[2] In the French version of the model, only physicians and nurses perform advanced care, and ambulance drivers have only minimal medical training.
In 2003, there was a reform movement to expand the "standing competency", especially in the realm of pain treatment, by offering additional training to the level of "Notfallsanitaeter".
In the French version of this model, even the triage of incoming requests for service is physician-led, with a physician, assisted by others, interviewing the caller and determining what type of response resource, if any, will be sent.
In this model, the medical director is typically more of a leader of physicians, and an advisor on the training of, and quality control for, subordinate staff.
This physician's role is to oversee EMS personnel in a defined area, typically a bigger city or county, and it corresponds to the position of medical director in North America.
In some early cases, "paramedics" operated blindly, providing medications from numbered or colour-coded syringes as they were directed by the physician, with no real understanding of the actions they were performing.
Control was absolute and immediate; there were examples of paramedics being trained, but not legally permitted to perform their skills, or in other cases, they could take action only with a physician or nurse present, much like the existing Franco-German model.
They generally perform a leadership role among the small group of physicians tasked with providing delegation to paramedics in the field.
In some parts of the world, most notably the U.K.,[16] Australia[17] and South Africa[18] some paramedics have evolved into a role of autonomous practitioners in their own right.
In such cases, individual paramedics may function in much the same manner as Physician assistants or Nurse Practitioners, assessing patients and making their own diagnoses, clinical judgments, and treatment decisions.
Most such training programs tend to feature very large components of hands-on clinical experience, generally conducted in the emergency room or similar environment, and usually in a one-to-one ratio with the physician.
The medical director will have a major role in determining the permitted scope of practice, and will investigate practice-related complaints.
The scope of practice and permissible procedures are determined at a national level by the Dutch Ambulance Institute, and all paramedics must function within this guidance.
Each ambulance service is required to employ a medical manager whose role is oversight and quality assurance, and who may be contacted for directions by any paramedic who has reached the limits of their scope of practice, just as in the Anglo-American model.
In these cases, a great deal of emergency intervention will occur on the scene, with the patient transported ultimately by land ambulance, as in the Franco-German model.
Scope of practice and all treatment protocols are developed by the Dutch Ambulance Institute on a national basis, and cannot be unilaterally changed at the local level by individual physicians.
These individuals do perform quality service functions such as chart audits and complaint investigation, but they cannot unilaterally change treatment protocols.
The Dutch system also operates a network of four helicopters staffed by physicians for rapid response to support paramedics in the field.