Paramedics as GPs—working until the PIPs squeak

NHS England is developing proposals to train paramedics to become Paramedic Independent Prescribers (PIPs), and provide certain services performed by GPs. I understand the driver: there is a shortage of GPs. I understand the solution: paramedics are medically trained and can, I’m sure, deliver certain GP services. However, we need to be careful not to add unmanageable burden to ambulance trusts, many of whom are already struggling.

In December last year, The Guardian reported that three ambulance trusts rated their status as ‘critical’, just short of the ‘potential service failure’ rating, with more classified as under ‘severe pressure’. But don’t believe that this is simply some sort of Christmas-period issue. In July last year, The Spectator has reported “Figures from the London Health Board showed that 238 people left the London Ambulance Service (LAS) in 2013–14. Only 80 left in 2011–2012.”

My first response to the proposals was “What?! Aren’t they busy enough??” But, the proposals do, of course, have pros and cons. On the one hand, they may offer paramedics valuable career objectives to train and develop further. This may stem the exodus observed by The Spectator. They may also offer the NHS a cost-effective means of satisfying a never-ending demand—hugely desirable by government, doctors and patients. The consultation document says paramedics could be used in “Accident and Emergency Departments, GP practices, Minor Injury Units, Walk-in Centres and Out-of-Hours services“—five very busy health settings that need support.

On the other hand, they may take an already busy workforce and make it work harder, perhaps for unsustainably long hours. And the additional burden doesn’t end with the paramedic. The consultation document says: “Employers will retain responsibility for ensuring adequate skills, safety and appropriate environments for paramedic independent prescribing.” So, training and development costs will be for ambulance trusts to manage—not the beneficiary organisation (such as an acute trust or Clinical Commissioning Group).

The proposals deserve close study and careful answering. Supporting the NHS is important; supporting the ambulance service is equally important. If these proposals are introduced, it’s important that they don’t simply benefit one system at the expense of another.

Swiss localism

​The average household net-adjusted disposable income per capita in Switzerland is £18,390 a year, more than the OECD average of £14,318 a year. Not a very sexy opening sentence. However, with 79 per cent of 15 – 64 year olds in work, Switzerland beats the OECD average by 14 per cent—and those people are working 133 fewer hours per year than the OECD average. That’s not bad.

According to the OECD, compared to the United Kingdom, Swiss life expectancy is higher, water quality is better, work life balance is better, life satisfaction is higher, education outcomes are better—and the list goes on. All this, and they get great skiing, banks and chocolate.

Interestingly, they get this within a domestically competitive tax system too.

In the Global Competitiveness Report 2012, Switzerland was again named the most competitive country in the world. There are lots of reasons why this is the case. Its health, education and labour market environments are excellent. The government has run budget surpluses for the past eight years. It has a VAT rate of eight per cent (yes, eight), but interestingly to me is the domestic tax competition between its cantons.

Local freedoms

Local tax sovereignty in Switzerland leads to continual domestic competition. Following Zug in the 1960s, which began using its social security and taxation autonomy to offer businesses a competitive environment, cantons all over Switzerland have been competing to offer multi-nationals reasons to base their global or European headquarters there.

Currently, the combined federal, cantonal/municipal pre-tax rate in Lucerne is 11 per cent, with half of Switzerland’s cantons offering between 13 and 16 per cent. And this approach has been pretty successful, with companies such as Kraft, Google, Yahoo, Johnson and Johnson, Burger King, Seimens and many, many more all taking the Swiss up on the offer.

How about the UK?

​The Localism Act 2012 attempted to link local fortunes with business rates, but it does not offer the freedoms the Swiss cantons have.

The Business Rates Retention Scheme allows for 50 per cent of business rate revenue to be kept by local councils and 50 per cent by government. Section 69 of the Localism Act 2011 gave councils a new discretionary power to reduce business rates in specific circumstances—as long as it doesn’t qualify as state aid. The onus is on local councils here, who would have to market those potential discounts to the sorts of multi-nationals that are settling in Switzerland so regularly. I’m not sure that councils yet have that sort of expertise and experience.

​These new freedoms are still pretty new—let’s see how they do.