As set out in the General Practice Forward View (NHS England, 2016), the success of general practice will rely on new ways of working, including having a multidisciplinary workforce. The difficulties of recruiting GPs in the UK are well publicised nationally, and GP surgeries are now embracing innovative ways of managing the crisis in general practice (NHS England, 2016). The introduction of the role of the paramedic practitioner (PP) working within a GP surgery was proposed in a report by the Primary Care Workforce Commission in 2015 (Health Education England (HEE), 2015). Despite a rapid expansion of PPs in general practice, there is a weak evidence base regarding the role.
It is important to note that the PP has different titles across the UK such as emergency care practitioner (ECP). Moreover, individuals who call themselves ‘PP’ or ‘ECP’ may have entirely different qualifications and experience (Woollard, 2006). Unlike the standard ‘paramedic’, the title of PP is not registered with the Health and Care Professions Council (HCPC). All titles have been used within the literature search to ensure the retrieval of all available evidence. Therefore, as a result of the different training that PPs receive, the literature is not comparing like for like, which is important to acknowledge for the analysis of this work. PPs working in general practice should be trained to an advanced level to diagnose, treat and refer autonomously. There appears to be wide heterogeneity in the evidence regarding what the role of the PP in general practice involves, including no formal definition of scope of practice; however, a recently commissioned document from HEE (2019) sets out a core capabilities framework of what PPs should be able to do in primary care. Part of the role of the PP is to attend home visits, usually undertaken by the GP. Bird et al (2016) found that home visits make up 6% of GPs' workload, equalling around six visits per week per GP. This equates to a high number of home visits in large practices, where the PP may be more appropriate to send.
Although there appears to be no published evidence to aid in assessing the contribution of the role of the PP on general practice, anecdotal evidence suggests that it inevitably frees up GP time, as seeing patients in their own home is something paramedics normally do (Evans, 2016). Additionally, the National Institute for Health and Care Excellence (NICE) (2017) wrote a report on PPs working within the ambulance service, which demonstrated that they reduced admissions to ED, further suggesting that PPs may be beneficial in this setting. However, Evans (2016) asks in his report: ‘how are patients responding to being attended to by a PP in place of the GP?’ It is essential to explore patients' perceptions of having a PP attend to them on a home visit, which is supported by Halter et al's. (2017) study, where the authors explore patient experience of the ‘physician's associate’. The authors suggest that patients' experiences of new health professionals when substituting for another's role is pivotal for understanding public acceptability and embedding the new role. A large proportion of home visits are to the older population (over the age of 65) (World Health Organization (WHO), 2017); hence this is the age range used.
Objectives
The following objectives were developed:
Design and methods
The methodological approach for this study is generic qualitative, involving semi-structured interviews and purposive convenience sampling. Thematic analysis was used to analyse the data collected. Caelli et al (2003) propose that a generic qualitative study should follow four areas including theoretical positioning, congruence between methodology and methods, strategies to establish rigour and, finally, an analytical lens through which the data are examined. Therefore, to ensure credibility, transferability, dependability and confirmability, which Lincoln and Guba (1985) argue are more suitable for assessing qualitative research, this study was influenced by the framework constructed by Caelli et al (2003).
Recruitment of subjects
Interviews were conducted one-to-one and were audio-recorded. To enhance credibility of this study and reduce bias, an independent interviewer (clinical pharmacist with sufficient expertise) conducted the interviews. Purposive convenience sampling ensured personal experience of the situation being researched, eliminating candidates who did not meet the inclusion criteria, subsequently increasing accuracy (Aveyard, 2010).
The first eight participants to volunteer were selected. A sample size of 40 were eligible to take part; however, owing to the limited time that the researcher had to undertake this study, a much smaller sample size of eight was sought. Cooper and Endacott (2007) suggest that information-rich data are more important than having a larger sample size from which data are less insightful. The first eight participants to consent to the study were used, which reduced the chance of bias, as the researcher did not select which patients to interview. However, unfortunately two participants cancelled the day before interview. Consequently, a sample of six was used. All of the interviews took place in the patients' own homes and refreshments were provided.
Forty letters were posted directly from the GP surgery to the patients who matched the inclusion/exclusion criteria. The letters included a participation information leaflet and a consent form, which the patient was required to sign and return with the stamp and envelope provided. In total, the consent forms were returned over a period of 6 weeks. The interviews were conducted on three separate days, face-to-face in the participants' own homes.
In developing the interview questions, Patton's (1990) technique of open-ended, conversational questioning was used. The data obtained from the interviews were transcribed from the audio recordings by an independent transcriber. The interview transcripts were studied by the researcher and the transcriber and themes were generated from the data to unify concepts. Having another individual studying the data and generating themes reduces bias and increases the validity of the study (Kahlke, 2014). Thematic analysis can be seen as a foundational method for generic qualitative analysis.
| Inclusion criteria | Exclusion criteria |
|---|---|
| Patient age 65 or older | Dementia/cognitive impairment |
| Patient who has called the GP surgery in hours asking for a GP to visit | Learning difficulty |
| Patient who has been seen by the PP | Under the age of 65 |
Ethical considerations
All procedures were performed in compliance with relevant laws and institutional guidelines and the appropriate committee approved them.
Findings
Description of participants
The six participants included three females and three males, aged 77–88 years, all of a white British ethnicity. None of the participants interviewed required hospital admission.
Thematic analysis
Three themes were identified as follows:
Theme 1: Variation in understanding of the role of the PP in general practice
When the participants were asked what they understood about the role of the PP, the answers varied broadly. All of the participants were uncertain of the role and demonstrated confusion over of a PP working in general practice. However, two of the answers concerning the role of the PP were accurate to some extent. One patient admitted they were entirely unsure of what the role involved:
‘I do not understand what a PP is, I suppose they are just doing the same job as a nurse or doctor aren't they?’
Equally inaccurately, several participants framed their description of the PP as being very closely related to a doctor:
‘I just assumed it was a young doctor’
Some of the participants described the role of the PP, by comparing it to other healthcare roles on the basis of knowledge, again inaccurately:
‘Hopefully the doctor knows more, the paramedic should know more than the nurse, I think that's how it goes down the scale in my opinion, the doctor, the paramedic and then the nurse.’
| Number of participants | Theme 1 | Theme 2 | Theme 3 |
|---|---|---|---|
| Patient A | X | X | |
| Patient B | X | ||
| Patient C | X | X | |
| Patient D | X | X | X |
| Patient E | X | X | |
| Patient F | X | X | X |
These quotes are both clearly inaccurate, and when participants were asked in more detail what the PP can do as part of their role, they revealed comments such as the following:
‘The PP comes out when the doctor is busy and they can prescribe for you, the nurse can't prescribe things for you, whereas a paramedic nurse can, as I understand it, but I might be wrong, and of course a doctor can do whatever’
At the time of the present study, paramedics were unable to prescribe and this is a very recent development (whereas nurse prescribers have existed for some time). This again reflects uncertainty and confusion about what the role involves.
One participant felt the examination by the PP was similar to when a GP had attended; however, they queried whether the PP had the knowledge to analyse the results. This suggests uncertainty about the education and knowledge that a PP has:
‘The PP examined me, same way basically the doctor would, and obviously the thing that carries on from that is whether she can determine the results that she gets from the stethoscope and the correct procedure to take from there’.
It was evident that the participants had not heard of the role of a PP in a GP surgery. At all times, the participants were expecting a GP. Despite being told that they were seeing a PP, participants repeatedly said ‘thank you doctor’ at the end of the consultation. One participant discussed the fact that she had been attended to by a PP with her friends; they did not believe her. This reveals that confusion about the role exists on a larger scale:
‘No I had no idea of the role, I've spoken with my friends and I showed them the form and they had never heard of it. I didn't understand that I was being attended to by a PP, I assumed it was a doctor. I mean she obviously told me she was a PP, but I didn't understand what she was saying.’
It appears a common theme that the participants assumed the PP was a doctor. Participants seemed to understand the role was new and implied that they were interested in finding out if it was available in other practices:
‘No I was not aware of the role, not until I was told, I didn't know that at all, so it must be something new, is it?’
‘I think there's a lot of the general public that wouldn't know, I didn't. Is it in a lot of other doctors as well?’
In comparison to these quotes, some participants expressed more accuracy of the role:
‘I know what a paramedic is, so I assume that it [PP] is someone that instead of going out on call with an ambulance, that they are actually based at the surgery.’
This demonstrates that the participant understands that the PP is a qualified paramedic and not a nurse or doctor.
One participant thought that the PP's main role was to save the GP's time as they are very busy, which is accurate on some level:
‘As far as I know it's to replace a doctor, to save a doctor coming out on call.’
Similarly, two participants believed that the role of the PP is to ensure speed of access and reduce pressure on the surgery:
‘I would be quite happy to see the PP than waiting longer to see the GP, as I see it, it's obviously a way of reducing the pressure on the surgeries which I can understand.’
The participants' accounts indicated variability in their understanding of the role. Despite all of the participants not being aware that the role existed, a positive perception existed among all participants of being attended to by the PP in place of the GP, which is demonstrated within the following theme.
Theme 2: Willingness to see the PP in place of the GP
A positive perception that is evident from this research was likely built from the experience of a positive consultation, and demonstrates trust in that individual PP. Participants expressed a rapid response; a feeling that the PP knew what they were doing; and examination and assessment similar to that of a doctor. They suggested that they do not mind whether a GP or PP attends to them, as long as the problem is managed:
‘I had no problems with the PP at all, not for an instant.’
One patient expressed their gratitude towards the PP attending to them and felt it was a great idea for older people:
‘No, I wasn't aware of the role, I just rang that particular morning to ask if someone could call because I couldn't get to the surgery and they sent the PP, I was so pleased with that, I think it is a wonderful thing if they could carry that on, especially for older people.’
‘I would be happy to see the PP again, GPs are so busy and can't be seen for 6-8 weeks, so helpful to see the PP quicker.’
This suggests that speed of access is more important to the patient than practitioner type. Although most participants expressed their willingness to see a PP again, others expressed willingness to see the PP conditional on the suitability of the problem. One participant reports that if they deemed their complaint inappropriate for the PP, they wished to see a GP, while another expressed uncertainty about PP knowledge.
‘I would prefer to be seen by a GP obviously, but it depends on the reason, if I had anything that a paramedic could deal with, then that would be absolutely fine.’
‘In this occasion (home visit) I was perfectly happy, if there was something seriously really wrong, then I'm not sure really, I'm not sure of what her knowledge is and that type of thing.’
While there were patients who would prefer to see the GP for more complex problem, the evidence above largely demonstrates a positive perception from participants with a willingness to see the PP in place of the GP.
Theme 3: Desire for further information regarding the PP role
Three of the participants reported a clear desire for more information on the role. One patient reported that they believe the general public would like to know more about the role:
‘Yeah, I think it's a good idea [the role of the PP in general practice]. I think there is a lot of the general public that wouldn't know, I think people would want to know, I'd like more information yeah.’
One patient discussed the role of the PP with her friends and felt more information was needed:
‘Speaking to friends of the same age as myself, none of them knew what it was and they live in all different areas, so I don't know when it was formed, and what publicity there is out there to tell people about them, is it just our surgery or is it a general thing?’
‘Yes I certainly would like to know what it is all about, what can be done and what is done, I would certainly like to know what qualifications they have, how close it is to a doctor's qualifications, what sort of level of training they have.’
Discussion
The findings presented differing patient perceptions regarding the role of the PP working in general practice, attending to them on a home visit in place of the GP. However, ultimately, the patients demonstrated that they were highly satisfied with the care received. Despite the positive perceptions obtained however, patients were clearly confused about the role of the PP working within a GP surgery.
This finding is supported by Halter et al (2007), who also concluded that patients had a predominantly positive view of the ECP in the out-of-hospital setting, despite there being a lack of clarity about their assessment and what the role constitutes.
At the outset of this study, the researcher questioned whether high satisfaction levels could be achieved with the PP in a non-emergency setting (Halter et al, 2007). The findings of the present study have identified positive perceptions of the PP, attending from a GP surgery. This suggests that high satisfaction levels can be obtained in the non-emergency setting, although it must be acknowledged that these results are based on a small sample size.
Halter et al (2007) hypothesised that patients would automatically have a negative opinion of the ECP, since they were expecting a GP. However, the current findings showed that although all patients expected a GP to attend to them, this did not appear to affect their perceptions negatively, even when informed they had been attended to by a PP instead.
The variety of patients' understanding of the role of the PP is echoed in other studies exploring the perception of PAs (Halter et al, 2017) and nurse practitioners (NPs) (Redsell et al, 2007). There is clear confusion regarding the role of the PP, evident from the quotes obtained in the present study. For example, one patient thought that PPs could prescribe (which was not the case at the time of the study) and others supposed that the PP was a young doctor. This emphasises the need to inform patients of the emerging roles across the NHS, which is another key finding of this study, as patients desired further information.
The study resonates with the findings of Redsell et al (2007) as the authors concluded, from their study involving interviews exploring patients' accounts of the differences between NPs and GPs, that information leaflets should be given to patients regarding the differences in the roles. Patients in the current study expressed a positive perception and felt that the assessment by the PP was similar to that of a GP, although they demonstrated uncertainty about whether the PP had the knowledge to interpret their findings from their examination, and asked whether a PP's training is similar to that of a GP.
While the majority of patients confirmed that they were willing to have a PP attend to them on a home visit, it is clear from others that this is conditional on the presenting complaint. This is echoed in Halter et al (2017), in which patients were happy to see PAs for minor complaints but if the problem was more complex, they would prefer to see the GP. Similarly, Laurant et al (2008) identified from self-administered questionnaires comparing patient satisfaction of seeing the NP and GP that patients preferred to see the GP for medical aspects and the nurse for health education.
The findings from the present study identified that as long as the problem was solved, patients did not mind which practitioner attended to them, which is in line with the findings of Roblin et al (2004) who compared the NP, PA and GP. The authors concluded that patients were just as satisfied with the NPs and PAs as they were with the GP; overall experience did not differ by practitioner type, as long as the problem was solved. Furthermore, the findings of the current study actually show that PPs provide comparable care to the GP, as participants believed the PP to be a young doctor. This is supported by Halter et al (2017) who reported a lack of understanding among patients of which practitioner had attended to them, often saying ‘thank you doctor’ at the end of the consultation.
The importance of speed and ease of access to patients is reflected in the findings of the present study. This is also reported in Evans (2016) in relation to patients' acceptance of seeing a different practitioner to the GP. Reports show that as the waiting time increases to see the GP, patients are content to consult with other practitioners (Dill et al, 2013). It can be questioned whether ease of access is becoming more important to the UK population than continuity of care.
Limitations
The researcher is not claiming that the findings outlined in this article are generalisable, as it is acknowledged that the full range of perceptions encompassed within the six interviews conducted does not provide a true reflection of the wider population. This is largely owing to the fact that only six participants from one GP surgery were interviewed about one PP. Although there was a good diversity of gender, the ages of the participants only ranged by 11 years, and they were all of the same ethnicity. Additionally, it is recognised that there is an element of bias as the researcher is also a PP. However, every effort was made to reduce internal bias by having an independent interviewer and transcriber. The present study provides a foundation for research into the role of the PP working within a GP surgery, with interesting insights into participants' perceptions of being attended to by a PP on a home visit, in place of the GP.
Conclusion
Patients' experiences and perceptions of new health professionals are important for understanding public acceptability and for embedding the new role. Despite some confusion around it, a largely positive view of the PP role was identified from the outcome of this study. None of the participants felt the need to contact the GP immediately after the home visit. The patients' experiences raised issues around their knowledge and understanding of the PP working in a GP surgery, and highlighted their desire to be more informed about the role. Qualitative analyses can provide valuable insight into the effectiveness of health system transformation, which is essential in today's climate with the inevitable pressures in general practice.
Research needs to be conducted on a larger scale for the results to be reliable and generalisable. Patients are willing to accept new roles within the changing NHS in order to meet demand. For those interested in skill mix within their own GP surgery, and for help in attending to home visits, where the GP would normally have attended, this study provides knowledge that patients are content to see the PP. The role of the paramedic is changing but there is little published research investigating the contribution of paramedics working in primary care. This pilot study serves to highlight areas that require further investigation in terms of the influence of the PP within general practice.