Title: The impact of paramedics in NHS primary care: Application of realist approaches to improve understanding, support intelligent policy and future workforce planning
Funder: Department of Health and Social Care

Abstract: BackgroundAccess 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? MethodsAn 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.

Lay abstract: Access to health and social care is changing. Increased demand for National Health Services, strained by staffing and financial burdens, has resulted in an evolution in the workforces providing unscheduled care. One such workforce is the ambulance service, and these changes have resulted in an upskilling of the paramedic workforce and an increased the scope of practice. Paramedics are predominantly known for their work responding to emergency 999 calls, however, as the care paramedics deliver within frontline ambulance services has developed towards more urgent case presentations their scope of practice to manage minor injuries and illnesses has developed. This change in the scope of work paramedics can undertake has established their role within primary care, where they can work alongside general practitioners and assist with staffing demands and time pressures faced within this sector. However, there is currently limited evidence to indicate the value of paramedics working in what are more typically seen as generalist physician roles, nor the impact of their care upon the patient. This study aims to identify the potential contribution paramedics can make to primary care by establishing what their role is when they work in primary care, and their relationships with other healthcare professionals and patients. It will answer questions and generate new evidence to show how, why, for whom and in what contexts do paramedics work in primary care. This will be answered through two distinct research activities: The first will find published material on the topic and develop an understanding as to how, why, for whom and in what contexts paramedics work in primary care, and what impact they have in their role. The second research activity will collect information from paramedics, general practitioners and other healthcare professionals (such as pharmacists and practice nurses) working in NHS primary care to further deepen our understanding. Information will also be collected investigating the patient experience. This information will be collected through surveys and in interviews. New information from the data collected in the second research activity will be used to refine the initial theory, fill in any gaps, and produce recommendations for how, why, in what contexts and to what extent paramedics may work in primary care. These results will be useful in informing policy, guidance and assessment tools to ensure paramedics working in primary care are safe and contribute to the primary care workforce. Whilst this research will be carried out as part of a DPhil at the University of Oxford, it is supported by key members from the professional bodies for paramedics (the College of Paramedics) and general practitioners (Royal College of General Practitioners), the non-departmental public body that supports the training and education of healthcare professionals (Health Education England) and representatives from patients and the public. Indeed, this plain English summary was composed and edited for clarity following their feedback. The findings of this research will be shared and discussed with these stakeholders over the course of the fellowship, to ensure they are able to elicit change within the wider healthcare workforce. This work will also be shared directly with healthcare professionals working in primary care, as well as patients and the public, to ensure that recommendations may be incorporated into practice. Overall, the findings of this study will contribute to the ongoing development of paramedics in primary care, which in turn will produce a tangible benefit for patients who access primary healthcare.

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