Paramedics working in general practice: a scoping review

Stage 1: Identifying the research question

Much of the published literature has analysed the implementation of community paramedic programs where paramedics conduct routine health assessments and home visits to people with low access to primary care services or have urgent but non-life-threatening needs^16,29. Paramedics with an expanded ‘primary care’ scope of practice within the emergency medical services have also been explored within the literature^16,23,29. Literature considering the concept of paramedic working in general practice settings is more limited. This review aimed to answer the research question: ‘What is the evidence for the scope of practice, nature of training and qualifications, challenges faced, and impact of paramedics working in general practice settings?’

Stage 2: Identifying relevant studies

A general search was conducted with multiple search terms combining the two key constructs “general practice” and “paramedic” to inform the search strategy for this review. Different programs with varying designs have been implemented in several countries^10–13,30 and titles of paramedics joining general practice were identified as relevant keywords. Such titles identified during the initial search included “advanced clinical practitioner”, “physician assistant/associate” and “advanced paramedic”. Search terms (Box 1) were grouped and entered to the electronic databases Pubmed (MEDLINE), EMBASE and the Cochrane Library. Further publications were identified through hand-searching reference lists of already identified relevant literature.

Stage 3: Selecting studies

The search process, as guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), is summarised in Figure 1.

Figure 1. PRISMA flow diagram.

Inclusion criteria were as follows:

Commentaries, grey literature, and personal accounts from paramedics working in expanded roles within general practice were all eligible for inclusion.

Stage 4: Charting the data

To facilitate comparison and thematic analysis the following data were extracted from the articles:

Stage 5: Collating, summarising, and reporting findings

A table (Table 1) was developed to summarise findings and enable better contextualisation for analysis considering the four key elements of our research question:

Stage 6: Consultation exercise

Consultation with relevant experts within this field (GA & MB) was conducted to gain additional insights and suggestions for any important studies that were not included for final review. Contributors also helped inform and validate findings from the main scoping review to enhance the quality of this study and contributed to the final authorship of this review.

Search results

Our initial database search identified 1023 records and an additional six records were obtained from hand-searching reference lists of key literature. After 171 duplicate records were removed, the remaining 858 records were screened by title, abstract and year of publication and fourteen records were selected for full-text review (Figure 1). Data were ultimately extracted from eleven records which met the eligibility criteria. Among the fourteen, one abstract describing an ongoing study of relevance from Wales was not included as it was not completed³¹.

Description of included studies

The eleven articles included in the final review (Table 1) incorporate case studies, cross-sectional studies, mixed methods studies, personal accounts, reports, commentaries, surveys and qualitative studies using interviews and focus group discussions. All but one article considered paramedics working in general practice in the United Kingdom. One report detailed developments in the expansion of paramedic roles in Australia referencing the origins and implementation of physician assistants in the United States¹⁰.

Scope of practice

Roles and responsibilities within general practice

Four articles – case studies in Mahtani et al., a survey conducted in the mixed methods study by Schofield et al., the personal account by Daly, and the editorial by Booker and Voss – outlined how paramedics already assume roles in chronic disease management, domiciliary visits, performing telephone and patient triage, seeing same-day and urgent cases^6,11,17,32. Examples of paramedic skills already deployed in GP settings included taking blood pressures, understanding ECGs, phlebotomy, providing first aid and suturing for wounds³². These papers suggested that, by virtue of their training, paramedics could assist in assessing, treating, and arranging further care for patients with acute presentations such as chest pain or dyspnoea^11,17,32. Given their training as generalists, paramedics could contribute to the management of undifferentiated illness from a wide spectrum of demographics¹⁷.

Variations due to local context

Paramedics may be hired to work in general practice based on the unique demands of a given practice. For clinics with large patient pools, paramedics may be relied on for their ability to provide domiciliary and out-of-hours care given their generalist ambulance service experience of dealing with a wide range of presentations^9,32,33. Schofield et al. noted that paramedic tasks and responsibilities in general practice could be related to different models of employment/local needs and suggested that individual GPs might have differing views on how best to deploy the abilities of paramedics⁶. The first-person account by Daly demonstrated a specific role in an immunisation program after the author was evaluated as competent by his GP supervisor and a patient group direction was signed to enable this practice³². Schofield et al. found in their survey that a majority of paramedics working in general practice were employed directly by that practice but others worked across a primary care network or were employed by an ambulance service or other community service provider⁶.

Variations due to paramedic’s qualifications and experience

Mahtani et al. summarised the higher qualifications and greater competencies acquired by paramedics as they progress within their field to become specialist paramedics, advanced paramedics and consultant paramedics¹¹. Mahtani et al. included two case studies that demonstrate that in the UK, specialist paramedics conducted home visits and out-of-hours care in place of GPs for acute presentations¹¹. Advanced practitioners/paramedics in the UK have recently been granted independent prescribing rights which many articles highlight as having specific relevance to working in general practice settings^11,12,17. Daly noted that with additional qualifications in teaching, paramedics can facilitate life support training programmes and provide additional training support to general practice in niche areas³². A personal account by Brown¹³ highlighted how an advanced clinical practitioner program allowed him to work autonomously to evaluate a range of patients presenting with varied conditions and arrange appropriate diagnostics and onward referral where necessary. Brown noted that the care provided to patients in general practice required extended skills and knowledge that were not core to paramedic basic training¹³.

Proposed models that underpin paramedic working in general practice

Silverston highlighted potential duplication in workload where GPs are uncertain of paramedic capabilities and proposed a new category of primary care practitioner for allied health professionals that would have a shared set clinical curriculum with GPs¹⁸. He suggested that such a role could improve delegation of tasks from GPs to paramedics¹⁸.

Booker and Voss propose three models for paramedic working in general practice: paramedics see routine patients thus freeing GP time to manage more complex patients; paramedics create additional capacity to allow general practice as a whole to manage urgent problems in a timely manner; paramedics have the potential to improve patient satisfaction and clinical outcomes if patients can enjoy timelier and longer consultations¹⁷. Booker and Voss also noted that paramedics can bring additional skills and knowledge that may not be already developed in general practice¹⁷.

Training and qualifications

The included literature considered additional training in terms of both new professional titles (Advanced Clinical Practitioner & Physician Assistant) and specific areas of professional practice such as prescribing and out-of-hours care^10,13,17,33.

Advanced Clinical Practitioner & Physician Assistant role training

Brown outlined training to work in general practice via an advanced practitioner program representing a two-year MSc course open to health professionals from various clinical backgrounds¹³. Trainees study at university for two days per week and work in clinical settings under an assigned medical mentor for the remaining three days. Modules offered included pathophysiology, advanced clinical examination and history-taking, clinical reasoning, and project management¹³. Raven et al. provided detail on physician assistant programs in the United States which were originally developed in response to a shortage of healthcare professionals and allowed military paramedics to take on other roles in healthcare such as primary care¹⁰. Students entering a physician assistant program hold a bachelor or master’s degree and have four years of health care experience, including as a paramedic¹⁰. The program duration is usually 24–27 months and the core content of the curriculum is similar to that of physician students¹⁰. To be certified upon completion of the program, students sit a Physician Assistants National Certifying Examination and to renew the certification, physician assistants have to complete 100 hours of continuing medical education every two years¹⁰.

Out-of-hours care training

Moule et al. employed a mixed methods approach involving interviews, questionnaires and data review from electronic health records to analyse a programme designed to allow paramedics to participate in out-of-hours services³³. The 450-hour programme included 12 weeks of full-time employment divided into 30-hour clinical practice and 7.5-hour self-study per week. The program was overseen by a medical director and had training and mentorship provided by GPs and Advanced Nurse Practitioners³³. Trainees completed a competency framework with 127 items and job proficiencies were graded on three rating descriptors³³.

Independent prescriber training

Booker and Voss highlighted independent prescriber training for paramedics working in general practice in the UK and provided basic details¹⁷. Paramedics are required to have a minimum of three years post-registration experience and general practices need to have necessary governance polices and safeguards¹⁷. One concern highlighted was a potential increase in unnecessary prescriptions such as for antimicrobials, however the authors noted a lack of evidence to support this concern¹⁷. Nelson et al. also highlighted the importance of prescribing training and privileges for successful working in general practice¹².

Challenges

Role ambiguity for paramedics working in the general practice setting

Stakeholders report differing views on the type of patients in general practice that paramedics should provide care for^6,12. Schofield et al. reported that a varying range of patient groups are sometimes excluded from review by paramedics working in general practice for example infants, pregnant women, and patients with mental health difficulties⁶. The overlap of responsibilities with other professionals such as nurse practitioners was also noted to sometimes represent a source of confusion¹². Such confusion has been shared by some patients, who report being unsure of the role of the paramedic in the GP clinic^6,12.

Multiple publications noted that the emergence of new job titles for paramedics was a further source of confusion for GPs, other allied health professionals, and patients^{6,9,10,12,17,18}. Uncertainty as to the core competencies of a trained paramedic was itself noted as a barrier to the integration of paramedics into general practice¹⁸. In Daly’s personal account of working in general practice he found his team were unaware of some of a paramedic’s clinical skills³². Unclear professional boundaries may at times create tension within the workplace due to significant overlap in clinical tasks and responsibilities^10,12,18. Regarding the awarding of prescribing rights to paramedics by the Health and Care Professionals Council (HCPC), Booker and Voss noted that paramedics are expected to be working at an “advanced level of practice”; however, the term ‘advanced practice’ has not been consistently defined¹⁷. Multiple bodies such as the College of Paramedics and Health Education England were noted to have provided role descriptors but these in turn had not been adopted uniformly across the UK¹⁷. Antagonism towards new roles in general practice has been reported but can be resolved once roles become familiar and scope of practice is clarified before work is commenced^10,12.

Preparing paramedics for transition to general practice

Schofield et al. and Booker & Voss highlighted how the specialised skillset required to work in general practice in order to manage patients with multi-morbidities and chronic diseases may not be part of a paramedic’s core capabilities^6,17. Other core tenets of general practice such as continuity of care, forming therapeutic relationships and management plans over time may also be unfamiliar to paramedics¹⁷. Stakeholders interviewed by Schofield et al. noted that the personality and adaptability of individual paramedics were crucial to effective integration within general practice⁶. Nelson et al. found that a key challenge was preparing advanced clinical practitioners to work in a clinical setting with higher levels of uncertainty, pace, and responsibility¹². The authors highlighted a need to match paramedics to the right general practice which could facilitate appropriate on-the-job training and support for new trainees¹². Nelson et al., Moule et al. and Schofield et al. highlighted significant mentorship requirements amongst paramedics transitioning to working in general practice and further highlighted how the time commitment required by mentors may represent a significant cost and barrier^6,12,33.

Moule et al. noted that providing additional training for paramedics while they may already be working full-time could be challenging due to night shifts and “unsocial hours”³³. The paramedics in this study highlighted a steep learning curve and considered the inability to prescribe as a hindrance³³. Interviews with the program medical director and participants noted that a 12-week training timeframe was too short for trainees³³. The medical director perceived this to be due to paramedics’ lack of experience with diagnosis and forming management plans³³. Paramedics did however report greater understanding of pathophysiology and increased confidence in their capabilities to manage a range of conditions after the programme³³. Although participants appreciated having support from a range of GPs and nurse practitioners, there was a suggestion that having one designated supervisor would be preferable as it may be easier to adapt to a consistent working style³³.

Outcomes. Booker & Voss, Schofield et al. and Nelson et al. highlighted a lack of literature evaluating cost-effectiveness, resource allocation and health outcomes in both current and theorised models of paramedic working in general practice^6,12,17. Booker & Voss did note a perspective that the potential benefits of paramedic working in general practice far outweigh potential limitations due to the sheer scale of the crisis in primary care capacity at present¹⁷.

Patient satisfaction

Proctor et al. performed a qualitative study (6 participants) that considered patient satisfaction in receiving home care by paramedics⁹. The study found that patients viewed paramedic practitioners favourably and were satisfied with the care provided if their needs were met. However, patients preferred to see a GP when requesting a home visit if they considered their problem severe or complicated⁹. Daly conducted a patient survey on a new paramedic-GP role³². It achieved a response rate of 90/140 and found that 95% of patients had a satisfactory impression of being treated by a paramedic in primary care³². Most patients (86%) reported that being treated by a paramedic did not delay treatment³².

Paramedic perspectives on the value of specific paramedic skills brought to general practice

In his personal account Brown, as an advanced clinical practitioner, noted that his paramedic training allowed him to bring additional value to general practice by managing emergency situations and supporting nursing colleagues with ECG interpretation¹³. Daly’s teaching certificate allowed him to be involved in annual basic life support training within his general practice and demonstrate the unique skillset paramedics can offer³². Mahtani et al.¹¹ and Spence⁴ highlighted how paramedic training facilitates assessment of patients during home visits then onward direction to appropriate services if needed.

Impact on the ambulance services

Schofield et al. noted that there were concerns of recruitment competition with the ambulance services during key informant meetings; however, they also noted that cooperative approaches with general practice could be a means to promote retention of paramedics within both sectors⁶.

Summary of key findings

Our search of the literature published within the last twenty years resulted in the inclusion of only eleven articles that considered the concept of paramedics working directly in general practice. This is somewhat surprising given that this concept has been promoted for some time²³. The literature suggests that paramedics already actively participate in general practice in some jurisdictions most notably in the United Kingdom and contribute to care delivery in a variety of ways. There appears to be variability in how paramedic involvement is structured, some of which reflects local arrangements and responses to service needs, more of which reflects the diverse post qualification training pathways paramedics undertake. In this context it is perhaps unsurprising that there is evidence of confusion both on the parts of clinicians and patients as to the role of paramedics in general practice.

In general, it appears that additional training and education is considered necessary for paramedic involvement in general practice and there already exists a variety of approaches to providing such training. Some pathways involve university-based substantial additional training that lead to novel qualifications, others are shorter and focused on specific domains of practice. To date the training programs referenced in the literature appear to involve a combination of classroom learning and on the job training.

The literature outlines some key challenges that emerge from paramedic working in general practice. Paramedics are likely to require additional training in chronic disease management and multimorbidity. They are likely to have to adapt from a protocolised model of practice to working in a clinical setting with higher levels of uncertainty. It may also be that medication prescribing is necessary to contribute to care in an effective and efficient manner. Further potential systems challenges including funding models, clinician and organisational indemnity, regulatory changes to address a widened scope of practice and maintaining competence across a wide spectrum of roles were not considered in any detail but also represent important considerations.

The value of paramedics working in general practice has been posited from a variety of perspectives including increasing capacity, facilitating a timelier service, freeing GP time to manage complex issues and bringing additional skills. Beyond some evidence to suggest that patients are satisfied with care provided by paramedics and anecdotal reports of positive outcomes^6,9,32,34, there exists little quantitative evidence to support the theories that underpin paramedic involvement in general practice. Notably we found no research that robustly examined health economics, safety, morbidity, or mortality effects.

The perspective that the potential benefits of paramedic working in general practice far outweigh potential limitations given a crisis in primary care capacity is problematic. Although benefits of primary care paramedics working within general practice teams have been identified³⁵, there is a dearth of evidence to guide training and practice in what represents a complex health systems intervention. Such a perspective also minimises the potential for significant unintended consequences including an exodus of senior clinicians from the ambulance services to general practice. Surprisingly, we found a lack of literature that explored the motivation of paramedics to transition to general practice roles. This issue would warrant consideration if further/future paramedics are to be recruited into general practice.

Implications for practice in Ireland

Sláintecare was introduced in Ireland to deliver universal integrated healthcare that caters to changing population demographics and the increasing burden of chronic diseases^36–38. General practice is known to be central to Sláintecare, however, recruitment of general practitioners is already challenging due to emigration and perceived unfavourable working conditions^38–40. In the future, paramedics could form part of the general practice work force but will need appropriate training and supported integration to do so. Any such innovation should proceed with caution, be guided by the limited existing evidence, and be further embedded in a research framework that can inform its evolution. While GP workload might decrease when paramedics take over urgent non-complex patients, this may be offset by the time taken for GPs to train and supervise paramedics⁶. Paramedics may struggle to adapt to the unpredictable nature of general practice and limited autonomy in terms of prescribing, may reduce productivity and in fact increase work duplication. Existing research demonstrates that patients may be open to assessment and treatment provided by paramedics in general practice, but a percentage are likely to still prefer being cared for by their own GP^6,11. More integrated working relationships may arise for paramedics as a result of initiatives to bring their skill sets into the primary care setting. While preserving professional identities, such initiatives will also require new alignments between different disciplines and new models of partnership.

Strengths and limitations

This scoping review adds to existing literature by providing an overview of the variations in employment models, skillsets, training programmes, and challenges faced when paramedics deliver general practice care. Findings from this review may form the basis for the exploration and potential implementation of novel paramedic-general practice partnerships in Ireland. This literature review serves to guide future empiric research in this field as it has identified notable gaps in the current literature base.

The scoping review methodology described by Arksey and O’Malley has some limitations. Whilst we adopted their rigorous approach and employed a comprehensive search strategy, it is possible that not all publications relevant to the inclusion criteria were identified by the searches or databases used. Scoping reviews do not include an assessment of study quality as the focus is on covering the range of work that informs the topic rather than limiting the work to studies that meet standards of scientific rigor. Finally, only articles published in the English language were considered for inclusion in our review, and this could have resulted in the exclusion of equally relevant literature published in other languages.