Title: A Realist Evaluation of Paramedics Working in General Practice: An assessment of clinical and cost effectiveness
Funder: Department of Health and Social Care

Abstract: General practices are under increasing pressure. There is a shortage of doctors to meet demand so general practices are using other health professionals to undertake some tasks. Paramedics (people trained to give emergency care outside of hospital) are one of the professions being used alongside doctors in general practice. However, we do not know if this is safe for patients or cost effective for the NHS. Research is needed urgently to inform national policy._x000D_ _x000D_ The role of paramedics in general practice varies greatly across England. For example, in many cases paramedics are employed to carry out home visits. However, some practices use paramedics for same day clinics or telephone appointments. Some paramedics do not see certain groups of patients (such as babies or pregnant women) whereas in other cases paramedics do see these patients. Due to these differences it is impossible to simply compare practices that employ paramedics with those that do not to see which patients get a better service and how much it costs. We are therefore using an approach called ‘Realist Evaluation’ to look at what works best in different circumstances._x000D_ _x000D_ Different practices have different problems to solve; one way of using paramedics may work well for one practice but not another. We will look at the effect this variation has on factors such as patient care, safety and experience, staff workload and costs to the NHS._x000D_ _x000D_ To begin, we will look at previous research on using paramedics in general practice. We will investigate issues that might be important in understanding what works for patients and staff and how it affects resources like time and money. We will talk to key people such as general practice managers, people who make funding decisions, doctors, paramedics and patients to ensure that we fully understand the important issues. This information will be used to guide a detailed investigation of general practices._x000D_ _x000D_ This investigation will focus on 24 different practices across England. Practices that represent the different ways that paramedics are being used, and those that do not have paramedics, will be included. We will include practices that vary in size, geography and other characteristics. In 12 of these practices, patients, doctors, nurses, managers and reception staff will be interviewed. We want to understand why certain models may work better in different situations and for different people. We will also collect information about patients who have seen a paramedic instead of a doctor. We can then investigate any differences in outcomes for patients or in costs to the NHS. In all 24 practices, a sample of patients who have and haven’t seen a paramedic will be invited to participate in the study to provide additional detail about their appointment, how they felt about it and what happened after it._x000D_ _x000D_ We will communicate the findings to academics. We will also use a wide-reaching communication approach for the general public. Customised materials, including digital stories and animations, video presentations and graphics will be held on a user-friendly website which will be coproduced with the study Patient and Public Involvement group._x000D_ _x000D_ The findings will provide a better understanding of how and why paramedics are best used in general practice under different circumstances, and the costs involved. This will have the potential to improve patient safety and experience and inform local and national funding decisions about NHS services.

Lay abstract: BACKGROUND_x000D_ General Practitioner (GP) services are under increasing pressure with growing demand; this is exacerbated by a shortfall in GPs. Other staff can address shortages and paramedics are increasingly being used alongside GPs. If paramedics manage minor illness, undertake home visits and provide same-day ‘urgent’ consultations, the perceived benefits include a reduction in practice costs and GP workload. However, there is significant variation in the types of condition and patients that paramedics are asked to see. Moreover, there are potential drawbacks if paramedics require a lot of supervision, take a long time to assess patients or make different referral and management decisions. There is a lack of evidence about the safety, clinical and cost effectiveness of paramedics working in general practice (PGP), and the different service models that exist._x000D_ _x000D_ AIM_x000D_ This study is a realist evaluation of the clinical and cost effectiveness of different models of PGP. Realist evaluation is a theory-driven approach to understanding complex interventions in complex environments in terms of what works, for whom, in what circumstances, how and why. The aim is to provide evidence from different models as to how they might: achieve good clinical outcomes for patients; provide safe care; improve patient experience; relieve GP workload pressure; influence the workload of other general practice staff; make efficient use of healthcare resources._x000D_ _x000D_ METHODS_x000D_ Two work packages (WPs) undertaken over 24 months:_x000D_ _x000D_ WP1: A rapid realist review to synthesise current information, classify models and produce a set of initial programme theories about how different PGP models work, with which resources in different situations. At the end of this WP, we will describe the crucial context-mechanism-outcome (CMO) configurations that underpin effective PGP service delivery models._x000D_ _x000D_ WP2: Case studies of general practices in England to test the programme theories. We will collect qualitative data from patients, carers and staff to understand the barriers and facilitators to PGP and the impact it has on access to general practice. We will use a combination of routine data and prospectively collected quantitative data to analyse the effects of differing models of PGP compared to no PGP; we will investigate patient reported clinical and safety outcomes, healthcare resource utilisation and costs to assess clinical and cost effectiveness. These case studies will examine the architecture of PGP models currently in practice. The realist analysis will scrutinize these findings against the CMO configurations from WP1 to produce a set of evidence-informed theories on PGP for future policy and planning._x000D_ _x000D_ ANTICIPATED IMPACT AND DISSEMINATION_x000D_ This study will report on the clinical and cost effectiveness of different PGP models. We will produce patient outcome, safety and economic data and synthesise these with information about which models are most acceptable to patients and staff. The findings will inform an understanding of the most efficient and safe use of paramedics in general practice. Short term impacts will be achieved through the production of the taxonomy and an early dissemination phase. In addition to academic and public dissemination, structured guidance for commissioning will be developed from the main study findings. This will improve demand management and workforce planning for primary and urgent care services.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: GENERIC HEALTH RELEVANCE