and support the realization of our strategic ambitions. We will be the first UK ambulance service not to have a medical director on its board, but the Welsh Ambulance Service always has been in the vanguard of change and evolution.”

A key component of operations without medical directorship is increased decision-making ability by the service’s crews and call-takers to activate non-hospital pathways and scheduled visits rather than transporting the patient to the hospital emergency department, said Killens.

“We are planning to tip the service delivery model on its head,” he said. "We are on a journey of change and improvement."