Emergency medical services systems in the European Union: report of an assessment project co-ordinated by the World Health Organization-Data book

This document is the result of a project whose aim was to describe and assess emergency medical services (EMS)
systems across the European Union (EU) and their links with national crisis management systems. Professional
standards, organizational structures and coordination mechanisms vary widely across EU Member States. A comprehensive EMS review was considered necessary in order to understand this variety and to identify gaps and possible means to improve harmonization and standardization. The project was co-financed by the Directorate General
for “Health & Consumers” of the European Commission and the World Health Organization (WHO) Regional Office
for Europe.
The project aimed: (i) to develop a standardized template for use as a data collection tool in order to facilitate
country comparisons and the compilation of an essential information package; (ii) to map current EMS preparedness within EU Member States including existing institutional, educational, operational and human resource capacity; and (iii) to collect data on existing crisis management mechanisms to manage health threats. Close
collaboration with all 27 EU Member States was considered an important prerequisite for successful implementation of the project and WHO formally requested the appointment of a national representative (NR) from the Ministry
of Health in each State. A group of EMS experts, with knowledge and expertise of the subject, was also selected.
The first phase of the project involved the development of a standardized template to collect general information
and data on EMS across EU Member States. NRs were requested to complete the questionnaire online and WHO
supervised the completion of data gathering and ensured finalization. Data from the 27 countries were compared
and matched with the aim of finding common features or possible gaps in the organization of EMS in EU Member
States.
The group of experts and all 27 NRs met again in Lisbon, Portugal, in December 2007. This meeting provided an
opportunity to review progress in data analysis and to agree the main conclusions from the study. Recommendations for improvements in the field of EMS were also discussed and voted on in Lisbon.
The objectives of the project were very ambitious and EU Member States and various stakeholders highlighted
their concern in this regard. The difficulty of assessing EMS links with national crisis management systems in the
absence of any previous EU-wide study of these national systems was raised. Another major limitation of the project is that all data have come from NRs appointed by Ministries of Health. This sometimes proved to be a constraint especially in those EU Member States where the organization and management of health-care provision are
delegated to sub-national authorities. A problem was also encountered in the attempt to promote a standardized
study, seeking comparable data using unique and common definitions. On the positive side, the project has followed a highly participatory methodology with reasonable levels of interest and motivation from the majority of participants; moreover the project utilized experts in the field of EMS to peer review the work carried out.
This book is divided into five chapters: legislation and financing; out-of-hospital EMS; in-hospital EMS; education
in EMS; and crisis management and EMS systems.
The main result of the study has been to underline the importance of an organic and comprehensive set of rules
and laws governing the organization and structure of a fundamental health care service and its integration within
the whole health system. Given this finding, WHO Regional Office for Europe is investing resources to help all EU Member States develop effective coordination mechanisms at a multisectoral level for crisis preparedness and response.
With regard to out-of-hospital EMS, two main concerns were raised by participants: (i) the need to develop performance indicators of an international standard. The application of these indicators to different EU EMS systems
could provide the data necessary for benchmarking, comparison and cost-effective optimization of the system; and
(ii) the need for greater awareness of 112 as the European emergency call number is necessary to ensure successful implementation, particularly in those countries that have not adopted 112 as the unique emergency call
number as yet. The foremost value of EU Directive number (91/396/EEC) is its clear statement of the need to prevent misunderstandings and delays in accessing EMS for all EU citizens.
In considering in-hospital EMS settings, it is evident from the study that hospital-based services play a crucial role
in Europe and the EMS system should be thoroughly evaluated for its effectiveness and quality, from the perspective of both public health and financing issues.
A key observation of the study is that the adoption by all EU countries of a common core curriculum, as the basis
for an emergency medicine (EM) speciality, would the most suitable way to meet the EU Doctor's Directive and
assure free exchange of EM physicians between EU countries. The situation of other cadres of professional medical staff is more complicated: the role, competencies and educational requirements of nurses and paramedics
or technicians are substantially different across countries, to the extent that achieving standardization and quality
improvements are unrealistic at the present moment.
In conclusion, EMS systems in the EU still need to find their place in the mechanisms for disaster preparedness
and response in many countries. Although rescue and first-line medical care to victims is the primary objective of
all emergency services in a disaster, the role of EMS in the EU appears marginalized in the coordination and command framework. Preparedness planning is insufficient if simply carried out at the level of each health service. It
should involve the whole EMS system at national or regional level, integrated into the whole health system and in
full coordination with other emergency services. International agreements can be effective only if and when they
are translated into practical protocols that have been tested and shared by all stakeholders.
Finally, the most important outcome of the project has been the formal creation of the European Inter-Ministerial
Panel on Emergency Health Care, a group of experts in the field of EMS, appointed by all concerned Ministries
of Health, that should meet on a regular basis and collaborate on exchanging and analysing information on EMS
systems across all countries. The proposal to establish this “Panel” could be instrumental in developing and sustaining a continuous process of risk and crisis management at EU level.