Authors' objectives: General practice services are under pressure due increased demand. Alongside substantial national recruitment challenges, there exists a shortage of general practitioners to meet current need. Resultingly, allied healthcare professionals, including paramedics, are being utilised in general practice. General practitioner (GP) services in England are facing significant pressure due to increased healthcare demand. GP consultations have been rising by up to 15% annually, costing the NHS £9B, with a shortage of GPs to meet the rising demand. To address this, there has been a shift towards utilising allied healthcare professionals (AHPs), such as paramedics, to support front-line service delivery in general practice. The NHS England General Practice Forward View and the NHS Long Term Plan have both emphasised the importance of developing the multidisciplinary, integrated workforce and increasing the number of AHPs and support staff in primary care. Paramedics have been identified as a professional group that can contribute significantly to general practice, particularly in managing minor illnesses, conducting home visits, and providing urgent consultations. Health policy and related primary care initiatives in England – including the Additional Roles Reimbursement Scheme – recognise that the generalist skill set of paramedics may be well suited to a GP setting. Legislation for paramedic prescribing was recently enacted, furthering the role this professional group may play in primary care. Consequently, there has been a threefold rise in the number of paramedics working in GP services in the last 5 years. However, there is a lack of research on the safety, clinical effectiveness, and cost-effectiveness of paramedics working in general practice. Previous studies have focused on the extended skills needed by paramedics and have made assumptions about their impact on reducing GP workload and costs without empirical evidence. General practice services are configured around a diverse array of local contexts, challenges and specific needs, meaning the paramedic skill set is utilised differently across the country. There is very limited evidence of how different models might suit different needs.

Authors' results and conclusions: 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 Patient-Reported Experiences and Outcomes of Safety in Primary Care practice activation scores were found at paramedics in general practice sites (perceived less engaged in promoting safety), in particular those with medium and low levels of paramedics in general practice integration and complexity. There was a small statistically significant difference in the Primary Care Outcomes Questionnaire ‘Confidence in Health Plan’ by paramedics in general practice complexity, such that confidence had deteriorated slightly more in the high-complexity group compared to non-paramedics in general practice. Paramedics in general practice sites had lower scores at initial visit and 30 days for the Primary Care Outcomes Questionnaire ‘Confidence in Health Provision’. We found little evidence that paramedics in general practice care led to substantial spillover effects via increased reconsultations, prescriptions, secondary care referrals or unplanned hospital admission costs. Paramedics in general practice care improves access to general practice. Safety and acceptability require resources for induction, supervision, training and education. Paramedics in general practice integration affects staff satisfaction and role longevity. Paramedics in general practice allows paramedics to develop and evolve. Paramedic working in general practice care can improve access to general practice (particularly same-day care). There is the potential for PGPs to take on a large volume of primary care workload without substantial spillover effects on other NHS colleagues and services. Acceptance of PGP models is based on an understanding of the primary care paramedic role, and confidence that mechanisms are in place to support it. PGP models exhibit substantial variation, and there is no single optimal model. Safety is achieved through a combination of comprehensive induction, ongoing supervision, appropriate postgraduate training and continuing primary care-focused education – all of which require substantial resource. The degree of PGP integration has less of an obvious impact on individual patient-level outcomes, and may be more associated with staff satisfaction, professional identity and role longevity. It may take time to adapt to the clinical context of primary care when transitioning from other areas of practice, and some evolution over time is likely when first operationalising PGP. Rotational working may mitigate some of the potential system-wide impacts on the emergency care workforce, but can require more investment from general practice to sustain. Nevertheless, PGP provides opportunities for the paramedic profession to develop and evolve.

Authors' methods: A mixed-methods realist evaluation comprised a rapid realist review followed by an evaluation of paramedics in general practice in general practice case study sites. Patient and public involvement and input was integral, ensuring validity from a patient and carer perspective. General practices in England. A total of 34 general practices participated as case study sites, of which 25 were ‘paramedics in general practice’ sites. Data from qualitative realist interviews (n = 69), quantitative questionnaires (n = 489) and electronic records (n = 22,509 consultations) were collected. Paramedics in general practice models were classified according to: (1) level of integration of the paramedic to the general practice team; and (2) complexity of patients seen by paramedics. 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 (safety); EuroQol-5 Dimensions, five-level version (health-related quality of life); Primary Care Outcomes Questionnaire; the Modular Resource Use Measure (health and care resource utilisation). Electronic health records provided data on primary care use. A rapid realist review of the published and grey literature, supplemented with direct enquiry with system leaders and key stakeholders. The study faced challenges in recruitment. Self-selected participating sites may not be representative of all general practitioners in England, and categorising paramedics in general practice models for analysis was more complex than anticipated. The comparison of costs and outcomes between paramedics in general practice and non-paramedics in general practice sites was based on an observational study design. We drew upon the epistemology of realist evaluation to explore how the different mechanisms of a range of PGP models were related to outcomes (clinical and economic) and different practice contexts. A mixed-methods approach combined quantitative and qualitative data to gather comprehensive insights into the deployment of PGP models in different contexts, and to iteratively develop and test theories underpinning their successful operation (or otherwise). The patient and public involvement and engagement group was integral to all stages of the study from writing the ethics applications, refining research instruments, designing patient material to interpretation and synthesis of quantitative and qualitative data, ensuring validity from a participant and carer perspective. We began by conducting a rapid realist review, including searches of empirical and grey literature, interviews with system leaders (n = 8), and a stakeholder prioritisation event (n = 22 participants, 14 professionals and 8 patient representatives). Data were analysed using a realist technique called ‘appraisal journaling’, which involved summarising and reflecting on key causal insights. We developed initial candidate programme theories that we would go on to refine in the evaluation stage. To conduct the evaluation, a case study approach was utilised, and a total of 34 general practice sites were recruited (n = 25 with paramedics and n = 9 without). These sites were located in England to maintain consistency in the policy environment. Sites were selected based on practice demographics, such as size, urbanity, and deprivation index, ensuring representation of different service models across England. Practices provided comprehensive detail on their PGP operating model, including details of practitioner competencies (including prescribing ability), patient eligibility for PGP care and practice workforce composition. Data were collected to explore various aspects of PGP care, including its impact on patient outcomes, patient-reported experiences, safety, costs, value for money, patient experience and the workload of GPs and other general practice staff. The quantitative element included both a prospective and a retrospective cohort component. Qualitative realist interviews (n = 69) were conducted with patient participants (n = 20), paramedics (n = 13), GPs (n = 12), practice managers (n = 13) and other members of the practice team (n = 11) using semistructured interview guides. Quantitative data were collected through prospective patient questionnaires completed by patients immediately after a consultation with a paramedic (at PGP practices) or GP (at non-PGP practices) and 30 days later (n = 489 completed questionnaire pairs). These assessed patient experiences and outcomes using validated measures, including: the Patient-Reported Experiences and Outcomes of Safety in Primary Care questionnaire (safety; Oxford University Innovation Ltd, Oxford, UK); EuroQol-5 Dimensions, five-level version (HRQoL; EuroQol Research Foundation, Rotterdam, The Netherlands); Primary Care Outcomes Questionnaire (PCOQ) (health outcomes; University of Bristol, Bristol, UK) and the Modular Resource Use Measure (ModRUM) (health and care resource utilisation). Additionally, a bespoke search was conducted on the electronic health records system (n = 10 practices) to undertake a retrospective analysis of the subsequent resource implications of consulting with a paramedic or GP at the start of a care episode. This analysis looked at coded data arising from 22,509 index consultations. Data analysis involved coding and thematic analysis of qualitative interviews, while quantitative data were analysed using the relevant statistical methods. Multilevel models were used to analyse the primary outcome. Economic analyses were based on published unit costs, where available, or derived from base principles. Sensitivity analyses were also conducted. The research team met regularly to discuss emerging findings, refine theories and ensure alignment between qualitative and quantitative data. Sites were classified based on the integration level of paramedics within the general practice team and the complexity of patients seen in the PGP service. These classifications aided in organising and comparing findings across sites. Overall, the study aimed to provide valuable insights into the effectiveness of PGP care by examining its impact on various outcomes and considering different contextual factors. The study was conducted during the response to and recovery from the COVID-19 pandemic, and during times of atypical pressure on general practice service (including the group A Streptococcus outbreak). Recruitment of both sites and individual participants was hampered, requiring amendments to our original plans and an uneven distribution of participants across sites and models. The case study design included sites that were by definition self-selecting, which may have decided to take part due to a desire to demonstrate the perceived effectiveness of PGP. These may not be representative of general practices in England. Additionally, despite attempts to recruit from practices with diverse characteristics, the final sample did not represent the full diversity of practice populations. Due to the range of PGP models, it was more complex to discretely categorise these for analysis than envisaged.

Project Status: Completed

URL for project: https://www.journalslibrary.nihr.ac.uk/programmes/hsdr/NIHR132736

Year Published: 2025

URL for published report: https://www.journalslibrary.nihr.ac.uk/hsdr/GTJJ3104

URL for additional information: English

English language abstract: An English language summary is available

Publication Type: Full HTA

Country: England, United Kingdom

DOI: 10.3310/GTJJ3104

Organisation Name: NIHR Health Services and Delivery Research programme

Contact Address: NIHR Journals Library, National Institute for Health and Care Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK

Contact Name: journals.library@nihr.ac.uk

Contact Email: journals.library@nihr.ac.uk