Realist Evaluation of Paramedics Deployed in General Practice: The 'READY Paramedics' Study
Primary care services are under increasing pressure due to a growing and ageing population with multiple co-morbid health conditions. Due to the shortage of GPs, primary care must look to members of the allied health professional workforce to meet this rising demand. This is particularly the case for urgent and ‘same day’ care. The General Practice Forward View (NHSE), the 2022 GP Vision (RCGP) and the Sustainability and Transformation Partnership blueprints all advocate the deployment of paramedics in GP services as part of the solution. Legislative changes allowing for paramedic independent prescribing, along with national policy and funding specifically for paramedics in primary care has resulted in a rapid expansion of paramedics working in General Practice settings. The variation between models is substantial, with very little in the way of evidence to inform which ways of working (if any) contribute to the perceived benefits.
This pilot study is using a realist-informed approach - across three work packages - to characterise the range of models in use, develop testable programme theories and explore the feasibility of using practice-level data to compare outcomes between the different ways of working. Our first work package involves a realist-informed review of the literature and policy background, supplemented by key stakeholder discussions and a survey of current practice. This aims to capture some of the concepts that define the contrasting models. Our second work package comprises a series of in-depth theory-driven interviews with key stakeholders, to examine the underlying assumptions about how different approaches to paramedic deployment are thought to work. This will sample experiences at various stages of paramedic model implementation. Our third work package will pilot methods for collecting supporting primary care data, such as patient safety metrics, health service utilisation, prescribing data and economic / cost-effectiveness measures.
Data collection and analysis are on-going. A range of fundamental theories appear to underpin paramedic deployment in primary care. These include: (1) the freeing up of GP time to manage more complex multi-morbid patients who may benefit most from continuity; (2) creating same-day capacity to see patients earlier in their illness and maximise opportunities for community treatment; (3) improved patient satisfaction (and possible clinical outcomes) if paramedics can spend more time with certain patient groups than GPs can. We will present an outline taxonomy of models in use, and how we propose to test how our theorised mechanisms link context with outcomes.
It appears likely that different models of paramedic deployment are required in different practice contexts. We aim to follow this pilot work with a realist evaluation and economic evaluation. It is anticipated this will help guide practitioners and commissioners about which models work in which contexts, supporting the optimal deployment of scarce NHS resources.