About the study

Findings

Patients at practices with one or more paramedics tended to have less confidence in their healthcare plan than those at practices without paramedics. The reasons for this were that patients perceive problems in communicating with healthcare staff, they lacked confidence that the practice was monitoring safety and they reported problems with blood and laboratory tests.

Appointments durations for urgent/same day appointments and telephone appointments may be slightly longer for practices employing paramedics.

Secondary care costs are higher for patients at practices with paramedics. More medications (almost twice as many) may be prescribed in the 30 days following a paramedic consultation compared to a GP consultation. However, these additional costs are offset by lower consultation costs of a paramedic compared to a GP.

When a paramedic service in a general practice begins, it takes time to embed and establish. It may be that a service starts with a low complexity and low integration paramedic model. Over time, the paramedic(s) gain experience and qualifications and are able to move towards managing more complexity as well as becoming more integrated into the team. Working along these continuums requires a significant investment of time, resources and training from the general practice. In other circumstances, the paramedic may operate as a member of a larger urgent care team and there may not be the same imperative to develop and train them in managing complexity.

What we did

Firstly, we conducted a rapid realist review which included searches of empirical and grey literature, interviews with system leaders, and a stakeholder prioritisation event. Initial theories were developed for testing in the evaluation phase.

Secondly, we recruited 34 general practice sites across England as ‘case studies’ for the evaluation. Sites were selected based on practice demographics, such as size, urbanity, and deprivation index, ensuring representation of different service models. Practices provided comprehensive detail on their paramedic operating model, including details of practitioner competencies (including prescribing ability), patient eligibility for paramedic care and practice workforce composition. Data were collected to explore various aspects of paramedic care, including its impact on patient outcomes, patient-reported experiences, safety, costs, value for money, patient experience, and the workload of GPs and other general practice staff. The quantitative element included both a prospective and retrospective cohort component.

Qualitative realist interviews (n=69) were conducted with patient participants (n=20), paramedics (n=13), GPs (n=12), practice managers (n=13) and other members of the practice team (n=11) using semi-structured interview guides. Quantitative data were collected through prospective patient questionnaires completed by patients immediately after a consultation with a paramedic (for those practices employing paramedics) or GP (for those practices not employing paramedics), and 30 days later (n=489 completed questionnaire pairs). These assessed patient experiences and outcomes using validated measures, including: the Patient Reported Experiences and Outcomes of Safety in Primary Care (PREOS-PC) (safety); EQ-5D-5L (health related quality of life); Primary Care Outcomes Questionnaire (PCOQ) (health outcomes); the Modular Resource Use Measure (ModRUM) (health and care resource utilisation). Additionally, a bespoke search was conducted on the electronic health records system (n=10 practices), to undertake a retrospective analysis of the subsequent resource implications of consulting with a paramedic or GP at the start of a care episode. This analysis looked at coded data arising from 22,509 index consultations.

Data analysis involved coding and thematic analysis of qualitative interviews, while quantitative data were analysed using the relevant statistical methods. Multilevel models were used to analyse the primary outcome. Economic analyses were based on published unit costs where available or derived from base principles. Sensitivity analyses were also conducted. The research team met regularly to discuss emerging findings, refine theories, and ensure alignment between qualitative and quantitative data.

Importantly, sites were classified based on the integration level of paramedics within the general practice team and the complexity of patients seen in the paramedic service. These classifications aided in organizing and comparing findings across sites.

Classification

Integration

Integration refers to the level to which the paramedic(s) are integrated into the general practice team and routinely work alongside other team members. The level of integration is based on the ‘form’ of the PGP service and clinical integration (e.g. supervision).

Complexity

Complexity refers to the type of patient that the paramedic(s) consult with. The level of complexity is to some extent determined by the skills and qualifications of the paramedic, but not definitively. For example, at some sites paramedics with prescribing qualifications are limited to seeing same day minor illness and at other sites, paramedics without additional qualifications, but with practical experience and/or a specialist interest in certain conditions, are seeing the frail and multimorbid population. Complexity is based on the ‘function’ of the PGP service (e.g. what the service is designed to do).