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Jones B, Anchors Z, Voss S, Walsh N. Challenges and enablers to implementation of the Additional Roles Reimbursement Scheme in primary care: a qualitative study. Br J Gen Pract 2024; 74:e315-e322. [PMID: 38228358 PMCID: PMC11044017 DOI: 10.3399/bjgp.2023.0433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 01/03/2024] [Indexed: 01/18/2024] Open
Abstract
BACKGROUND The Additional Roles Reimbursement Scheme (ARRS) was set up to recruit 26 000 additional staff into general practice by 2024, with the aim of increasing patient access to appointments. Despite the potential benefits of integrating ARRS practitioners into primary care, their implementation has not always been straightforward. AIM To explore the challenges and enablers to implementation of the ARRS including its impact on primary and secondary care systems. DESIGN AND SETTING Qualitative interview study with ARRS healthcare professionals and key professional stakeholders involved in staff education or scheme implementation across three integrated care systems in England. METHOD Participants (n = 37) were interviewed using semi-structured individual or paired interviews. Interviews were audio-recorded and transcribed. Data were analysed using framework analysis until data saturation occurred. RESULTS Using framework analysis, 10 categories were identified. Three were categorised as successes: staff valued but their impact unclear; multiple and certain roles maximise impact; and training hub support. Seven were categorised as challenges: scheme inflexibility; creating a sustainable workforce with career progression; managing scope and expectations; navigating supervision and roadmap progression; infrastructure and integration challenges; ARRS roles impact on wider systems; and tensions and perspectives of existing staff. CONCLUSION Most ARRS staff felt valued, but the scheme broadened expertise available in primary care rather than reducing GP burden, which was originally anticipated. Some PCNs, especially those in areas of high deprivation, found it difficult to meet the population's needs as a result of the scheme's inflexibility, potentially leading to greater health inequalities in primary care. Recommendations are proposed to optimise the effective implementation of the primary care workforce model. Further research is required to explore administrative role solutions, further understand the impact of health inequalities, and investigate the wellbeing of ARRS staff.
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Affiliation(s)
- Bethan Jones
- Centre for Health and Clinical Research, University of the West of England Bristol, Bristol
| | - Zoe Anchors
- Centre for Health and Clinical Research, University of the West of England Bristol, Bristol
| | - Sarah Voss
- Centre for Health and Clinical Research, University of the West of England Bristol, Bristol
| | - Nicola Walsh
- Centre for Health and Clinical Research, University of the West of England Bristol; National Institute for Health and Care Research Applied Research Collaboration West, Bristol
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Stott H, Goodenough T, Jagosh J, Gibson A, Harris N, Liddiard C, Proctor A, Schofield B, Walsh N, Booker M, Voss S. Understanding paramedic work in general practice in the UK: a rapid realist synthesis. BMC PRIMARY CARE 2024; 25:32. [PMID: 38262987 PMCID: PMC10804758 DOI: 10.1186/s12875-024-02271-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 01/08/2024] [Indexed: 01/25/2024]
Abstract
BACKGROUND General practice in the UK is under substantial pressure and practices are increasingly including paramedics as part of their workforce. Little is known about how different models of paramedic working may affect successful implementation of the role, as viewed from patient, clinician and system perspectives. This realist synthesis developed theories about 'models of paramedic working in general practice' in different UK contexts to understand their impact. METHODS The rapid realist synthesis comprised data from: (1) empirical and grey literature searches; (2) semi-structured realist interviews with system leaders involved with the implementation of the role; and (3) a stakeholder event with healthcare professionals and the public, to develop initial programme theories that can be tested in future work. Sources were analysed using a realist approach that explored the data for novel or causal insights to generate initial programme theories. RESULTS Empirical sources (n = 32), grey sources (n = 95), transcripts from system leader interviews (n = 7) and audio summaries from the stakeholder event (n = 22 participants) were synthesised into a single narrative document. The findings confirmed the presence of a wide variety of models of paramedic working in UK general practice. The perceived success of models was influenced by the extent to which the paramedic service was mature and embedded in practice, and according to four theory areas: (1) Primary care staff understanding and acceptance of the paramedic role; (2) Paramedic induction process, including access to training, supervision and development opportunities; (3) Patient understanding and acceptance of the role; (4) Variations in paramedic employment models. CONCLUSIONS Variability in how the paramedic role is operating and embedding into general practice across the UK affects the success of the role. These findings provide a theoretical foundation for future research to investigate various 'models of paramedic working' in different contexts.
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Affiliation(s)
- Hannah Stott
- University of the West of England, Centre for Health and Clinical Research, Glenside Campus, Blackberry Hill, Bristol, BS16 1DD, UK
| | - Trudy Goodenough
- University of the West of England, Centre for Health and Clinical Research, Glenside Campus, Blackberry Hill, Bristol, BS16 1DD, UK
| | - Justin Jagosh
- Centre for Advancement in Realist Evaluation and Synthesis (CARES), Vancouver, Canada
| | - Andy Gibson
- University of the West of England, Centre for Health and Clinical Research, Glenside Campus, Blackberry Hill, Bristol, BS16 1DD, UK
| | - Nicky Harris
- University of the West of England, Centre for Health and Clinical Research, Glenside Campus, Blackberry Hill, Bristol, BS16 1DD, UK
| | - Cathy Liddiard
- University of the West of England, Centre for Health and Clinical Research, Glenside Campus, Blackberry Hill, Bristol, BS16 1DD, UK
| | - Alyesha Proctor
- University of the West of England, Centre for Health and Clinical Research, Glenside Campus, Blackberry Hill, Bristol, BS16 1DD, UK
| | - Behnaz Schofield
- University of the West of England, Centre for Health and Clinical Research, Glenside Campus, Blackberry Hill, Bristol, BS16 1DD, UK
| | - Nicola Walsh
- University of the West of England, Centre for Health and Clinical Research, Glenside Campus, Blackberry Hill, Bristol, BS16 1DD, UK
| | - Matthew Booker
- Bristol Medical School, University of Bristol, Centre for Academic Primary Care, Bristol, BS8 2PS, UK
| | - Sarah Voss
- University of the West of England, Centre for Health and Clinical Research, Glenside Campus, Blackberry Hill, Bristol, BS16 1DD, UK.
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Petschack S, Lasslett R, Ross L. The paramedic-general practitioner relationship: a scoping review. Aust J Prim Health 2023; 29:547-557. [PMID: 37574261 DOI: 10.1071/py23060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 07/20/2023] [Indexed: 08/15/2023]
Abstract
BACKGROUND Health services internationally are implementing programs that increase working ties between paramedics and general practitioners (GPs) to reduce unnecessary transport to emergency departments (EDs) and improve access to primary health care. As paramedic involvement in primary health care develops, there is increasing focus on the GP-paramedic collaborative relationship. Resulting issues regarding professional boundaries may occur, as paramedics practice in fields that were previously solely in the GP scope. An effective paramedic-GP working relationship will be an essential foundation to the success of future strategies. METHODS A search of three electronic databases was completed (Ovid MEDLINE, Embase Classic+ Embase and CINAHL Plus). Eligibility for inclusion required analysis of the relationship between paramedics and GPs. All processes were completed by two independent reviewers. RESULTS After removal of duplicates, 4995 titles were screened by title and/or abstract. After full-text review, 15 studies were included. Five themes were identified that contribute significantly to the strengths and weaknesses of the relationship - the importance of communication, understanding scope of practice, leadership roles, responsibility for patient care and interdisciplinary training. Issues identified included significant variation in the structure of different emergency medical services and varying standards of education requirements for paramedics worldwide. CONCLUSIONS There were no published Australian studies that had the primary aim of examining the paramedic-GP relationship. The depth of research on this topic is lacking, despite increased interest over the past decade. The relevance of the international literature to the Australian setting is questionable.
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Affiliation(s)
- Sarah Petschack
- Department of Paramedicine, Monash University, Frankston, Vic. 3199, Australia
| | - Robert Lasslett
- Department of Paramedicine, Monash University, Frankston, Vic. 3199, Australia
| | - Linda Ross
- Department of Paramedicine, Monash University, Frankston, Vic. 3199, Australia
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Barry T, Batt A, Agarwal G, Booker M, Casey M, McCombe G. Potential for Paramedic roles in Irish General Practice: A qualitative study of stakeholder’s perspectives. HRB Open Res 2022; 5:40. [PMID: 36072818 PMCID: PMC9418754 DOI: 10.12688/hrbopenres.13545.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2022] [Indexed: 11/20/2022] Open
Abstract
Background: Irish health policy emphasises the role of Primary Care and General Practice however, there is a growing shortage of General Practitioners (GPs) in Ireland. Paramedics have traditionally focused on emergency care in the community. More recently Paramedics have taken on roles in General Practice in international jurisdictions, but not yet in Ireland. This study aimed to explore key stakeholder perceptions of ‘the potential for Paramedic roles in Irish General Practice’. Methods: We conducted an exploratory, qualitative stakeholder consultation study incorporating in-depth semi structured telephone interviews followed by thematic analysis. Interviews were conducted with a total of eighteen participants that included six senior Paramedics (Advanced Paramedics), seven General Practitioners (GPs), three Practice Nurses and two Practice Managers. Results: Participants in this study expressed polarised views on the potential for Paramedic roles in Irish General Practice. Paramedics were enthusiastic, highlighting opportunity for professional development and favourable working conditions. GPs, Practice Nurses and Managers were more circumspect and had concerns that Paramedic scope and skillset was not currently aligned to General Practice care. GPs, Practice Nurses and Managers emphasised a greater role for expanded General Practice Nursing. There were varied perceptions on what the potential role of a Paramedic in General Practice might entail, but consensus that Government support would be required to facilitate any potential developments. Conclusions: The findings of this research can inform future development of novel roles in Irish General Practice and suggests that there is appetite from within the Paramedic profession to pursue such roles. A pilot demonstration project, grounded in an action research framework could address data gaps and potential concerns. Any future developments should occur in tandem with and with due consideration for the expansion of General Practice Nursing in Ireland.
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Affiliation(s)
- Tomás Barry
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Alan Batt
- Paramedic Programs, Fanshawe College, London, Ontario, Canada
| | - Gina Agarwal
- Departments of Family Medicine and Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Matthew Booker
- Centre for Academic Primary Care (CAPC), Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Mary Casey
- UCD School of Nursing, Midwifery and Health Systems, University College Dublin, Dublin, Ireland
| | - Geoff McCombe
- School of Medicine, University College Dublin, Dublin, Ireland
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Barry T, Batt A, Agarwal G, Booker M, Casey M, McCombe G. Potential for Paramedic roles in Irish General Practice: A qualitative study of stakeholder’s perspectives. HRB Open Res 2022; 5:40. [DOI: 10.12688/hrbopenres.13545.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2022] [Indexed: 11/20/2022] Open
Abstract
Background: Irish health policy emphasises the role of Primary Care and General Practice however, there is a growing shortage of General Practitioners (GPs) in Ireland. Paramedics have traditionally focused on emergency care in the community. More recently Paramedics have taken on roles in General Practice in international jurisdictions, but not yet in Ireland. This study aimed to explore key stakeholder perceptions of ‘the potential for Paramedic roles in Irish General Practice’. Methods: We conducted an exploratory, qualitative stakeholder consultation study incorporating in-depth semi structured telephone interviews followed by thematic analysis. Interviews were conducted with a total of eighteen participants that included six senior Paramedics (Advanced Paramedics), seven General Practitioners (GPs), three Practice Nurses and two Practice Managers. Results: Participants in this study expressed polarised views on the potential for Paramedic roles in Irish General Practice. Paramedics were enthusiastic, highlighting opportunity for professional development and favourable working conditions. GP’s, Practice Nurses and Managers were more circumspect and had concerns that Paramedic scope and skillset was not currently aligned to General Practice care. GP’s, Practice Nurses and Managers emphasised a greater role for expanded General Practice Nursing. There were varied perceptions on what the potential role of a Paramedic in General Practice might entail, but consensus that Government support would be required to facilitate any potential developments. Conclusions: The findings of this research can inform future development of novel roles in Irish General Practice and suggests that there is appetite from within the Paramedic profession to pursue such roles. A pilot demonstration project, grounded in an action research framework could address data gaps and potential concerns. Any future developments should occur in tandem with and with due consideration for the expansion of General Practice Nursing in Ireland.
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Muldoon D, Seenan C. The introduction of advanced paramedics into primary care in Northern Ireland: a qualitative descriptive study of the experiences of general practitioners. Br Paramed J 2021; 6:1-6. [PMID: 34970077 DOI: 10.29045/14784726.2021.12.6.3.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Background Primary care is dealing with an ever-increasing workload. The causes are multi-factorial but include a decreasing number of General Practitioners (GPs), combined with increased numbers of patients with multiple co-morbidities and an ageing population. As a result of these pressures, nursing and allied health professionals are now working within a growing number of advanced practice roles delivering community-based care. One such example is paramedics taking up advanced roles within General Practice settings in Northern Ireland. What is not known, however, is what GPs' experiences are of these developments. Aims To examine the experiences of GPs who have introduced an advanced paramedic into their primary care team in Northern Ireland. Design A qualitative descriptive design was chosen as the most suitable approach to allow participants to relay their experiences in their own words within the loose confines of a semi-structured interview. Methods Semi-structured interviews were conducted with a group of four purposively selected GPs who had direct experience of the phenomena of interest. These interviews were transcribed verbatim, anonymised and then analysed thematically. Results The thematic analysis produced three superordinate themes of alleviating pressure, acceptance and psychological well-being. These were underpinned by seven ordinate themes that were supported using verbatim quotes. These were then discussed and contextualised with themes from existing literature. Conclusion Generally, there was widespread support from the GPs for the introduction of advanced paramedics into primary care teams. The reasons were multi-factorial but the reduction in GP workload featured prominently. The participants reported benefits in terms of increased resilience and work-life balance. The capacity to provide a clinician with experience of dealing with acute and emergency presentations, in combination with managing routine procedures, was also reported to be of great importance.
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Experiences of out-of-hours task-shifting from GPs: a systematic review of qualitative studies. BJGP Open 2021; 5:BJGPO.2021.0043. [PMID: 34158369 PMCID: PMC8450886 DOI: 10.3399/bjgpo.2021.0043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 04/19/2021] [Indexed: 11/17/2022] Open
Abstract
Background The current GP workforce is insufficient to manage rising demand in patient care within out-of-hours (OOH) primary care services. To meet this challenge, non-medical practitioners (NMPs) are employed to fulfil tasks traditionally carried out by GPs. It is important to learn from experiences of task-shifting in this setting to inform optimal delivery of care. Aim To synthesise qualitative evidence of experiences of task-shifting in the OOH primary care setting. Design & setting Systematic review of qualitative studies and thematic synthesis. Method Electronic searches were conducted across CINAHL (Cumulative Index of Nursing and Allied Health Literature), PsychINFO, Cochrane, MEDLINE, Embase, and OpenGrey for qualitative studies of urgent or OOH primary care services, utilising task-shifting or role delegation. Included articles were quality appraised and key findings collated through thematic synthesis. Results A total of 2497 studies were screened, of which six met the inclusion criteria. These included interviews with 15 advanced nurse practitioners (ANPs), three physician assistants (PAs), two paramedics, and a focus group of 22 GPs, and focus groups with 33 nurses. Key findings highlight the importance of clearly defining and communicating the scope of practice of NMPs, and of building their confidence by appropriate training, support, and mentoring. Conclusion While NMPs may have the potential to make a substantial contribution to OOH primary care services, there has been very little research on experiences of task-shifting. Evidence to date highlights the need for further training specific to OOH services. Mentorship and support to manage the sometimes challenging cases presenting to OOH could enable more effective OOH services and better patient care.
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Barker RO, Stocker R, Russell S, Hanratty B. Future-proofing the primary care workforce: A qualitative study of home visits by emergency care practitioners in the UK. Eur J Gen Pract 2021; 27:68-76. [PMID: 33978544 PMCID: PMC8118426 DOI: 10.1080/13814788.2021.1909565] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background Broadening the skill-mix in general practice is advocated to build resilience into the primary care workforce. However, there is little understanding of how extended-scope practitioners from different disciplines, such as paramedicine and nursing, embed into roles traditionally ascribed to general practitioners (GPs). Objectives This study sought to explore patients' and professionals' experiences of a primary care home visiting service delivered by emergency care practitioners (ECPs), in place of GPs; to determine positive impacts/unintended consequences and establish whether interdisciplinary working was achieved. Methods Three practices in England piloted an ECP (extended-scope practitioners with a paramedic or nursing background) home visiting service (November 2018–March 2019). Following the pilot, focus groups were conducted with each of the three primary healthcare teams (14 participants, including eight GPs), and one with ECPs (five participants) and nine individual patient interviews. Data were analysed using a modified framework approach. Results The impact of ECP home visiting on GP workload and patient care was perceived as positive by patients, GPs and ECPs. Initial preconceptions of GPs and patients about the ECP role and expertise, and reservations about the appropriacy of ECPs for home visiting, were perceived to have been overcome by the expertise and interpersonal skills of ECPs. Fostering a culture of collaboration between ECPs and GPs was instrumental to remodelling professional boundaries at the practice level. Conclusion Broadening the skill-mix to incorporate extended-scope practitioners such as ECPs, to deliver primary care home visiting, presents an opportunity to increase resilience in the general practice workforce.
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Affiliation(s)
- Robert Oliver Barker
- Population Health Sciences Institute, Newcastle University, Newcastle-upon-Tyne, United Kingdom
| | - Rachel Stocker
- Population Health Sciences Institute, Newcastle University, Newcastle-upon-Tyne, United Kingdom
| | - Siân Russell
- Population Health Sciences Institute, Newcastle University, Newcastle-upon-Tyne, United Kingdom
| | - Barbara Hanratty
- Population Health Sciences Institute, Newcastle University, Newcastle-upon-Tyne, United Kingdom
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Xi D, McCombe G, Agarwal G, Booker M, Cullen W, Bury G, Barry T. Paramedics working in general practice: a scoping review. HRB Open Res 2021. [DOI: 10.12688/hrbopenres.13250.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: The term ‘paramedic’ has traditionally related to a healthcare professional trained to provide pre-hospital emergency care; however, paramedics are increasingly taking on novel additional non-emergency roles. General practice is facing unprecedented demand for its services related to rising expectations, an aging society and increased prevalence of chronic disease. Paramedics may be recruited to work in general practice to meet some of these demands. We undertook a scoping review to map the current literature considering paramedics working in general practice and inform follow-on research. Methods: We employed the six-stage scoping review framework developed by Arksey and O’Malley. Our research question was ‘to identify the scope of practice, nature of training/qualifications, challenges faced, and impacts of paramedics working in general practice’. Results: After searching PUBMED (Medline, n = 487), EMBASE (n = 536) and the Cochrane Library (n = 0) in June 2020, we identified eleven full-text articles that met our inclusion criteria. The literature suggests that paramedics have diverse skills that enable roles within general practice, some of which are context specific. Additional training is considered necessary to facilitate the transition from emergency care to general practice. We found no research that quantitatively assessed the impact of paramedics working in general practice on healthcare expenditure or patient health outcomes. Conclusions: There is a paucity of empiric scientific literature considering paramedic working in general practice. Further research is needed to inform training pathways, the structure of clinical practice and to measure outcomes.
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