Skill mix in primary care is not a new concept. Nursing roles have expanded significantly in recent years and practices are also starting to embrace the idea of employing pharamcists as part of the practice team. However, there has been growing recognition that other professions could also help to address the GP workload and recruitment crisis.
One of these professions is paramedics. Broadening the skill mix of GP practices to include paramedics was proposed by the Primary Care Workforce Commission last year in its report The future of primary care, Creating teams for tomorrow, and NHS England’s General Practice Forward View, which was published earlier this year.
What can paramedics do in general practice?
The Mount View Practice in Fleetwood, Lancashire, which has 12,000 patients, recruited a paramedic to join its team in January.
‘We have worked with paramedics in our local out-of-hours service for 20 years now. It has been a success and made us question why we couldn’t make that arrangement work for working hours well,’ explains GP partner Dr Mark Spencer who is also co-chair of the New NHS Alliance.
At Mount View the paramedic spends the morning working in a minor ailments surgery as part of an acute access team. The team is led by an on-call GP, but the bulk of face-to-face delivery is undertaken by a nurse practitioner, pharmacist and the paramedic.
Following this, the paramedic then does home visits, covering the vast majority of acute visits that would otherwise have been undertaken by a GP. ‘This has freed up an enormous amount of GP time and had a huge impact,’ Dr Spencer says.
While GPs still carry out home visits for patients showing new symptoms, where a diagnosis hasn’t been made and for end-of-life care, the paramedic now takes on the bulk of visits for patients, where, for example, there has been a worsening of a pre-existing condition. It tends to be mainly elderly, or housebound patients or those in a residential home, Dr Spencer says.
‘Seeing patients at home is something paramedics would normally do,’ says Dr Spencer. ‘It is their bread and butter so this seems a natural step.’
The paramedic at Mount View has full access to patient clinical records but isn’t working absolutely autonomously. ‘Once at the patient’s home the paramedic will phone the on-call GP or set up a video link using their laptop. A three-way consultation is carried out between the patient, paramedic and GP back at the practice so the paramedic is fully supported,’ says Dr Spencer.
Benefits of employing a paramedic
The benefit of this is the amount of travel time saved for the GP - around 30 minutes per visit. ‘With anything between 8 and 16 visits per day depending on the season, this is a significant amount of time saved for doctors. But it’s also about improving the skill mix within a multidisciplinary team and making more efficient use of the workforce available,’ Dr Spencer says.
‘Some people would say they would prefer a GP but the fact is there just aren’t any. Paramedics are not a replacement for GPs but have a range of skills that are very useful in a multidisciplinary team.’
Paramedic Kevin Reid is employed at the six-partner Maryhill Practice in Elgin, Scotland and has been working in primary care for 12 years – six were spent with the local GP out-of-hours service and the past six at Maryhill.
Mr Reid’s role as an emergency care practitioner also sees him take prime responsibility for handling acute home visits. A key difference is that he works largely autonomously.
‘I was recruited by the practice to help with unplanned and unscheduled care. It was a very unusual decision then and was a risk but it has paid off,’ he says.
'The six years spent in out of hours gave me vital primary care experience so I am able to close most of the calls myself, either by admitting the patient to hospital or putting in place an appropriate management plan for care at home by community nurses and a multi-disciplinary team.
‘Obviously some patients have multiple co-morbidities and there is always a GP on duty with whom I can discuss the patient’s case if I need to.’
Mr Reid emphasises that it is working as part of a multidisciplinary team that makes the arrangement successful. However, he adds: ‘The real beauty of the single paramedic practitioner doing house calls is that they are seeing the patient day-to-day and can very quickly identify if there is any deterioration.’
Mr Reid also works with the practice team to deliver a telephone triage service. And like the paramedic at Mount View holds planned acute or minor ailment clinics.
At Mount View, Dr Spencer says the paramedic role has also significantly reduced stress levels for GPs and had a positive effect on recruitment and retention. ‘Having a paramedic has made the working day for GPs much more manageable because they no longer have to worry so much about visits after the afternoon clinic,’ he explains.
‘One GP who left the practice because of stress levels actually returned to the job because they could see the working environment had improved so much.’
Patient response
But how do patients respond to being treated by a paramedic when they expect to see a GP?
Dr Spencer says his practice hasn’t collected formal feedback from patients as yet but anecdotally they welcome the speed of access (the paramedic can get to home visits quicker). ‘Some patients call up specifically requesting to see the paramedic now,’ he says.
Skills and training needs
However, a crucial drawback to employing a paramedic is they are currently not allowed to prescribe. Dr Spencer admits this remains a hurdle.
As is the case for any practitioner, training and CPD is also essential. Regular courses and mentorship sessions play an important role. For paramedics used to dealing with emergency medicine honing consultation skills is key, explains Dr Spencer. ‘Our paramedic regularly sits in on the GP or nurse clinics.’
Beyond his paramedic training Mr Reid holds degree-level modules in minor injuries, acute illness, minor illness and the advanced clinical examination among many others.
He says: ‘Practices should look for paramedics with some sort of background in an extended role but who know their limitations. I’m happy to work at the top end of my licence and work with a high level of autonomy and risk but, at the same time, I absolutely understand when to ask for help.’
He adds: ‘Practices are struggling to recruit GPs. We are not the equivalent to them, of course, but we can be part of the answer to help fill the gap.’
The New NHS Alliance is now looking to create a primary care network for paramedics so they can link up and share best practice.
Click here to download an example job description from the Mount View practice
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