THE JOURNEY SO FAR
The community paramedic role was piloted at The Swan Practice in Buckingham in November 2016 in response to the national problems of recruiting both GPs and nurses alike. The paramedic was able to provide care for patients in their home environment, enabling the practice to tackle the challenges of unscheduled home visits. The role became an extension of the services offered by the practice, with excellent lines of communication between this autonomous practitioner and GPs to ensure safe patient management. The pilot project demonstrated that by using a paramedic to attend unscheduled home visits while closely liaising with a GP, the practice could effectively reduce the amount of time spent by GPs doing such visits both safely and effectively. This approach quickly gained patient acceptance and reduced the number of acute hospital admissions during the pilot.
The practice appointment system was redesigned in April 2017 and the paramedic role was integrated into this. Appointments were offered on a ‘Same Day’ (urgent) or ‘Any Day’ (routine) basis, with requests being directed by care navigators to the most appropriate service. The Any Day service had a typical scheduled appointment system for routine reviews, complex care-planning, and long-term condition care utilising GPs, practice nurses, and healthcare assistants. The Same Day service offered patients the choice of a face-to-face appointment with a GP or minor illness-trained nurse, GP telephone triage call or an urgent home visit. The paramedic concentrated on the home visit requests under the guidance of a dedicated GP.
Home visits ranged from minor illness presentations in patients who are housebound to referrals from other community healthcare professionals, including acute-on-chronic presentations of long-term conditions and palliative care.
Over time, the paramedic role evolved through the completion of further minor illness training alongside members of the practice nursing team. This meant that the paramedic was now able to consult patients with minor illnesses in clinics under the supervision of a GP alongside conducting home visits. The nurses, together with the paramedic, formed the Minor Illness Practitioner (MIP) team which, given the success of the paramedic pilot, was expanded in 2018 with the recruitment of more paramedics. The MIPs became responsible for managing all acute emergencies within the practice, freeing up the GPs to continue with their patient lists, thereby reducing the impact on patients and staff.
As of 2019, the MIPs save GPs between 4–6 hours per day in acute home visits. They also provide around 90 minor illness appointments per day saving around 23 hours a week of GP appointments.
In addition to this, they now contribute over 4 hours to the extended hours capacity per week. Integrating the paramedic role into the existing clinical team at the practice has reduced the number of home visits undertaken by GPs, allowing them to concentrate on more complex cases and save time and resources for an expanding practice with over 30 000 patients.
THE JOURNEY AHEAD
The Buckinghamshire Training Hub and NHS England are working to collate different approaches to integrating the paramedic role into primary care by planning and designing forums in order to ensure sustainability, support, and stability for practices and practitioners.
Alternative models to the direct employment of paramedics by a practice could be through employing the practitioner across a network of practices (as per the new GP contract) or using the rotating paramedic model. The network model offers access to paramedics for smaller practices working in partnership with other practices to share resources, clinical hours, costs, training, and continued professional development (CPD). The rotating paramedic model was intended to develop a flexible workforce utilising specialist and advanced paramedics. These paramedics rotate between a number of settings including primary care, ambulance control rooms, and as part of multidisciplinary teams. Four ambulance services are piloting the rotating paramedic model, where the paramedic remains employed by the ambulance service thereby reducing costs to practices (it is the ambulance service that provides staff and equipment alongside holding responsibility for management, training, and CPD). The experience gained from GP practices and multidisciplinary teams is retained within the ambulance service. With paramedics rotating between different clinical settings, it is vital for each area to arrange induction programmes and work plans for every new rotation. This is not without cost — including increased GP supervision at the outset alongside time to fully integrate into the practice team, which may not be possible during their limited rotation. The use of paramedics and indeed other healthcare professionals in primary care offers the opportunity to enhance patient care through supplementing the GP and nurse workforce and broadening the collective clinical expertise and experience available in the community.