Health and Care Professions Council |
College of Paramedics
HSSIB recommends that the Health and Care Professions Council and the College of Paramedics work in collaboration with relevant stakeholders to improve the undergraduate teaching of 12-lead electrocardiograms by reviewing and updating any relevant standards, guidance, and curricula to provide clarification on:
- the level of education and expected level of competency and assessment required of student paramedics in relation to electrocardiograms
- any minimum expected standards for electrocardiogram education in higher education institutions, including the time spent on electrocardiogram learning, methods used, and subject matter expertise required of teaching staff
- how patient protected characteristics, health inequalities and other specific patient factors are taught in relation to electrocardiograms
- how effective feedback mechanisms can be developed between higher education institutions and ambulance services.
This is to help improve consistency in the way paramedic students are educated about electrocardiograms.
Response received from the College of Paramedics
The College of Paramedics welcomes Safety Recommendation R/2025/058 and affirms its commitment to improving pre-registration education and training in 12-lead electrocardiogram (ECG) interpretation. We are actively collaborating with the Health and Care Professions Council (HCPC), higher education institutions (HEIs), ambulance services, and other stakeholders to ensure greater consistency and clinical safety in paramedic ECG competence.
In alignment with this recommendation, we are undertaking several initiatives. First, we are reviewing our professional curriculum and guidance in line with HSSIB’s findings and working jointly with the HCPC to ensure they inform the standards for paramedic education and training. This includes ongoing engagement to support the consistent adoption of our 6th edition curriculum across UK HEIs.
We are progressing towards an increased national pass mark of no less than 75% for all ECG assessments undertaken as part of pre-registration programmes. This reflects the critical importance of ECG interpretation and is in alignment with both the HCPC’s and our own view that such competence is essential to safe practice.
The College has also delivered multiple national ECG webinars and continues to offer structured continuous professional development opportunities. We are currently developing a pre-recorded ECG Masterclass that will cover foundational interpretation skills as well as clinical considerations relevant to ethnically diverse patient populations. Evidence demonstrates that patient characteristics—including age, sex, and ethnicity—can influence ECG appearance and risk of misdiagnosis (e.g., Macfarlane et al., 2014; Moss, 2010). These considerations are being integrated into our training materials to improve clinical decision-making and reduce inequalities.
Through these actions, we are committed to supporting paramedic education reform and advancing patient safety standards across the UK.
Actions planned to deliver safety recommendation:
- Continue collaboration with the Health and Care Professions Council (HCPC) to align pre-registration ECG standards with College of Paramedics curriculum, which is ongoing. Resources in place: Senior education and policy leads; existing HCPC engagement mechanisms. Other dependencies identified: HCPC standards of education review timelines; HEI adoption of revised curriculum. Additional comments: We are working closely with HCPC, as part of their current Standards of Education and Training (SETs) review and more broadly to ensure curriculum alignment and broader stakeholder engagement.
- Promote national adoption of 6th Edition CoP Curriculum across UK Higher Education Institutions (HEIs), by December 2025. Resources in place: Education networks; endorsement frameworks; comms strategy. Other dependencies identified: Voluntary adoption by HEIs; institutional resource limitations. Additional comments: The College will continue to advocate for it’s Curriculum as a national reference standard for education (this includes ECG training). The HCPC is supporting by enquiring as to the adoption of the curriculum when reviewing paramedic programmes in usual cycle.
- Stipulate the recommended national pass mark for ECG assessments be 75% in CoP Programme Management guidance, which is already implemented. Resources in place: Revised curriculum and published Programme Management guidance. Other dependencies identified: HEIs and examination boards responsible for formal adoption. HCPC recognises CoP position and encourages adoption. Additional comments: Pass mark expectation has been communicated; we are engaging stakeholders to support implementation.
- Explore with key stakeholders the appetite for a CoP administered ‘professional exam’ for paramedics (at the point of registration), decision whether to proceed by December 2025. Resources in place: Proposal paper to be presented to CoP board following initial consultation with Chief Paramedic Group, HCPC and Education Network. Other dependencies identified: Relies on engagement, support and collaboration with Chief Paramedic Group, HCPC and education providers. Additional comments: The CPG are keen to pursue this, ideally as part of the pre- registration training pathway. This would also be transferable for those returning to practice or internationally trained paramedics.
- Promote and drive HEI pre-registration programme endorsement, which is ongoing. Resources in place: All endorsement resources and personnel training in place. Other dependencies identified: Voluntary adoption by HEIs; institutional funding limitations. Additional comments: We are driving endorsement to continue to address unwarranted variation. ALB support in England and Scotland. HCPC recognises the value of CoP endorsement and articulates via ‘Working together’ statement on website.
- Deliver a national ECG Masterclass, including clinical considerations for patients from ethnically diverse backgrounds, by September 2025. Resources in place: Subject Matter Experts; webinar and learning platform infrastructure. Other dependencies identified: Clinical evidence base; availability of diverse ECG examples for teaching HCPC are supportive of the College CPD provision and sign post registrants to it. Additional comments: Incorporates findings from Macfarlane et al. (2014) and Moss (2010) on ethnic and sex-based ECG variation.
- Continue to deliver ECG interpretation webinars and CPD sessions, which is ongoing. Resources in place: Existing online education infrastructure; webinar hosting and registration tools. Other dependencies identified: Engagement from registrants and clinicians; speaker availability. Additional comments: Webinars to include a range of topics from basic interpretation to advanced ACS recognition.
- Advocate for protected time for paramedics to access ECG refresher training, by March 2026. Resources in place: Joint forums with ambulance trusts and NHS organisations. Other dependencies identified: NHS and ambulance service workforce pressures; funding constraints. Additional comments: Advocacy to be supported through national reports, policy briefings, and liaison with AACE and NHS England. HCPC CPD guidance supports the advocacy for protected time.
- Support development of feedback mechanisms between HEIs and ambulance services on ECG competence development, by December 2025. Resources in place: Regional education networks; liaison with ambulance service education teams. Other dependencies identified: HEI-ambulance service partnerships; existing communication infrastructure. HCPC are using their standards to also underpin this recommendation. Additional comments: Part of wider work to improve placement quality and alignment of expectations across the system.
- Explore with key stakeholders the appetite for a CoP administered ‘professional exam’ for paramedics (at the point of registration), decision whether to proceed by December 2025. Resources in place: proposal paper to be presented to CoP board following initial consultation with Chief Paramedic Group, HCPC and Education Network. Other dependencies identified: Relies on engagement, support and collaboration with Chief Paramedic Group, HCPC and education providers. Additional comments: The CPG are keen to pursue this, ideally as part of the pre-registration training pathway. This would also be transferable for those returning to practice or internationally trained paramedics.
- Promote and drive HEI pre-registration programme endorsement, which is ongoing. Resources in place: All endorsement resources and personnel training in place. Other dependencies identified: Voluntary adoption by HEIs; institutional funding limitations. Additional comments: We are driving endorsement to continue to address unwarranted variation. ALB support in England and Scotland. HCPC recognises the value of CoP endorsement and articulates via ‘Working together’ statement on website.
- Deliver a national ECG Masterclass, including clinical considerations for patients from ethnically diverse backgrounds, by September 2025. Resources in place: Subject matter experts; webinar and learning platform infrastructure. Other dependencies identified: clinical evidence base; availability of diverse ECG examples for teaching HCPC are supportive of the College CPD provision and sign post registrants to it. Additional comments: Incorporates findings from Macfarlane et al. (2014) and Moss (2010) on ethnic and sex-based ECG variation.
- Continue to deliver ECG interpretation webinars and CPD sessions, which is ongoing. Resources in place: Existing online education infrastructure; webinar hosting and registration tools. Other dependencies identified: Engagement from registrants and clinicians; speaker availability. Additional comments: Webinars to include a range of topics from basic interpretation to advanced ACS recognition.
- Advocate for protected time for paramedics to access ECG refresher training, by March 2026. Resources in place: Regional education networks; liaison with ambulance service education teams. Other dependencies identified: HEI-ambulance service partnerships; existing communication infrastructure. HCPC are using their standards to also underpin this recommendation. Additional comments: Part of wider work to improve placement quality and alignment of expectations across the system.
Response received on 19 September 2025.
Response received from the Health and Care Professions Council (HCPC)
We would like to thank colleagues at HSSIB for engaging with us throughout their investigation.
We are considering our response to the recommendations in discussion with other stakeholders (such as professional bodies and educational institutions). Our initial thoughts on approach are set out below:
The principles underlying our standards requirements for registered professionals (“registrants”) are of relevance to the level of education, expected level of competency, and assessment required of paramedic learners in relation to electrocardiograms.
Our standards requirements for both registrants and educational institutions are principle-based and outcome-focussed, requiring those responsible for carrying them out to demonstrate due consideration and to use their professional judgement and experience to practically apply them.
In some areas, this means that we provide specific guidance or support. However, our remit does not include the provision of clinical guidance for professionals or educators, which is dealt with by a combination of legislative requirements, employer policies, and professional best practice (including advice and guidance from professional bodies as appropriate).
Standards of Proficiency (SOPs)
Our SOPs are profession-specific and must be met by all registrants within each given profession in order to become registered and to remain on the Register.
They are the “threshold (entry-level) standards we consider necessary to protect the public”, and “set clear expectations of our registrants’ knowledge and abilities when they start practising. Once on the Register, registrants must continue to meet the [SOPs] that apply to their scope of practice.”1
Within the SOPs, “we avoid referring to specific pieces of legislation or particular approaches, to ensure the standards remain relevant over time” 2 and to ensure that registrants have a degree of flexibility in line with their professional judgement, provided that they remain fit to practise and the public is adequately protected.
The College of Paramedics (COP) builds on the paramedic SOPs with a further level of detail within their curriculum guidance. Our SOPs “Complement other sets of standards, such as our standards for conduct, performance and ethics, and policies and guidance from employers and professional bodies” (ibid). We also “recognise the valuable role played by professional bodies in providing guidance and advice about good practice which can help [registrants] meet the [SOPs]…” 3
How we review SOPs
We keep our standards under continual review, considering their impact and whether they continue to reflect current best practice. We aim to conduct a periodic review of the standards every five years. The most recent updates for each profession came into effect on 1 September 2023 and were formed after extensive consultation with a range of stakeholders, including employers, professional bodies, educators and individual registrants.
The current versions of our SOPs became effective for our registrants and for new cohorts on education and training programmes from September 2023. We will consider changes to the paramedic SOPs when SOPs as a whole are next reviewed, with this expected to take place during 2027-2028.
Because our standards requirements are grounded in principles and behaviours rather than specific clinical competencies, specific medicines or medical devices are generally absent from the standards requirements we expect from registrants in practice. Through our engagement work and formal consultation process in our last SOPs review, stakeholders also did not raise competencies involved in 12-lead electrocardiograms or suggest that they should be included in the paramedic SOPs.
Expectations for educational standards, learning, methods used and expertise of teaching staff Education providers and programmes need to meet our standards of education and training (SETs) to become and remain approved by the HCPC 4. These are separated into institution level standards and programme level standards, and are supported with a guidance document 5.
This set of standards is currently under review as part of the rolling process we have outlined above 6. The standards are also principle-based and outcome focused. They help ensure that learners who complete programmes in the UK meet our requirements for registration, namely the profession-specific SOPs, and the standards of conduct, performance, and ethics (SCPEs).
Encouraging education providers to develop new education and training programmes, and providers of existing programmes to structure or deliver them in different or innovative ways, are key policy aims of the SETs.
Therefore, we have avoided setting detailed requirements for how providers should meet the standards. Similarly, we do not set specific requirements for the time spent on teaching and learning, methods used, or subject matter expertise of teaching staff linked to specific tools.
Instead, we approve and monitor how they have achieved the required outcomes, the policies and processes they have in place, and how they implement, review and evaluate them 7.
Further, we feel that it is important to note that education providers should not make assumptions about the experience and competence of staff delivering programme content, and for those involved in practice-based learning, recognising that practice changes over time.
We consider a programme’s curriculum content against our requirements for registration (SETs 4.1 and 4.2), the appropriateness of learning and teaching methods to the effective deliver of learning outcomes (SET 4.6) and how staff are appropriately qualified and experienced to deliver learning and teaching (SET 3.9, 3.10, 5.5 and 5.6).
We expect that programmes “reflect the philosophy, core values, skills and knowledge base as articulated in any relevant curriculum guidance” (SET 4.3), and that the education provider had mechanisms to ensure the curriculum remains relevant to current practice (SET 4.4). Part of the work supporting this means working closely with professional bodies to make sure that content remains relevant and up to date. Our work with professional bodies has resulted in us issuing a statement on how we influence and work collaboratively with professional bodies 8.
Through programme assessments, anyone who completes an approved programme must be effectively assessed against our requirements for registration (SET 6.1 and 6.2), and assessment methods used must be appropriate to and effective at measuring learning outcomes (SET 6.5).
In the case of paramedics, this would mean that programmes would need to ensure that those completing a programme would need to be able to fulfil several SOPs which are relevant to the report recommendations, including:
13.4 select and use appropriate assessment techniques and equipment
13.5 undertake and record a thorough, sensitive and detailed assessment
13.7 conduct appropriate assessment or monitoring procedures, treatment, therapy or other actions safely and effectively
13.12 know the theories and science that underpin the theory and principles of paramedic practice
13.13 know the indications and contra-indications of using specific paramedic techniques in emergency and urgent care and primary and community care, including their limitations and modifications
13.14 ensure decision-making is supported by effective safety-netting
13.15 modify and adapt practice to meet the clinical needs of service users within the emergency and urgent care environment
13.16 know how to select or modify approaches to meet the needs of service users, their relatives and carers, when presented in the emergency and urgent care environment
13.18 conduct a thorough and detailed physical examination of the service user, using appropriate skills to inform clinical reasoning and guide the formulation of a differential diagnosis across all age ranges.
We are currently in the initial stages of reviewing our SETs with a planned public consultation to take place during 2025, which will include consideration of Standard 4.3:
4.3 The programme must reflect the philosophy, core values, skills and knowledge base as articulated in any relevant curriculum guidance.
We would be happy to consider the report’s recommendations as part of the overall SETs review process, insofar as they are compatible with the overall policy intent and framework supporting the SETs and other standards. We encourage the stakeholders with an interest in the report recommendations to make representations during the process.
How patient protected characteristics, health inequalities and other specific patient factors are taught in relation to electrocardiograms
Our SOPs and SCPEs require that registrants can provide healthcare to all their service users. Our requirements provide that registrants must be able to treat each service user as an individual, and understand how to do this as an autonomous professional.
Through education and training programmes, education providers must ensure that learners meet our requirements for registration, which means that registrants must be able to meet the standards we have outlined above in their use of medicines and medical devices, including electrocardiograms.
Our standards also include Equality, Diversity and Inclusion (EDI) considerations which must apply across registrants’ practice, including with specific techniques or tools used.
How effective feedback mechanisms can be developed between higher education institutions and ambulance services
Our SETs require that there “must be regular and effective collaboration between the education provider and practice education providers” (SET 3.5). Linked to this, we expect to see:
Strategic partnerships in place with relevant organisations, such as practice partners, employers or commissioners, which ensure that programmes are well resourced, and keep quality high; and Structures at an operational level, to manage different aspects of programmes where partners are involved.
We test this collaboration through our initial approval assessments, and through our regular monitoring portfolio requirements for education providers.
Analysis of findings from our assessments shows that education providers widely recognise that collaboration with practice partners is key to the sustainability and quality of their programmes. This is due to the centrality of practice-based learning within education and training, which requires programmes to be adequately resourced to deliver practice-based learning to all learners, and to support the delivery of the learning outcomes and the SOPs 9.
Learners meeting standards is a common goal for education providers and practice education providers. Ensuring future registrants are fit to practice is essential for employers. Therefore, education providers and employers share incentives and a common obligation to work collaboratively to address issues within education and training. This is supported by our regulatory requirements, but as our policies develop we also work closely with both education providers and employers as formal and informal consultees. We encourage the sharing of information between our stakeholders where we have appropriate opportunities to convene and collaborate, especially where there are developments in statutory or regulatory requirements for professionals. This includes the College of Paramedics (COP) as the professional body for paramedics. We have an information sharing arrangement with the COP, to share information and inform each other’s work linked to the education and training of paramedics in the UK.
Additional actions:
We consider that it is important that education providers delivering paramedic programmes are aware of this report and its recommendations, therefore we plan to:
- Share the report via our regular Education Update e-newsletter in June 2025, specifically for all paramedic programme leads at our educational providers. We would expect this to reach around 100 contacts across the UK, helping to clearly communicate what is expected of educators and registered professionals.
- Share the report and key recommendations with paramedic learners and registrants via the work of our professionalism and upstream regulation team where appropriate opportunities arise in their existing programme of work.
- Registrants are required to stay up to date with current good practice, comply with our Standards on Continuous Professional Development 10, and employer should ensure protected time for CPD. In our regular contact with employer stakeholders, we will seek feedback on what can be done to influence learning and development expectations.
- Share the report with employer organisations
- Continue our work with the College of Paramedics in order to identify practical ways to make progress against the findings and recommendations of the report.
We will give further consideration to the findings and recommendations and potentially ask paramedic education providers to reflect on these through our regular performance review monitoring activities.
The HCPC also provides materials on preceptorship 11. This is a period of structured transition to guide and support newly qualified practitioners from students to autonomous professionals. This aims to ease their transition and develop their practice, and unlike our education requirements, also applies to registrants trained overseas. The preceptorship documents link to our CPD requirements and materials. In the dissemination work summarised above, we could also promote these materials framed alongside the report findings.
Summary of response
The Health and Care Professions Council (HCPC) welcomes the report, its findings and the recommendation outlined above. We plan to work closely with stakeholder organisations, including the College of Paramedics (COP), to make sure that learning from the report is carried into practice and complements our wider regulatory work and requirements.
The following area from the recommendation directly links to one of our Standards of Education and Training:
- how effective feedback mechanisms can be developed between higher education institutions and ambulance services.
We will therefore seek to further understand and develop how education providers and ambulance services collaborate effectively, including feedback mechanisms, to ensure there are no issues with our regulatory standards being met.
Our standards requirements for professionals (Standards of Proficiency, Standards of Conduct, Performance and Ethics, and Standards for CPD) include a number of obligations which apply to the use of medicines and medical devices or technology and which must be considered to direct all registrants in their knowledge of, approach to, and use of electrocardiograms.
It is important to note that our standards are not directive about which specific technologies must be used, and how, in specific practice settings, but provide high level expectations about competence at the point of registration, and principles about how registrants must use their professional judgement in practice situations.
They also require that registrants remain within their scope of practice, and develop their practice in line with changes to their role and the broader profession. This is further supported by the requirements outlined in our Standards of Education and Training and our approach to approval and monitoring of education providers and their programmes.
Our standards requirements in each case seek to empower professionals in the use of their professional judgement and to ensure general applicability in a world of changing technologies and models of delivery for health and care. This means that our standards are drafted to apply principles and steer outcomes rather than taking a clinically prescriptive approach.
Therefore, where we have a role in the following areas from the recommendation, we cannot directly address these under our regulatory powers:
- the level of education and expected level of competency and assessment required of student paramedics in relation to electrocardiograms
- any minimum expected standards for electrocardiogram education in higher education institutions, including the time spent on electrocardiogram learning, methods used, and subject matter expertise required of teaching staff
- how patient protected characteristics, health inequalities and other specific patient factors are taught in relation to electrocardiograms.
However, we welcome the findings and intentions underlying the recommendations, and will therefore commit to addressing these as our statutory and regulatory remit best allows. In particular, it is important to ensure understanding of a) the importance of electrocardiogram usage in the process of educating new registrants, and b) what our standards requirements mean for paramedics who use them. Our remit does empower us to use our influence, our existing standards approach and our stakeholder relationships to help support this aim, thereby achieving similar outcomes to those sought directly through the recommendations.
We have also outlined additional steps alongside existing approaches and materials which can be used to promote understanding of electrocardiograms throughout professional education and development, and the importance of our standards in providing a framework for their use.
Further to these commitments, the findings and recommendations of the report will help to inform future cyclical reviews of our standards for professionals and educational providers.
Actions planned to deliver safety recommendation:
- Consider the content of the recommendations as part of our next SOPs review, by 2027.
- Consider the content of the recommendations as part of our current SETs review, by 2025.
- Open communication with stakeholders to improve communication between education providers and ambulance services, by 2025. Additional comments: We would deliver this work in collaboration with the College of Paramedics.
- Signpost educational providers and employers to College of Paramedics materials / webinars, by 2026. Other dependencies: Depends on provision of materials from COP. Additional comments: This would be delivered as part of routine stakeholder engagement.
- Assess collaborative relationships between education providers and delivery stakeholders, which is ongoing / rolling.
- Assess role of Equality, Diversity and Inclusion in delivery of programmes (including with regard to medical devices), which is ongoing / rolling.
- Support education providers to understand that safety and quality must underpin staff resourcing of programmes in the academic and practice setting, by 2025.
- Continue conversation with COP to help establish good practice, link this to existing standards and ensure clarity in roles, by 2025.
- Promote the report to paramedic learners and registrants, by 2025/26. Resources in place: Professional Liaison and Upstream Regulation team – staff time. Additional comments: The Head of Communications and Engagement is currently covering the relevant role in an interim capacity.
- Share the report with relevant employer organisations, by 2025.
Response received on 16 September 2025.
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