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

Booker, Matthew; Voss, Sarah; Harris, Nicky; Hollingworth, William; Jeynes, Nouf; Taylor, Hazel; Garfield, Kirsty; Baxter, Helen; Benger, Jonathan; Gibson, Andy; Goodenough, Trudy; Jagosh, Justin; Kirby, Kim; Liddiard, Cathy; Proctor, Alyesha; Purdy, Sarah; Schofield, Behnaz; Stott, Hannah; Scrimgeour, Grace; Walsh, Nicola

Abstract

Background:
General Practice (GP) services are under pressure due increased demand . Alongside substantial national recruitment challenges, there exists a shortage of GPs to meet current need. Resultingly, allied healthcare professionals (AHPs), including paramedics, are being utilised in general practice.
Aim:
To determine the models of paramedics in general practice settings (PGP); mechanisms that underpin effective PGP; impact of PGP on safety, costs, clinical and patient reported outcomes and experience.
Design:
A mixed methods realist evaluation comprised of a rapid realist review followed by an evaluation of PGP in general practice case study sites. PPI input was integral, ensuring validity from a patients and carer perspective.
Setting:
General practices in England.
Participants:
Thirty four general practices participated as case study sites; 25 were PGP. Data from qualitative realist interviews (n=69), quantitative questionnaires (n=489) and electronic records (n=22,509 consultations) were collected.
Interventions:
PGP models were classified according to a) level of integration of the paramedic to the general practice team b) complexity of patients seen by paramedics.
Main Outcomes 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 (PREOS-PC) (safety); EQ-5D-5L (health related quality of life); Primary Care Outcomes Questionnaire (PCOQ); the Modular Resource Use Measure (ModRUM) (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 PREOS-PC practice activation scores were found at PGP sites (perceived less engaged in promoting safety) in particular those with medium and low levels of PGP integration and complexity. There was a small statistically significant difference in the PCOQ “Confidence in Health Plan” by PGP complexity, such that confidence had deteriorated slightly more in the high complexity group compared to non-PGP. PGP sites had lower scores at initial visit and 30 days for the PCOQ “Confidence in Health Provision”. We found little evidence that PGP care led to substantial spillover effects via increased re-consultations, 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 GPs in England, and categorising PGP models for analysis was more complex than anticipated. The comparison of costs and outcomes between PGP and non-PGP sites was based on an observational study design.
Conclusions:
PGP care improves access to general practice. Safety and acceptability require resources for induction, supervision, training, and education. PGP integration affects staff satisfaction and role longevity. PGP 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 PGP on clinical outcomes and episode of care costs.
Study Registration:
ISRCTN56909665 https://doi.org/10.1186/ISRCTN56909665
Funding:
This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in XXX Journal; Vol. XX, No. XX. See the NIHR Journals Library website for further project information.
 

• Journal Article Type: Article
• Acceptance Date: May 3, 2024
• Online Publication Date: Feb 28, 2025
• Publication Date: Mar 14, 2025
• Deposit Date: Jun 6, 2024
• Publicly Available Date: Mar 17, 2025
• Print ISSN: 2755-0060
• Electronic ISSN: 2755-0079
• Publisher: NIHR Journals Library
• Peer Reviewed: Peer Reviewed
• Volume: 13
• Issue: 6
• DOI: https://doi.org/10.3310/GTJJ3104
• Keywords: Aged, ALLIED HEALTH PERSONNEL, Allied Health Personnel, Middle Aged, PARAMEDIC, Cost-Benefit Analysis, Male, HEALTH WORKFORCE, EVALUATION STUDY, General Practice - organization & administration - methods - economics, Female, URGENT CARE, Adult, GENERAL PRACTITIONERS, Humans, England, EXTENDED ROLES, Surveys and Questionnaires, Paramedics, PRIMARY HEALTH CARE, Patient Reported Outcome Measures, Interviews as Topic
• Public URL: https://uwe-repository.worktribe.com/output/12036734