A realist evaluation of paramedics working in General Practice: An assessment of clinical and cost effectiveness

Study team

• Dr Sarah Voss (UWE Bristol), Co-chief Investigator
• Dr Matthew Booker (University of Bristol), Co-chief Investigator
• Professor Jonathan Benger (UWE Bristol)
• Professor Sarah Purdy (University of Bristol)
• Professor Nicola Walsh (UWE Bristol)
• Professor William Hollingworth (University of Bristol)
• Dr Justin Jagosh (University of Liverpool)
• Hazel Taylor (NIHR Research Design Service South West)
• Dr Helen Baxter (University of Bristol)
• Dr Behnaz Schofield (UWE Bristol)
• Dr Andy Gibson (UWE Bristol)
• Alyesha Proctor (UWE Bristol)

Study summary

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.

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.

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.

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.

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.

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.

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.