Clinical and cost-effectiveness of paramedics working in general practice: a mixed-methods realist evaluation.

Abstract

Background: General practice services are under pressure due increased demand. Alongside substantial national recruitment challenges, there exists a shortage of general practitioners to meet current need. Resultingly, allied healthcare professionals, including paramedics, are being utilised in general practice.

Aim: To determine the models of paramedics in general practice settings; the mechanisms that underpin effective paramedics in general practice; and the impact of paramedics in general practice on safety, costs and clinical and patient-reported outcomes and experience.

Design: A mixed-methods realist evaluation comprised a rapid realist review followed by an evaluation of paramedics in general practice in general practice case study sites. Patient and public involvement and input was integral, ensuring validity from a patient and carer perspective.

Setting: General practices in England.

Participants: A total of 34 general practices participated as case study sites, of which 25 were 'paramedics in general practice' sites. Data from qualitative realist interviews (n = 69), quantitative questionnaires (n = 489) and electronic records (n = 22,509 consultations) were collected.

Interventions: Paramedics in general practice models were classified according to: (1) level of integration of the paramedic to the general practice team; and (2) complexity of patients seen by paramedics.

Main outcome measures: Qualitative interviews investigated initial programme theories with staff and patient participants. Patient participant questionnaires utilised validated measures: the Patient-Reported Experiences and Outcomes of Safety in Primary Care (safety); EuroQol-5 Dimensions, five-level version (health-related quality of life); Primary Care Outcomes Questionnaire; the Modular Resource Use Measure (health and care resource utilisation). Electronic health records provided data on primary care use.

Review methods: A rapid realist review of the published and grey literature, supplemented with direct enquiry with system leaders and key stakeholders.

Results: The rapid realist review highlighted significant variation in paramedics' roles in general practice. Qualitative interviews identified domains related to access, safety, workforce reconfiguration, infrastructure, patient experience, and outcomes. Lower Patient-Reported Experiences and Outcomes of Safety in Primary Care practice activation scores were found at paramedics in general practice sites (perceived less engaged in promoting safety), in particular those with medium and low levels of paramedics in general practice integration and complexity. There was a small statistically significant difference in the Primary Care Outcomes Questionnaire 'Confidence in Health Plan' by paramedics in general practice complexity, such that confidence had deteriorated slightly more in the high-complexity group compared to non-paramedics in general practice. Paramedics in general practice sites had lower scores at initial visit and 30 days for the Primary Care Outcomes Questionnaire 'Confidence in Health Provision'. We found little evidence that paramedics in general practice care led to substantial spillover effects via increased reconsultations, prescriptions, secondary care referrals or unplanned hospital admission costs.

Limitations: The study faced challenges in recruitment. Self-selected participating sites may not be representative of all general practitioners in England, and categorising paramedics in general practice models for analysis was more complex than anticipated. The comparison of costs and outcomes between paramedics in general practice and non-paramedics in general practice sites was based on an observational study design.

Conclusions: Paramedics in general practice care improves access to general practice. Safety and acceptability require resources for induction, supervision, training and education. Paramedics in general practice integration affects staff satisfaction and role longevity. Paramedics in general practice allows paramedics to develop and evolve.

Future work: Larger studies utilising different study designs with longer follow-up are needed to fully understand the impact of paramedics in general practice on clinical outcomes and episode of care costs.

Study registration: This study is registered as ISRCTN56909665 https://doi.org/10.1186/ISRCTN56909665.

Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR132736) and is published in full in Health and Social Care Delivery Research; Vol. 13, No. 6. See the NIHR Funding and Awards website for further award information.