After years of regulatory ambiguity, the profession of "paramedic" now has a state educational standard that defines the training, qualifications and competencies of specialists. This is the first serious step towards their real integration into the emergency medical care system, which has been suffering from an acute shortage of personnel for years. What will paramedics be able to do after the changes, will they help overcome the personnel crisis in Emergency Care and how close is Bulgaria to the European model.. The chairwoman of the Union of Paramedics in Bulgaria, Iva Pehlivanska, spoke to FACTI.
- Ms. Pehlivanska, the changes in the status of the profession of "paramedic" have already been published in the "Official Gazette". What has actually changed and why are these changes so important for the emergency care system?
- The most important thing is that the profession “Paramedic“ is now leaving the regulatory gray area in which it was for years. For the first time, Bulgaria has a state educational standard that clearly defines how paramedics are trained, what competencies they acquire and what they can do according to their level of qualification.
This is extremely important not only for the paramedics themselves, but for the entire emergency care system. Until now, the lack of such regulation has often served as an argument why these specialists cannot be fully integrated into the system, although it has been suffering from a serious shortage of personnel for years. For us, this is a big step forward. But I always emphasize that this is not the end of the reform, but its beginning. The real success will be when this standard starts to actually work for the benefit of the patient.
- For years you have been pushing for clearer regulation of the profession. Do you think that the state has now made a sufficient step forward, or is this just the beginning of a longer reform?
- The most important regulatory step so far has undoubtedly been taken. It is the result of nearly three years of work, dozens of meetings, opinions and conversations with institutions, often in conditions of political instability. We are grateful that the Ministry of Education and Science and NAVET ultimately supported this process.
But I would not say that the reform ends here. The most difficult part is yet to come - the implementation of the standard. Clear rules are needed for the transitional period, updating the curricula, real job openings and integrating new specialists into the system. Legislation already provides the basis. From now on, a consistent state policy is needed.
- What new powers will paramedics have after the changes come into force and which activities will they now be able to perform independently?
- For the first time, the competencies are clearly described in a national regulatory act. This provides certainty for both employers and the paramedics.
Paramedics with the third level will independently perform activities related to transporting patients, monitoring vital signs, preparing and maintaining equipment and working according to established algorithms. In more complex interventions, they work together with medical specialists.
Paramedics with the fourth level already have a significantly wider range of competencies. They can perform an initial assessment of the patient, provide emergency care within the framework of established protocols, and in the absence of a doctor, lead a team of paramedics and organize actions until the patient is handed over. This does not mean that they replace the doctor. It means that the state has finally regulated their professional role.
- Will these changes alleviate the chronic shortage of staff in Emergency Medical Care Centers, or does the problem remain mainly financial?
- The standard itself will not automatically solve the staffing crisis. But it removes one of the main obstacles to hiring paramedics. We are following the latest publications on the critical shortage of doctors in the system and on one of the national television stations, the Ministry of Health's opinion was clearly expressed that appointing paramedics to the vacant positions would alleviate the staff shortage.
But this problem also has a financial side. Remuneration, working conditions, professional development and public recognition are also extremely important. If these factors are missing, it will be difficult to keep young people in the system.
But without regulatory clarity, there was no way we could even begin to solve the other problems. Now we have this foundation.
- One of the big topics is training. Does the current system for training paramedics meet European standards and what else needs to be changed?
- The new standard was built with the idea that the training should be comparable to the European qualification frameworks. There is already a clear distinction between the third and fourth levels of professional qualification, the competencies and expected learning outcomes have been defined.
However, educational institutions are yet to bring their programs into line with the standard. It is no less important that the practical training be of sufficient quality and correspond to the real work in emergency care. A paramedic is not trained only in the classroom, but mostly through practice.
- Do you expect more young people to choose the profession after the regulatory changes, or will the low pay and difficult working conditions continue to discourage them?
- I think that a clear professional perspective always motivates people. When a profession has certain competencies, opportunities for career development and easier international recognition, it becomes much more attractive.
But we cannot be naive. If working conditions and remuneration do not improve, regulatory changes alone will not be enough. People want not only recognition, but also security for their future, a clear place in the system, opportunities for constant maintenance and improvement of qualifications, and advanced training.
- How will the interaction between paramedics, doctors and nurses change? Is there a risk of tension due to the expansion of powers?
- There is and has never been a reason for opposition. On the contrary - well-functioning emergency care is always a team effort and each of these specialists complements the others. The new standard does not take away competencies from any medical profession. It simply clearly defines the role of a paramedic. When everyone knows their responsibilities, tension does not increase, but decreases.
Our goal was never to replace doctors or nurses. The goal is for every professional to fully use their knowledge and skills in the interest of the patient.
- In many European countries, paramedics are the backbone of emergency care. How close is Bulgaria to this model and what still separates us from it?
- We are still at the beginning of this model. In many European countries, the profession has been clearly regulated for years, there is a sustainable model of training, professional development and implementation. In our country, this regulatory basis has been lacking for a long time.
Now we are taking the first necessary step. The next steps are the real inclusion of paramedics in the system, the effective use of their competencies and the development of a sustainable personnel policy. And it is high time we stopped fooling ourselves - there are clear statistics and data that in countries where emergency care is supported by well-trained and prepared paramedics, the mortality rate is many times lower. The doctor's place is in the hospital, the job of the Emergency Department is not to treat, but to stabilize a critical patient and quickly deliver him to a medical facility where they can help him. I can ask the critics of the model who claim that emergency departments should have doctors working in them - if you get into an accident, what would you prefer - a retired gynecologist to come to your aid, or a young paramedic trained to stabilize you and get you to the nearest hospital alive and with minimal risk of subsequent injury?
- What are the next steps after the publication of the changes in the “State Gazette“? Are new by-laws, training or changes in the organization of work necessary for the new rules to work in practice?
- Yes. Methodological guidelines on some issues of the transition period are to be developed, training institutions must bring their programs to the new standard, and employers must begin its actual implementation.
We - as the Union of Paramedics, will continue to work with the institutions and support colleagues with explanations and information.
In addition, we insist on greater publicity regarding the state of emergency care - the public must have access to data on staffing, response time, the implementation of new specialists and patient outcomes. Only when these indicators are public and measurable can the right management decisions be made.
Recently, I read in a media outlet the testimony of an eyewitness to an incident. The words struck me: “the medics wondered what to do, whether to put on an immobilization splint, or just put him in the ambulance“. Such things should not happen, but they do happen. We could tell dozens of such stories - and how neighbors are sought out to carry the sick, and how patients who should be immobilized, wrapped in blankets, are dragged along. It is high time for a sincere conversation and for acknowledging the problems, because they will not be solved if they are not acknowledged.
- If you had to name one change that is still missing, but is vital for the future of the “paramedic“ profession in Bulgaria, what would it be?
- If I had to choose just one, it would be a clear state strategy for the development of emergency medical care. A public, measurable vision is needed - how many specialists are needed, how they will be trained, how they will be retained in the system and how the quality of care the patient receives will be measured.
Ultimately, all these changes are not being made for the sake of one professional group. They are being made for people who, at a difficult moment in their lives, rely on someone to arrive on time and help them. It is the patient who must remain at the center of any reform in emergency care.