Plans to establish emergency care trusts could bring 999 services out of 'isolation' and integrate them with other parts of the NHS.

It is something of a paradox that the ambulance service, at the forefront of the public's perception of the NHS, has always been marginalised within the health service. As one of the emergency services, it has had an arm's-length relationship with trusts and health authorities. But as delegates gathered for the Ambulance Service Association's annual conference last week, they heard ideas that could change this.

The next decade could see the launch of emergency care trusts, conceived during research carried out for the ASA by Sheffield University. They would blend the features of a 999 service with a broader role as part of the NHS, according to Janette Turner, research fellow at Sheffield's school of health and related research.

Although still on the drawing board - under an advisory panel chaired by former chief medical officer Sir Kenneth Calman - it is thought there could be around 30 new trusts. They would each cover up to three districts and co-ordinate an integrated emergency and healthcare service, including accident and emergency and helicopters, emergency dental and mental health services, and minor injury units. 'One of the appealing factors is that the ambulance service becomes part of a wider trust rather than being a very small isolationist trust, ' said Ms Turner.

Professor Jon Nicholl, leader of the research project, informed delegates that jobs would not be at risk but roles would change. He later told HSJ : 'At the moment, ambulance services, whether we're talking about clinicians, paramedics or management, tend to be rather isolated. It's difficult for paramedics to move into clinical practice or other roles, and equally so for managers in ambulance trusts. One of the principal changes of this sort of model is greater fluidity of movement.'

More flexible roles would lead to cost efficiencies in the long run, and would offset the initial costs of setting up the trusts, he added.

Emergency care trusts have met with support from ASA members.

Malcom Hazell, chief executive of Warwickshire Ambulance Service, said: 'We are marginalised within the NHS and you see that at virtually every NHS meeting where, if there are funding issues, the acute and community will win out over ambulance services. If we continue along a very basic emergency service model, that situation will grow worse.'

The role of the paramedic is another target for change. Compulsory state registration is due within 18 months.

The health professions committee will enforce a new code of conduct and paramedics will have to meet tough continuing medical education standards to stay on its register, Ken Wenman, chair of the committee's paramedics board, told the conference.

Professor Douglas Chamberlain, chair of the royal colleges' ambulance liaison committee, described his proposals to reform ambulance training.

He backs a new practitioner in emergency care role. Practitioners would take a four-year course, including core nurse training, modular university education and a year's probation on ambulances. Once qualified they could work separately from the regular ambulance crews. 'It might make more sense to have these people with independent transport to deal with serious emergencies, ' said Professor Chamberlain.

They could also triage category C (non-urgent) calls. Initially, some 2030 per cent of the current paramedic workforce would become PECs, while in future the role may be open to school-leavers.

Government thinking appears to be in tune with these moves. Junior health minister Gisela Stuart announced consultation plans to give paramedics powers to administer six life-saving drugs, including morphine and the clot-busting streptokinase for heart attacks. She also pledged£500,000 to provide crews with more defibrillators.

ASA chair Paul Leopold described this as 'a good move forward' and was optimistic that the government's national plan, due later this month, would finally bring the ambulance service in from the cold.

He said: 'The minister clearly recognises the important part we play and I think she will endeavour to ensure that the plan reflects that role within the NHS.

'We are a highly professional organisation , and that change has been driven from within the service. Now the time has come that some further development needs to come from the centre.'

Now and next Now : emergency services model limited scope, focus on life-threatening conditions;

medically directed, protocol-driven, rigid clinical standards;

more difficult clinical decisions made remotely;

crews trained entirely within ambulance service.

Next: health service model scope and range of conditions much wider;

training with NHS;

much higher level of clinical decision-making by crews;

national and local standards.