Employing a paramedic in general practice

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. Obstacles such as prescribing limitations are soon to become a thing of the past, and with our ambulance services under immense pressure, there is no shortage of paramedics keen to consider careers in primary care.

Job role

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
• 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
• 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

Practicalities – including pay

When we hired a paramedic, we used NHS pay banding descriptions to determine an appropriate salary, opting for Band 8A rather than Band 7 based on experience. Now, they will be covered as part of 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 should bear in mind.

The new GP contract will fund up to 70% of a new paramedic’s salary from 2021 for networks. This cost will be based on Agenda for Change pay scales – at current rates, this is forecast to be around £33,000. Two points to consider: first, this will be a paramedic for the network, and you will need to discuss with other member practices how this will work; second, if you hire a paramedic before then, 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.

Role benefits 

A paramedic can bring a unique perspective to 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.

Potential drawbacks

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.

Key points

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.’  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.

Further reading: Spence, D. Bad Medicine: Good Medicine – The GP Paramedic. Br J Gen Pract 2017; 67 (660): 314 Fareham and Gosport and South Eastern Hampshire CCG. A Guide for General Practice Employing a Paramedic. June 2018, 2nd Ed 

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