Primary care networks (PCNs) will be funded to take on paramedics from April. GP partner and PCN co-lead Dr David Coleman outlines what paramedics can bring to general practice and how to decide if the role would suit your practice or network team
Paramedics are highly skilled professionals with a wealth of experience. As first responders to myriad emergencies, they have developed exceptional communication skills and are adept at making timely assessments and management decisions.
A paramedic can be a valuable addition to the primary care team. Paramedics are now able to train to be independent prescribers, and with our ambulance services under immense pressure, there is no shortage of paramedics keen to consider careers in primary care. Furthermore, paramedics can now be employed under the Additional Roles Reimbursement Schemes (ARRS) from April 2021.
When we hired a paramedic, we used NHS pay banding descriptions to determine an appropriate salary, opting for Band 8A on the Agenda for Change (AfC) pay scale, rather than Band 7, based on experience. The latest guidance for ARRS provides reimbursement costs at Band 7 for the paramedic role, or Band 8A for an advanced practitioner paramedic role.
Paramedics working in general practice will be covered by the state indemnity scheme, but they may still wish to have cover for GMC action and additional advisory services. When we hired, we spoke with our medical defence provider about adding the paramedic onto our group indemnity scheme for employed staff. This worked out as the most economical path to protecting her practice.
In terms of equipment, we provided a doctor’s bag of basic kit. She drives her own vehicle, and part of her contract requires her to have car insurance that covers business use. We operate out of a large LIFT building, so there were no issues regarding room space, although this is something more spatially restrained practices or PCNs should bear in mind.
Under the ARRS, PCNs are now guaranteed 100% reimbursement for the costs of employing a paramedic including a salary at Band 7 on the AfC pay scales (around £39,000 to £45,000 per annum outside London) – at current rates, forecast to be around £54,000 – or at Band 8A for an advanced practitioner (around £46,000 to £52,000 outside London).
Two points to consider for the ARRS: first, this will be a paramedic for your PCN, so you will need to discuss with other member practices how this will work; and second, if you hire a paramedic before April, you will not be able to claim back part of their salary, although you would be able to hire an additional member of staff – another paramedic, physician associate, pharmacist or social prescriber, if you so wish.
Paramedics can develop their clinical expertise in a number of directions and can become involved in audit, education and even management. Primarily, however, they are used to support GPs and assess the condition of patients who present to practices with acute symptoms.
Clinical
• To assess the condition of patients with acute conditions
• Highly suited to making home visits within the community – aligned with a practice or as part of home visit MDT across a PCN.
• To see cases in the surgery, initially starting with minor illness and musculoskeletal cases before gradually widening the case mix, in line with experience and further training
• Anticipatory care plans
• Fifteen-minute appointments with two catch-up slots per clinical session.
Non-clinical
• To free up GP time during the day, allowing extra capacity for doctors to be involved in education and complete administrative tasks
• Thirty minutes of debrief and thirty minutes of admin time at the end of the day.
NHS England recently set out key requirements of the paramedic role for reimbursement under the ARRS.
In summary it says their role is to ‘assess and manage patients presenting with acute presentations which include minor illness or injury, abdominal pains, chest pains and headaches’.
Among the clinical responsibilities is that the paramedic must work as part of a multi-disciplinary team (MDT) within the PCN.
The training requirements are:
To qualify for reimbursement at the higher band for an advanced practitioner, the role needs to have the following additional minimum training requirements:
The role must also take on extra responsibilities such as providing definitive treatment (including prescribing medications), managing undifferentiated undiagnosed conditions, identifying red flags and underlying serious pathology and taking appropriate action, as well as providing supervision to other roles within primary care, for example first contact practitioners and the personalised care roles.
A paramedic can bring a unique perspective to practice clinical meetings and significant event analysis, particularly if the case has an acute care flavour. The paramedic may also be a qualified CPR instructor.
Our initial thought was that a paramedic’s ability to assess and manage emergencies in the community would make them ideally suited to undertaking home visits in the community. As a practice with a high volume of home visits, we felt that freeing up GP time during the day would allow extra capacity for doctors to be involved in education and to complete administrative tasks.
Around the visiting period, we decided the best use of the paramedic’s skillset was to see cases in the surgery, initially starting with minor illness and musculoskeletal cases before gradually widening the case mix, in line with experience and further training.
In terms of proactive care and case planning, a paramedic’s experience and highly developed communication skills make them well suited to challenging discussions about future wishes, including attitudes towards resuscitation and end-of-life care.
A paramedic’s skills are not limited to emergency scenarios, although on the rare occasion that these do occur, it is a pleasure to have a cool, experienced head in the responding team.
And, critically, as we grapple with the rigidity of the new GP registrar contracts, paramedics can provide a welcome degree of flexibility. If GPs are coping with appointment demand but struggling to manage an unexpected volume of home visits, paramedics can pick up the slack. Each day in primary care presents its own set of challenges, and employing staff who both recognise and relish the challenges this presents is a genuine game changer.
Consider whether a paramedic would be a good fit for your practice. Most practices could benefit from an experienced paramedic. The key is having the capacity to provide the right level of supervision, particularly in the first 12 months. Regular progress review meetings should be conducted in the first six months to assess learning needs and plan support.
Educational support, such as allowing the paramedic to attend appropriate GP registrar tutorials and clinical meetings, is also key.
Triaging all our appointment requests allows the right patients to meet the right clinicians. This is particularly vital with the paramedic appointments. Playing to everyone’s strengths leads to happier staff and happier patients. That said, when the time is right, the case mix can be adjusted to support development.
If you recruit a non-prescribing paramedic, you will need to have a smooth system for prescription management. An accessible on-call doctor – allowing a paramedic to discuss a case and obtain the necessary script – means that 15-minute paramedic appointments are possible.
Another unforeseen problem is conflicts of role. On home visits to acutely unwell patients, paramedics may feel professionally obliged to stay with the patient until the ambulance arrives. This will lead to other patients being rebooked.
If you decide to employ a paramedic under ARRS at a PCN level, you need to think about how they will fit into the wider MDT.
For example they might be based in a handful of PCN practices with a particular need, such as practices with a high visiting caseload. In this case, you need to consider how they will be shared out equally, and if they will they form part of a home visiting team.
Such a team could comprise a range of ARRS staff, to manage a proportion of home visit requests on a PCN footprint. The team could triage visits and allocate the most relevant clinician to each request, be it a pharmacist, a paramedic or first contact physiotherapist.
This kind of model could free up significant GP time in the middle of the day, creating space for supervision and education of the ARRS staff. In our PCN, we have identified that structured education and enthusiastic support is vital in terms of both recruitment and job retention.
1. Be realistic
A paramedic can bring a lot to the surgery, but we must respect their skills and be mindful of limitations. At first, they are unlikely to have a deep knowledge of chronic disease management. That can be acquired, but if that is your clinical need a practice nurse or advanced nurse practitioner may be a wiser choice. For acute cases and home visits in particular, they can be an excellent asset.
2. Keep patients informed
Patients are generally very happy to see a paramedic, particularly if they have an acute problem. The key is transparency. We make it clear on our website, practice leaflet and over the phone when booking that they will be seeing an experienced paramedic practitioner.
When adding enhanced skills to the practice team, it can be useful to publicise and explain the rationale for this to the patients. A video in the waiting room, an article in the practice newsletter, or a presentation to the patient participation group are all good ways of doing this.
Writing in the BJGP, Dr Des Spence suggested ‘[referring] to our health professionals as “GP doctor”, “GP nurse” and “GP paramedic”, with all primary care clinical staff wearing the same simple uniform, like a scrub top.’[1] We haven’t gone as far as that, but it is one approach to consider.
3. Keep an open mind
As the average GP practice becomes larger, the structures necessary to support a wide range of skillsets are becoming more commonplace. With GP numbers dwindling, we will all need to approach recruitment with an open mind or risk unfilled positions. With the correct approach and a degree of patience, a primary care paramedic is an excellent option for practices that are ready to break with tradition and embrace the future.
Dr David Coleman is a GP partner and PCN co-clinical director in South Yorkshire
Reference
Further reading
Fareham and Gosport and South Eastern Hampshire CCG. A Guide for General Practice Employing a Paramedic. June 2018, 2nd Ed
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