Using realist approaches to explain and understand the optimal use of paramedics in primary care.
Background Access to healthcare is changing. Ambulance services have traditionally deployed paramedics to life-threatening emergencies, however these emergencies now make up just 8% of calls (Keogh, 2017), indicating a large proportion of patients access the ambulance service with lower acuity presentations This change in demand has catalysed the evolution of ambulance services, positioning as see-and-treat healthcare providers rather than transport services. This changing demand on ambulance services has caused a change in what is expected of a paramedic. As well as advanced life support, paramedics now need to be skilled in managing a range of urgent case presentations, with emphasis on treat-at-scene. Education to support this is found within postgraduate study, and results in specialist, advanced and consultant roles. With new legislation supporting non-medical prescribing by advanced paramedics, their ability to manage low acuity and complex case presentations appears to be well suited to primary care.As paramedics' transition to roles within primary care, their knowledge and skill set will undoubtedly change (National Institute for Health and Care Excellence, 2017a, 2017b; Primary Care Workforce Commission, 2015). The current opportunities for paramedics' employment in primary care requires careful evaluation. In order to contribute to patients and the NHS primary care agenda, evidence must be generated to show how and why these changes would work, for whom, in what context and to what extent.
Objectives This study aims to investigate the contribution of paramedics to the delivery of patient care in primary care services in England. This will be answered by addressing the following research questions: How, why, for whom and in what contexts do paramedics work in primary care settings? What is the impact of paramedics working in primary care teams on the working practices of other healthcare professionals and the experience of patients? What knowledge, capabilities and skills do paramedics working in primary care need to work in primary care within the NHS?
Methods An initial scoping review has informed the need for realist approaches to frame this research. A realist review has started and will identify from the literature the different contextual influences that inform practice outcomes for paramedics in primary care. A programme theory will be developed from this, identifying any theoretical gaps in this literature. The theory produced will then be further refined using primary data collected using a pragmatic mixed methods approach, consisting of survey data and qualitative interviews. This evaluation will provide an understanding of the factors and relationships that underpin paramedics working in primary care.
Anticipated impact and dissemination At present it is unclear how paramedics work in primary care and what knowledge and skills paramedics working in primary care need to deliver high quality care. This research will develop the resources needed to address this issue. I will develop these resources with input from PPI and Health Education England, the Royal College of General Practitioners and the College of Paramedics. Their support will ensure the results of this project are fit for purpose and will reach those who need them.
As a clinical academic Advanced Paramedic, I am an NIHR Doctoral Research Fellow (NIHR300681).
My DPhil project seeks to explore the impact of paramedics in NHS primary care, using realist approaches to improve understanding, support intelligent policy and make recommendations for future workforce planning.
I am also the Trustee for Research on the Board of Trustees for the College of Paramedics. I hold other roles within the professional body, including National Education Advisor for England (Alternate) on the Education Advisory Group (setting the nationwide strategic direction of paramedic education); and as a clinical member of the Primary and Urgent Care Special Interest group – focusing on the employment of specialist and advanced paramedics in these settings.
I work clinically as the Clinical Practice Development Manager for Advanced Paramedic Practitioners in Urgent Care for London Ambulance Service NHS Trust, working across ambulance, urgent and primary care settings.