Paramedics in primary care - how do they impact the workforce?
6 July 2021
DPhil Policy & health systems Research methods & EBM
Building workforce capacity into health systems is a priority for many countries, and access to primary care has been a persistent problem for decades in the NHS. Current policy to address this issue has focussed on increasing the number and range of clinicians working in primary care. As a result, more and more paramedics have been employed to work in primary care, with a recently published ‘roadmap’ from Health Education England to facilitate this in England.
To understand the ways in which paramedics impact (or not) the primary care workforce, we undertook an evidence synthesis on the potential implementation of paramedics into primary care.
This is the most comprehensive policy-sensitive review of this topic, and the first to offer insight into understanding the impact paramedics may have on the primary care workforce and shaping how they might be optimally deployed. This is incredibly important at a time when paramedics are being actively recruited into roles in primary care, and patients, GP practices and paramedics themselves need to be able to understand how this role fits in for them.
We carried out our review using realist methodology to ensure that our findings consider how, why and under what circumstances paramedics can be optimally deployed into primary care. Our resulting programme theory considers data from 205 pieces of literature from Australia, Canada, the USA and the UK. We have provided a narrative overview of three key abstract categories that were developed from these documents, and combined with substantive theories, to produce a programme theory about how paramedics work in primary care roles:
Expectations of paramedics working in primary care
Understanding the expectations of how paramedics may contribute and work within primary care was viewed through different perspectives:
Patients may view the role of the paramedic in primary care favourably after being informed of it by a trusted source. Uncertainty exists when the role is not made clear to patients or their expectation is not met if they attend an appointment with a paramedic when they believed they were seeing their usual GP.
Whilst there was much positivity when considering the paramedic in primary care, in some reviewed literature GPs saw paramedics as offering assessment-only roles (i.e. to make a diagnosis but not treat the patient). Deployment of paramedics in such a way was unlikely to free up GP time and often led to unintended consequences such as patient frustration in the unnecessary duplication of consultations.
Paramedics perceive themselves as generalist clinicians who, by virtue of their work within emergency medical services, need to respond to all types of patients, across all ages, with any presenting complaint. Due to their generalist nature, paramedics would seek opportunities to work in primary care, believing their capabilities would fit well within this workforce.
Contribution to primary care teams
The idea that paramedics were pluripotential (i.e. able to do a range of tasks) was considered a useful addition for primary care teams. However, where the skills and competencies of the paramedic duplicated existing services (such as when urgent assessment clinics were already being run by another discipline, such as nurses), paramedics were not considered to be a useful addition to the team.
Transition from EMS into primary care roles
Our research found that paramedics are more likely to be effective in contributing to primary care workforces when they have significant experience as a paramedic and are supported to expand their existing role through formal education and clinical supervision.
The clinical gaps in paramedic knowledge that need to be filled for successful transition to primary care centred around biochemistry (for the understanding and interpretation of blood tests), pharmacotherapy (to support independent prescribing for long term conditions or complex patient groups), and some technical skills such as wound care, urinalysis, and imaging.
Clinical supervision enabled paramedics to feel supported as they adjusted their skill set to a new clinical setting and gave them confidence and satisfaction in their new role. Supervision also enabled GPs to build up trusting relationships with the paramedics.
Paramedics, employers and policymakers emphasised the need for paramedics to have had significant experience within the ambulance service prior to working in primary care. This role consolidation was considered crucial for successful transition and development of clinical capabilities.
Role and responsibilities
Unless paramedics are fully integrated into primary care services, they do not experience the socialisation needed to build trusting relationships within the team to work to the best of their capabilities.
Working in a team
Integration into the primary care team is crucial to avoid role duplication. These are less likely to occur when the professional role boundaries of the paramedic in primary care do not overlap with existing healthcare professionals. However, where role boundaries became blurred, or where the paramedic was viewed as a jack-of-all-trades, resistance could occur from other healthcare professionals due to a lack of confidence in the capabilities of the paramedic or feelings of threat in terms of their own job security.
The ability of paramedics to build rapport and trusting relationships in a short amount of time (as required during emergencies) was considered an important component for replication in primary care. Patients were more satisfied when attended by paramedics with strong interpersonal skills and enthusiasm, citing their ability to connect to these healthcare professionals as a key marker of the success of their work in primary care.
This is the first published systematic synthesis of the literature, using a realist lens, to explore how this role can be implemented optimally. Based on this realist review, the employment and integration of paramedics into primary care should consider the following, outlined in the framework to support implementation below:
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This work is conducted at the University of Oxford and is funded by Health Education England and the NHS National Institute for Health Research, highlighting its relevance to practice and policy. It is published open access in BMC Medicine.