Paramedics’ management of people experiencing mental health issues: An investigation of knowledge gaps and support needs in England

Demand for mental health care from U.K. ambulance services is increasing, yet paramedics report feeling underprepared to manage these presentations. This study aimed to identify knowledge gaps, educational needs, and systemic factors shaping frontline paramedics’ ability to provide mental health care in England, examining: (1) mental health education and training at pre- and post-registration levels; and (2) paramedics’ experiences of managing mental health presentations. A two-phase mixed-methods design was employed across England. Phase 1 comprised a national review of pre-registration curricula across Higher Education Institutions and post-registration training provided by NHS ambulance services. Data were collected via surveys of programme and mental health leads, supplemented by publicly available curricula, synthesised descriptively. Phase 2 involved semi-structured interviews with 20 frontline paramedics. Case-based vignettes and a think-aloud approach were used to explore clinical reasoning. Data were analysed inductively using reflexive thematic analysis. Phase 1 identified substantial heterogeneity in the structure, content, and transparency of mental health education. Dedicated mental health modules, placements, and simulation were inconsistently provided, and post-registration training varied widely in duration, mandatory status, and topic coverage, with limited protected time for mental health learning. Phase 2 generated four interrelated themes. Paramedics described feeling underprepared for the complexity of mental health care, with reliance on experiential learning (“No one taught me any of this”). System constraints further complicated care (“Pitfalls and loopholes”). Managing risk, capacity, safety, and autonomy was described as ethically and emotionally demanding (“You have to deal with complexity”). Communication and relational skills were viewed as central yet insufficiently supported through formal education (“It's all about how you talk to them”). There is a clear misalignment between the realities of frontline paramedic practice and current mental health education and training. A more consistent, applied, and system-informed approach is required to strengthen clinical confidence and improve patient care.