Paramedics in general practice can improve access for some patients, but they should not completely substitute GPs
Making it easier and quicker for patients to get the help they need from primary care is a key health policy priority. Patient buy-in and adequate supervision are needed to make paramedics in general practice clinically- and cost-effective
About the research
Alongside measures to increase the GP workforce, the NHS Long Term Plan and NHS England’s GP Forward View both emphasise the importance of a multi-disciplinary workforce in general practice.
Paramedics are more traditionally associated with delivering emergency care in ambulance services, but have been a part of the GP workforce since 2002.
The Additional Roles Reimbursement Scheme (ARRS), launched in England in 2019, was a pivotal policy decision to improve patient access to general practice by releasing funding for GP surgeries to recruit other (non-doctor) healthcare professional and support roles.
Paramedics have been included in ARRS since 2020, and numbers have more than trebled over the last 5 years – from 345 to 10831.
However, despite working alongside GPs for over two decades, there is very little evidence of the implications of this workforce shift for patients and the wider health system.
The READY study is the first major study of the clinical and cost-effectiveness of paramedics working in general practices.
The two-year study was conducted as a realist evaluation, and included 34 GP surgeries across England, chosen to represent a broad range of practice sizes and populations, including urban/rural and deprived/affluent areas.
Data from over 22,000 consultations was combined with information obtained from nearly 500 patient questionnaires and in-depth interviews with 69 patients, carers, GPs, paramedics and other practice staff.
Policy implications
- Paramedics can be a clinically- and cost-effective addition to the general practice workforce. However, paramedics cannot completely substitute for GPs.
- When working as part of a GP-led multi-professional team, paramedics can help support access to GP services without substantial spill-over costs to the wider NHS.
- Patient education and awareness raising is needed, for the role of paramedics (and other non-doctor health professionals) to be fully understood and accepted by patients.
- Whilst some element of role substitution is possible, it requires significant on-going investment in resourcing to support training and supervision. The paramedic workforce cannot limitlessly expand without commensurate increase in GP supervision capacity.
- Paramedics wish to, and can, develop professionally beyond traditional emergency ambulance-based roles, and have a skillset that has some transferability to the primary care setting.
- If more paramedics move to primary care settings, this has workforce planning implications for the ambulance sector.
- Models involving rotational working between ambulance settings and general practice are not straightforward. Whilst this form of portfolio working across several diverse settings may be appealing to paramedics, support professional development and boost workforce retention, this may be at the expense of true integration into primary care settings.
- With some elements of primary healthcare delivered increasingly by a non-GP workforce, the long-term safety and effectiveness outcomes of these changes needs to be studied.
Key findings
- Paramedics worked very differently across different GP settings, with variable models of care ranging from a focus on low-complexity ‘same-day’ urgent problems, through to more complex planned care.
- There is no universal paramedic scope in general practice, with activities spanning telephone triage, home visits, same-day urgent clinics and routine chronic disease management. There are varying degrees of professional autonomy. Where paramedics do not independently prescribe medicines, this may be a perceived limitation to their effectiveness.
- Paramedics are generally accepted by patients and other members of the professional team, although patients may experience less confidence in their healthcare plan when seeing a paramedic who is not well integrated into the GP team. This might be related to patient-perceived problems in communicating with healthcare staff.
- Patients did not always immediately understand the paramedic role in general practice, and required some time and exposure to develop familiarity with the role and its boundaries.
- In terms of NHS costs, whilst a paramedic consultation is cheaper than a GP consultation, this is offset by higher costs over the subsequent 30 days. Overall, paramedic-delivered care did not result in substantially increased ‘spill-over’ costs, such as re-consultations, prescriptions, secondary care referrals or unplanned hospital admissions.
- A key component of success was adequate induction, supervision, training and support for the paramedics to transition to this new area of practice, which requires a significant investment in GP time. Optimal supervision time remains to be quantified.
“I know that paramedics are probably well trained … I mean they are intelligent human beings, but I’m thinking on the broad sense, that some people may not have that perception, but I do think that if you go to a GP practice, you actually want to see a GP.”
“I think if I’m honest … the doctors thought they [paramedics] might be more help straightaway … I think you always underestimate the time and commitment for anybody coming, that requires training and support.”
Further information
Stott, H., Goodenough, T., Jagosh, J. et al. Understanding paramedic work in general practice in the UK: a rapid realist synthesis. BMC Prim. Care 25, 32 (2024). https://doi.org/10.1186/s12875-024-02271-1
NIHR Award https://fundingawards.nihr.ac.uk/award/NIHR132736
ISRCTN registered study https://doi.org/10.1186/ISRCTN56909665
https://www.ready-paramedics.uk
Acknowledgement
This project represents a collaboration between teams at the University of Bristol, the University of the West of England and University Hospital Bristol and Weston NHS Foundation Trust. The project leads would like the acknowledge the contribution made by the principal analysts and methodologists involved, and all the participating practices, staff, and patients. This research was funded by the NIHR Health and Social Care Delivery Research Programme (NIHR132736). The views expressed are those of the authors and not necessarily the NIHR or the Department of Health and Social Care.
Authors
Dr Matthew Booker, Consultant Senior Lecturer in Primary Care, Professor Sarah Voss, Professor of Emergency Care
Policy Briefing 148: April 2024
Contact the researchers
Dr Matthew Booker, Consultant Senior Lecturer in Primary Care: matthew.booker@bristol.ac.uk
Professor Sarah Voss, Professor of Emergency Care: sarah.voss@uwe.ac.uk
