Potential for Paramedic roles in Irish General Practice: A qualitative study of stakeholder’s perspectives

Policy context

‘Sláintecare’, Irelands ten-year health strategy outlines a high-level policy roadmap for reform by reorienting the Irish health system towards integrated primary and community care¹. Currently, primary care services in Ireland are under increasing workforce pressure amidst a growing shortage of general practitioners (GPs)^2,3. Responses such as the further development of primary care teams, the expansion of General Practice Nursing and the potential for novel roles within General Practice, have been described^4–6. The Sláintecare report also highlights significant possibilities for extending the roles of Paramedics alongside other health care professionals to provide services in the community⁷. Paramedics already actively participate in routine General Practice care in some jurisdictions such as the United Kingdom and Canada, but not yet in Ireland⁸.

General Practice in Ireland

Ireland’s population in excess of five million, has in the region of 4,000 GPs who provide primary care to patients and communities across the lifespan^9,10. General Practice in Ireland is structured around a small business model where approximately 40% of the population qualify for free GP care contracted by the Irish State, with the remainder paying privately¹¹. Approximately 21 million GP consultations and seven million Practice Nurse consultations occur annually¹². More than 14% of Irish GPs are 65 years or older, with females representing a growing demographic now accounting for 42% of the workforce¹³. Prior to the COVID-19 Pandemic, on average Irish GPs completed more than 25 face to face consultations over a ten-hour working day with 36% of overall time spent on administrative activities¹⁴. Ninety percent of GPs in Ireland participate in out-of-hours care¹³. Although GP numbers increased by 20% between 2005 to 2015, there remains significant concern (in the context of population increases and a shift toward care in the community) regarding a growing shortage of GPs, which is expected to exceed 1,000 by 2025^3,15. Significant initiatives have been launched to increase capacity in GP training, however it remains unclear whether this alone can address future demand for services¹⁶.

Paramedicine in Ireland

In Ireland, statutory emergency medical services (EMS) are provided by the Health Services Executive via the National Ambulance Service and Dublin Fire Brigade¹⁷. These services respond to approximately 320,000 emergency ambulance calls annually¹⁸. The scope of practice of EMS practitioners is determined by an independent statutory agency, the Pre-Hospital Emergency Care Council (PHECC) who publish clinical practice guidelines and maintain a practitioner register¹⁹. Statutory EMS care is provided by PHECC registered Paramedic and Advanced Paramedic practitioners. As of July 2021, there were 2426 PHECC registered Paramedics and 700 Advanced Paramedics in Ireland²⁰. Paramedics have traditionally qualified via a two-year university diploma, and with two years additional post-registration experience can apply to undertake Advanced Paramedic training via a two-year university graduate diploma. While entry level Bachelor of Science degree qualifications have been introduced, they are not yet a requirement for professional registration. Until recently the role of Paramedics and Advanced Paramedics in Ireland has been exclusively focused on emergency care, however a recent pilot project has explored the feasibility of ‘Community Paramedicine’ where Paramedics operate in expanded primary care roles within the ambulance service²¹.

Paramedics in General Practice: International perspectives

The ‘Community Paramedicine’ development in Ireland mirrors international developments in paramedicine. A number of recent reviews have detailed the evolving role of paramedics in the delivery of primary care through collaborative partnerships with general practitioners, practice nurses and multidisciplinary teams, aimed at providing care in the community closer to home^21–23. This is particularly true where paramedics provide access to primary healthcare in settings where it would otherwise not be available or delayed, such as in rural and isolated communities, and with populations that have historically faced barriers in accessing healthcare, such as those experiencing homelessness^21,24. Paramedics have already undertaken roles in primary care assessment and onward referral, health promotion, vaccination, chronic disease monitoring and management, palliative care and urgent primary care²³. Community paramedicine programmes can result in a net reduction in acute healthcare utilization for enrolled patients, appear to be economically viable for the health service and result in positive patient outcomes with high patient satisfaction with care²³. However, the international literature demonstrates the need for a greater understanding in the areas of education, scope, role, and governance and supervision of paramedics when working in primary care settings. Without first exploring these issues paramedic roles in primary care may not realise their full potential.

Aim

Given the health policy context in Ireland, a growing shortage of GPs and the development of Community Paramedicine, we aimed to explore perceptions of ‘the potential for Paramedic roles in Irish General Practice’ via a qualitative stakeholder consultation.

Ethical approval

This study received research ethics approval on the 14^th of July 2020 from University College Dublin, Human Research Ethics Committee (LS-20-35-Barry).

Researchers’ positionality

Our research team incorporated professional perspectives from General Practice, Nursing, Paramedicine and Primary Care research. TB and GMC acted as lead researchers. Of note TB is an Academic GP who has research, education and clinical interests in emergency medical services including community paramedicine. TB is a member of the Irish Pre-Hospital Emergency Care Council and has a lead role in the development of national regulatory frameworks for community paramedicine. GMC is a research scientist with significant prior experience of qualitative research but no direct experience of community paramedicine prior to this research project.

Participants

Interviews were conducted with a total of eighteen participants (Table 1) that included six senior Paramedics (Advanced Paramedics), seven General Practitioners (GPs), three Practice Nurses and two Practice Managers.

Recruitment

As this exploratory study was one of the first to consider the potential for Paramedic roles in Irish General Practice, we hypothesised that key stakeholders were patients, members of the Paramedic profession, General Practitioners, Practice Nurses and Practice Managers. In this study we focused our data collection on professional groups only. Planned follow-on work will consult directly with patients as a distinct group.

We employed a purposive approach to sampling. At the outset we targeted a total sample of between 16–20 participants with approximate thirds representing Paramedics, GPs, and Practice Nurses/Managers (as a combined group). We based this sample size target on our previous experience of conducting qualitative research and the overall aim of achieving a thorough understanding of the phenomenon under study^28–30. We considered GPs and Paramedics to be core initial stakeholders with Practice Nurses and Managers also representing important stakeholders. Our sampling frame sought to achieve maximum-variation sampling considering gender and location of practice³⁰. Recruitment occurred in an incremental fashion, and continued until we considered that an appropriate sample size had been achieved, one that could facilitate a thorough understanding of the phenomenon under study. Over the recruitment process a single email invitation was sent to a total of twenty GPs, eleven Paramedics and five Practice Managers. GPs, Paramedics and Practice Managers were all drawn from the University College Dublin (UCD) professional network. UCD is Irelands largest medical school and has provided academic training programs for Paramedics and Advanced Paramedics since 2005³¹. The University actively engages a large pool of adjunct clinical faculty that supports undergraduate medical General Practice (approximately 200 GPs) and Paramedical training (approximately 60 Advanced Paramedics). The University also has engagement with GP Practice Managers around undergraduate student placements. Practice nurses were recruited via the professional networks of Professional Development Coordinators for Practice Nursing who disseminated an invitation to participate on behalf of the research team.

Data collection

One researcher (GMC) conducted all interviews, which were via telephone and took place between January and October 2021. Prior to conducting the interviews TB & GMC formally planned the interview process. A semi-structured interview format was adopted to allow flexibility of response, and follow up ‘unplanned’ questions via a participant led exploration of topics²⁷. Our approach involved the development of a topic guide that facilitated outline structure but did not mandate rigid adherence³². This guide was informed by a prior scoping review⁸. The guide included five domains: general awareness, acceptability, feasibility, potential and challenges. Each domain involved standard initial open-ended prompt questions and flexible follow-on questions based on the interviewee’s initial responses. A copy of the topic guide can be found in the Extended data³³. Informed written consent was obtained before commencing each interview. Interviews ranged between ten- and twenty-four-minutes duration, (average seventeen minutes). The initial interview acted as a pilot. Brief field notes were kept throughout the interview process. All interviews were audio recorded using Skype and later professionally transcribed. TB then checked against the recordings for accuracy, made minor corrections as necessary, and removed any information that was considered to identify participants. Transcripts were stored electronically as password protected files.

Data analysis

Data were analysed using the thematic analysis (TA) framework outlined by Braun and Clarke that includes six phases: ‘Data familiarisation’, ‘Generating initial codes’, ‘Searching for themes’, ‘Reviewing themes’, ‘Defining and naming themes’ and ‘Producing a report^26,34. This framework was selected based on the research teams prior experience of employing the methodology, its accessibility as a qualitative research approach and its flexibility in terms of theoretical framework³². Initial coding and all further phases of TA were supported by NVIVO 12 for Windows. TB and GMC acted as co-researchers during the analytic process to ensure credibility. TB coded all transcripts while GMC coded a sample of four transcripts independently. Both TB and GMC reviewed all candidate and final worked out themes thus supporting a reflexive process throughout the data analysis³⁴. The analysis ultimately produced a structure of themes relating to the key domains that reflect the focus of our study.

Overall structure of themes

Comprehensive data analysis generated a structure of themes as illustrated in Figure 1, and described below. A central organising theme was that of ‘polarised perspectives’ where Paramedic participants expressed enthusiasm for the concept of Paramedics working in General Practice while the General Practice community were by in large more sceptical. This central theme was driven by four distinct sub-themes. In terms of Paramedic enthusiasm these subthemes related to a perception that novel roles would offer the opportunity for increased autonomy and professional development and in addition have more favorable working conditions. In contrast, General Practice scepticism was driven by a perceived misalignment between the professional nature of Paramedicine and General Practice. In addition, there was a definite sense that addressing unrealised Practice Nursing potential was a higher immediate priority for General Practice.

Figure 1. Overall structure of themes.

Beyond this central thematic structure, a background sub-theme represented a function of the large variety of potential future Paramedic roles within General Practice suggested across all participant groups. Suggested roles varied across in and out-of-hours care, chronic and acute disease management as well as in terms of levels of responsibility and complexity. There was however consensus that formal government support would be required to allow the development of any such roles.

Polarised Perspectives: Paramedic Enthusiasm & General Practice Scepticism

The senior Paramedics interviewed were uniformly supportive of the concept of Paramedics working in General Practice.

However, most GP’s, Practice Nurses & Managers were more circumspect.

Paramedic Enthusiasm: Autonomy & Professional Development

Paramedics interviewed highlighted the potential increasingly autonomous nature of new roles.

From the Paramedic perspective such roles in General Practice were particularly attractive in terms of opportunities for professional development.

In terms of alignment with a broadening scope of practice, Paramedics did feel that these novel roles would be appropriate for senior, experienced Paramedics.

Paramedics also highlighted the need for specific training and for mentorship in preparation for these proposed new roles. They highlighted that the nature of this preparation should be tailored to what the role will incorporate.

One specific area highlighted as requiring further training was mental health presentations. This was described as a significant issue relevant to both novel roles in General Practice and relevant in terms of day-to-day emergency work.

This issue was also highlighted by one GP participant.

Paramedic Enthusiasm: Favourable Work Conditions

Paramedics described how novel roles could be attractive at the later stages of their careers in terms of more sociable hours, better work conditions and salary.

Paramedics noted that experienced colleagues might also be less motivated by the excitement or pace of emergency care and more willing to work in the less acute environment of General Practice.

In parallel though there was some recognition that the small business context of General Practice could also imply less stable employment arrangements, that may not be attractive to those coming from public service employment.

General Practice Scepticism: Professional Misalignment

GPs, Practice Managers and Nurses highlighted a discordance between the traditional emergency focus of Paramedic training and the nature of General Practice. Although they acknowledged some overlap in terms of Paramedic and GP practice emergencies, General Practice was considered a distinct domain unlikely to be reflected in Paramedic training.

Key issues relevant to General Practice were highlighted including continuity, complexity, and reassurance. These issues were not considered to be core to Paramedic training or experience.

Some expressed significant concern that Paramedics would not be able to adapt their practice to the primary care context.

Others highlighted the significant differences in duration and depth between Paramedic and GP training.

Some participants believed Paramedic training and skills would be more appropriately deployed in environments other than General Practice.

Despite the assertion that the General Practice context was not a natural fit for Paramedics, the general sense was that patients were likely be open to Paramedics providing General Practice care.

In some contrast to the General Practice concern around professional misalignment, Paramedics did highlight very significant exposure to low acuity conditions during their experience of working in the EMS system.

In addition, they highlighted their generalist nature, having experience of a breadth of undifferentiated presentations across all age groups.

General Practice Scepticism: Unrealised Practice Nursing Potential

Throughout the interviews GPs, Practice Nurses and Practice Managers highlighted the current key role and future potential of ‘Practice Nursing’. A recurrent issue raised was whether the addition of Paramedics to General Practice could bring relevant additional skills and capacity over and above what could be accessed via further resourcing and developing Practice Nursing in Ireland.

One Practice Manager observed that Paramedics would need significant additional training to work in General Practice whereas nursing training was viewed as more applicable to the General Practice setting.

The potential for novel advanced nurse practice roles, with more responsibilities in the context of a GP shortage were highlighted. This was perceived as a more logical way to solve a GP staffing crisis.

One GP framed the issue in terms of the allocation of scare resources and opportunity cost. Their perspective was that as nursing was already established in General Practice, resources would be better deployed in enhancing the nursing role rather than developing a new role.

Another GP highlighted the risk that Paramedic working in General Practice could result in a workforce shortage in front line emergency ambulance services.

Several participants from the General Practice setting highlighted the alignment of existing GP funding with Practice Nursing and revenue streams.

Although most GPs, Practice Managers and Practice Nurses were sceptical as to what additional benefit Paramedics would bring to General Practice above and beyond a Practice Nurse, this was not universal. One GP believed Paramedics would be a good fit for General Practice in terms of their communication skills, attitude and ability to integrate.

Other participants highlighted the reality of a shortage of Practice Nurses in addition to GPs. These participants acknowledged that there may not be sufficient GP or nursing supply to manage work demands in General Practice into the future.

One Practice Nurse specifically linked the nursing supply issue to the terms and conditions of employment in General Practice, which were perceived as inferior to the hospital environment.

Other Practice Nurses expressed concern that the addition of Paramedics to General Practice could undermine development and resourcing of the Practice Nursing role. There was a concern that by pursuing Paramedic involvement in General Practice, public resources would be channelled away from the development of Practice Nursing.

Another Practice Nurse highlighted the difficulty with potential employment arrangements in General Practice and a perception that Paramedics working in General Practice would continue to be directly employed by the public health service, and thus have access to benefits not currently enjoyed by Practice Nurses.

Varied perceptions of Multiple Potential Roles for Paramedics Working in General Practice

Across the participants interviewed there were varying perceptions in terms of the potential scope of practice of a Paramedic working in General Practice and the roles that one might fulfil.

Some participants highlighted the potential to take on domiciliary care thus freeing up GP time.

Others envisaged the role as revolving around acute problems or acute presentations of chronic illness.

One Practice Manager took a pragmatic view. If a Paramedic working as an advanced practitioner could demonstrate the capacity to cover for periods of leave or GP shortages this would be considered an attractive proposition in the current workforce shortage climate.

At the other end of the spectrum some participants envisaged that Paramedics working in General Practice could free up nursing time by taking on some of the more straightforward or procedural duties currently undertaken by Practice Nurses.

Some participants did highlight that the concept might have specific relevance in out of hours care and in rural areas where the GP workforce shortage is particularly acute.

Independent of the specifics of scope and role, participants uniformly highlighted the need for government support and funding to facilitate Paramedic working in General Practice. In particular, the small business nature of General Practice was highlighted as a potential challenge.

In addition to Paramedic renumeration, participants again highlighted that support would be needed in terms of training and also regulation.

Summary

Participants in this study expressed polarised views as to the overarching potential for Paramedic roles in Irish General Practice. The senior Paramedics (Advanced Paramedics) interviewed were positive about the concept citing opportunity for professional development and favourable working conditions. They detailed significant experience of lower acuity presentations via their existing day to day roles but considered additional training for novel General Practice roles a necessity. Participants from the General Practice community (GPs, Practice Nurses and Practice Managers) were more circumspect and had concerns that Paramedic’s core training and scope of practice was not aligned to most General Practice care.

Although not a specific element of our research question, participants from general practice (GPs, Practice Nurses and Practice Managers) noted the issue of the current role and future potential of General Practice Nursing as a priority. For some, consideration of Paramedic roles in General Practice was considered a distraction from what was a greater priority. There was a sense that the potential of General Practice Nursing had not yet been realised and that systemic barriers existed that must be addressed in the first instance. In addition, participants discussed the employment model of Practice Nursing within a small business framework, and with limited state support for further professional development.

Participants had varied perceptions of the nature of potential roles for Paramedics in General Practice that included elements of domiciliary care, same day acute presentations and chronic disease management. For some, the role could involve autonomous decision-making, bridging that of the Practice Nurse and GP and for others the role would involve concrete procedural tasks that could free up nursing time. Out-of-hour’s care and rural practice were considered to be specific areas of current workforce supply-demand mismatch and thus were seen as most relevant to potential Paramedic roles. There was uniform agreement across participants that state support would be necessary in terms of educational and service delivery elements of any future model.

Comparison with existing literature

In keeping with the theme of ‘varied perceptions of the potential role’, the wider literature also notes significant real-world variation in terms of Paramedics working in General Practice roles, often reflecting differing training and support mechanisms as well as local circumstances^8,35. Booker and Voss have suggested three overarching models for Paramedic working in General Practice: Paramedics provide routine patient care thus freeing GP time to manage more complex issues; Paramedics create additional capacity and thus allow general practice to manage urgent problems in a timely manner; Paramedics provide timelier and longer consultations and thus have the potential to improve patient satisfaction and clinical outcomes³⁶. Participants in our study noted that there was potential for paramedics to provide additional general practice capacity in Ireland across these three models.

The degree of scepticism toward the concept of Paramedics working in General Practice expressed by the General Practice community in this study does not appear to be reflected widely in the literature⁸. A degree of scepticism is however understandable in the context of a current relatively limited evidence base considering clinical and cost effectiveness as well as safety^8,22,37–39. That said the scepticism identified in this current study does appear to contrast with a largely positive view of Paramedics working in General Practice held elsewhere, one that frequently relates to a perceived association with reduction in GP workload^22,37. The results of our study suggest that the Irish General Practice community may be unaware of the evidence and thus wider possibilities of ‘Community Paramedicine’ in both chronic disease management and in addressing gaps in primary care provision. For instance, research from Canada demonstrated that Community Paramedic programs can act as primary care extenders and met the needs of vulnerable populations²⁴. In Ontario, a Paramedic-led community-based program for older adults living in subsidized housing was found to be cost effective, lowered blood pressure and was associated with improved functional independence^40,41. Interestingly, a recent additional study from Ireland that focused on rural General Practitioners, suggests that this specific group may be significantly more enthusiastic about the potential for paramedic involvement in the near term⁴².

Though not the focus of our study our research does highlight the importance and potential of the General Practice Nursing role in Ireland. There appears to be a dearth of scientific literature considering this domain despite the observation that approximately one third of all clinicians working in General Practice in Ireland are Practice Nurses⁴³. Previous research suggested that the role of the Practice Nurse in Ireland centred on immunisation, direct clinical care and elements of chronic disease management⁴⁴. Recent research involving a survey of Practice Nurses and GPs in one county found that the large majority considered an expanded role for practice nurses to be a high priority⁶. Further research is ongoing and aims to quantify the provision of quality Nursing care in Irish General Practice⁴⁵.

Participants from General Practice in this study raised concerns regarding the potential for role conflict and competition for resourcing when considering Nursing and Paramedicine in the General Practice Setting. The wider literature does highlight potential antagonism towards new Paramedic roles in Primary Care but suggests that this can be resolved through exposure, familiarity, and the clarification of scope of practice from the outset^8,46,47. The importance of full integration with the primary care workforce has been identified as a key feature of successful models of Paramedic working in primary care²¹. The interface of GP, Practice Nurse, Paramedic and other Primary Care Staff warrants ongoing consideration. An important component of the Irish ‘Sláintecare’ strategy is the facilitation of efficient models that allow health care professionals to work to the ‘full scope of their licence’⁴⁸. The results of this study suggest significant further potential for the Practice Nursing Role at least in tandem with (and perhaps before) any major drive to recruit Paramedics into General Practice.

Our previous scoping review noted a lack of literature that explored the motivation of Paramedics to transition to General Practice roles⁸. In this study we found that a desire for further professional development as well as increased autonomy may be important motivating factors. Furthermore, Paramedics at a certain stage of their careers may perceive the work conditions in General Practice to be more favourable than in front line ambulance care. It remains to be seen whether these perceptions will in fact be realised in any model that emerges. Notably both Practice Nurses and GPs highlighted significant existing issues in terms of the employment conditions and existing professional supports relevant to Practice Nursing.

Strengths and limitations

Our study has several strengths that support its ability to inform understanding of this topic. These include the use of published reporting guidelines to inform design from the planning stage, consultation with a patient and public advisory group, and the use of a prior scoping review to inform the development and implementation of this research. However, there are some important limitations that should be considered in interpreting our results. The interviews conducted yielded a rich understanding of participants perspectives across a range of relevant disciplines. It is however not clear to what extent these perspectives apply more generally outside of the research sample. Most participants had some affiliation or prior relationship with University College Dublin, and this may have influenced their perceptions. Ultimately the findings need to be viewed as hypothesis generating and further research is needed to establish whether the findings are generalisable to the wider population of Paramedics, GPs, Practice Nurses and Practice Managers in Ireland.

Implications for research and practice

The data collected in this study suggests that Paramedics may be well disposed to the concept of working in General Practice however the General Practice community may be more circumspect. Further research should be conducted to ascertain whether these findings apply more generally in Ireland. If General Practice reticence is widely held this will represent a significant barrier to be overcome as any initiative is progressed. A recent pilot project has involved ‘Community Paramedics’ operating in expanded primary care roles within the Irish ambulance service [20]. These Community Paramedics spend time in designated GP practices during their training and maintain a relationship with that practice after. The small cohort of GPs (and potentially Practice Nurses and Managers) involved in this pilot will have now accrued significant exposure to the Community Paramedicine concept and are likely to have a key perspective on the future potential of Paramedic roles within core General Practice. The perspective of this group is not captured within this current research but may be critical in informing future developments. While focusing on Paramedicine our research also highlights the importance of Practice Nursing roles as a key issue for Sláintecare, General Practice and the Irish health system. It appears crucial that any novel Paramedic roles in General Practice are developed in tandem with and with due consideration for General Practice Nursing, both as currently configured and as envisaged into the future. Given these observations coupled with a current lack of evidence considering patient centred outcomes and cost, novel models involving Paramedic working in General practice should be piloted within a research framework that gathers real world evidence to inform developments⁸.

Underlying data

As this is a qualitative study the underlying data represents audio recordings and written transcripts that have been derived from the recordings. The participants have been guaranteed anonymity in the consent form, and the studies ethical approval requires that both the recordings and transcripts are not shared outside the study team. Therefore, underlying data for this study cannot be shared with other researchers. The Methods section contains detailed information to allow replication of the study. Any queries about the methodology should be directed to the corresponding author.

Extended data

Open Science Framework: Potential for Paramedic Roles in Irish General Practice: A Qualitative Study of Stakeholder’s Perspectives. https://doi.org/10.17605/OSF.IO/7TA35³³.

This project contains the following extended data:

Data are available under the terms of the Creative Commons Zero "No rights reserved" data waiver (CC0 1.0 Public domain dedication).