coupled to this the ongoing viability of NZQA Unit Standards as a realistic platform to deliver comprehensive paramedic education (many felt they had outlived their useful life for higher practice levels) Moves by comparative jurisdictions in Australia totally towards tertiary education only The lack of a distinct qualification for the intermediate tier practitioner; originally the Certificate in Intermediate Aid was awarded upon completion of the ICO course however with the introduction of the National Certificate and Diploma in 1995 there was no longer a distinct external qualification for this level and this was even more true for the "upskilled" provider as this was an internally run course The need for structured ongoing clinical education once a qualification had been gained The very low completion rate of the National Certificate by volunteers (19%) when considering the goal of NAOTS had been to qualify all Ambulance Officers to the "basic" level (originally Proficiency but later National Certificate) Increasing complexity of ambulance practice beyond "scoop and run" and early Paramedic practice focussing mainly on early defibrillation/cardiac arrest and trauma care Increasing chronic disease, Impracticality of delivering all patients to a hospital emergency department, particularly in the face of increasing chronic disease or mental health problems which are not ideally handled in an acute presentation to ED. Increasing public expectation (see above) Inconsistency between service providers' levels of practice and the requirements of a newly introduced Ambulance Sector Standard which defined three levels of practice (discussed below) The long-held view (since 1993) that Paramedics should be registered health practitioners in their own right. The 2007 Health Select Committee report into the provision of ambulance services and the resulting National Ambulance Service Strategy included requirements to "achieve national consistency" in ambulance education and scope of practice (clinical competency). St John had during this time developed a draft "Operations Competency Framework" which would become the foundation of more recent developments; specifically the replacement of the National Certificate, the requirement for all the various intermediate level officers to transition to a new "Paramedic" level which would approximate the "Upskilled Paramedic (ALS-A/ALS-B)" levels and become a Degree course, the development <refof a Post-Graduate program for Advanced Life Support (Advanced Aid) and the introduction of a mandatory program of continuing clinical education. Current System (2008-present) National Diploma In 2008 the National Diploma in Ambulance Practice (Level 5) replaced the National Certificate in Ambulance Patient Care and Transport (Level 4)