In the UK a growing problem is the dispariaty between paramedics who have been trained via a degree route and ones who have been trained in-service. While in-service may take longer, it provides a better base of experience of people. The other, which I hope to pursue, does provide a great deal of knowledge in a short amount of time, but possibly limits experience? Another problem is that paramedics are being expected more and more to bridge a gap outside of hospital that doctors have left, since re-negotiating their contracts regarding out-of-hours work. ECP (Emergency Care Practioners) are slowly taking over out of hours cover, they are trained paras, but with more skills in terms of diagnosis. They can also refer above an A&E department (ER to the USA) straight to an appropiate health care service to reduce people being in A&E without need. I feel this is putting a great deal of strain onto ambulance services, in conjunction with increasing call numbers, and I can only hope patient care is not affected.