Paramedics have increasingly been expected to determine the most appropriate outcome for patients over the last few years. NHS England (2015) advocates that see-and-treat models benefit from the help of primary care professionals, and general practitioners (GPs) must assist the ambulance service in this role 24/7 with full integration of community health and social care services.
Blodgett et al (2017) investigated paramedic perspectives towards GP referral schemes. They highlighted a deficiency in qualitative research around this topic and identified GPs as effective stakeholders in attitudes and decision-making.
Branding GPs as ‘gatekeepers’ is unhelpful, as this term implies that they hold a monopoly in the NHS, and neglects any potential contribution from other professions including paramedics (Whitaker, 2016). The power of GPs may reduce paramedics' level of esteem and effectiveness in leading appropriate patient care strategies.
However, this has not prevented ambulance personnel from broadening their horizons to deal with contemporary challenges. Bigham et al (2013) claim that despite a historical void in reports about urgent and low-acuity care in the out-of-hospital environment, paramedics have gradually shown that they can cope with the demands of an expanding scope of practice in the community.
This realisation internally within paramedicine has also been reciprocated in changing perceptions externally from the public. Many patients who had refused transport to hospital had high expectations that paramedics would provide good advice and alternatives (Keene et al, 2015). There needs to be data collected that documents assumptions made about paramedic practice by GPs, other health professionals, and the wider population.
There have been many obstructions over recent years to resolve and alleviate strains and demands. O'Hara et al (2014) evaluated a higher risk to overall patient care if paramedics are not appropriately skilled to deal with complex clinical needs, and therefore not capable of finding alternatives to the emergency department (ED). The consequences of not acquiring fundamental knowledge about patients insinuates an unsuitable pathway and outcome.
One of the biggest barriers for paramedics is the lack of access to gain substantial accurate health information records for patients, which adversely effects reliable decision-making for appropriate care (Zorab et al, 2015). Paramedic practitioners must work more interdependently with health professionals in the urgent and primary care (U&PC) setting—especially GPs—in order to efficiently improve knowledge and skill bases, as well as minimise insufficient information about individual patients.
Poor networking and deprived services are detrimental to pre-hospital care. Brooker et al (2014) stated that emergency ambulances are often the recipients of an unnecessary default to the most immediate response, without an ability to be stood down while deviating a call to the remaining community infrastructure. A statement that suggests a mismanagement of resources is prevalent, as one marked system has been a noted cause for concern. Patients would receive better appropriate care if more NHS 111 service users were immediately referred to GPs as opposed to ‘unskilled’ call handlers supplemented by inflexible technological protocol (Anderson and Roland, 2015). There has been an overwhelming pressure on both paramedics and GPs, which has not been sustainable.
The reasons for the high demand on all respective services need to be understood. Edwards et al (2013) showed that a majority of frequent callers to the ambulance service were living in extenuating circumstances, suffering from acute or chronic medical conditions, were of older age, and/or possessed wider social care needs. A recognition of the incessant 24/7 poorly filtered exertion of referrals placed on organisations is a clear rationale in itself to establish a closer bond between services in order to share knowledge, skills, and practices.
Closer integration of services and centralisation of patient information will provide a better standard of care—particularly during GP out-of-hours (OOH) when patients require simple measures such as prescriptions (Dowden, 2016). A deeper discussion between paramedics and GPs is indicated to evaluate how services can be better navigated together, and where responsibility lies in the health community.
Many anxieties and frustrations throughout the population are expressed about the limitations of healthcare knowledge, skillsets, and resources. Olthof et al (2015) associated the most GP referrals with medically unexplained physical symptoms. This may demonstrate the sense of entitlement in the public spirit to persist on pressing for immediate answers, even when patients have been recycled through the same system repeatedly. There is a fragmented streamlining in structures with a lack of resources in child, adolescent, and adult mental health services, underpinned by restrictive eligibility criteria (Belling et al, 2014).
In a time of very high expectations, GP services require interaction with other health professionals to evaluate gaps in the U&PC arena. Paramedics need to express how they can be used more effectively and help to consistently discover ways to deliver the most appropriate patient care.
Methods
Ethical approval for the current study was sought and obtained with further support from the researcher's employers. Initial contact (via email) then commenced with an administration team, in which potential participants were identified without direct contact from the researcher. Purposive sampling can be used for qualitative research and is a non-probability method, which is most effective in studying knowledgeable experts within a cultural domain (Tongco, 2007). Permission was sought via administrators and management, who approached GPs that were interested in engaging in the study. Once the relevant GPs were established, only then was direct contact made with participants.
The chosen contributors were allowed to describe their own lived experiences in relation to paramedic referrals. A phenomenological approach can be used to express meaning of issues that include description and interpretation (Zenobia et al, 2013). Semi-structured interviews were conducted with seven GPs—most of whom operate predominantly in Wirral, Merseyside, while some also function in other areas of North West England. Their range of practice is across different services, including GP surgeries, OOH settings, or generally covering the U&PC spectrum.
Interactions were audio-recorded and interviews were conducted for a duration of 10–20 minutes depending on the contributor. Braun and Clarke (2014) declare that a thematic analysis offers a sophisticated technique to gather qualitative data, which can transcend from academia into policy or practice surroundings. All conversations were transcribed and later word-coded with meanings extracted. Three superordinate themes, outlined in the next section, were created after all data had been collected and analysed.
Findings
The first topic identified a variability in the appropriateness of paramedic referrals with significant room for improvement. The next subject highlighted that the value of paramedic referrals can be overlooked owing to the anecdote, emotions, and frustration in other parts of the system. The final theme proposes a need for skills development in paramedic practice to ensure referrals are more compatible with U&PC services.
Variability in the appropriateness of paramedic referrals with significant room for improvement
‘On the whole, I've always found the referrals to be very appropriate. Certainly just to have a discussion with a paramedic over the phone, as sometimes they haven't got any clinical background to the patient.’ (Participant 1)
‘Paramedics make very appropriate referrals. I know paramedics are not diagnosticians but you can decide the observations are fine and they look well etc.’ (Participant 2)
‘Some have been extremely appropriate. However other times, I've had paramedics who have been quite dogmatic. Even when I've said I know the patient well and I'll come out in a little while, their response has been that they need to be seen now or we're taking them to hospital. There is a range of appropriateness—50/50 I would say.’ (Participant 3)
‘Sometimes paramedics will slip into diagnostic certainty. These patients have often got multiple issues. There is an issue around proper risk assessment. Some paramedics are very good at passing the message over in neutral terms, and having a consensual conversation with a GP. Other paramedics hand the patient over in terms of “the patient is now yours, you need to do this, and you're going to do this.” The paramedic has to hand the decision over to the doctor. The making of the diagnosis isn't really the paramedic's job.’ (Participant 4)
‘Generally paramedic referrals have been positive.’ (Participant 5)
‘Paramedic referrals are entirely appropriate.’ (Participant 6)
‘Sometimes they are appropriate but sometimes they are really inappropriate—it's probably 50/50. Paramedics are pretty much telling me that the patient doesn't need to be seen, but they want me to take responsibility for that. He had been to see somebody with back pain and had to give Entonox to get the patient off the floor. The paramedic was thinking we could just prescribe Codeine but they hadn't asked about any neurological symptoms. Other paramedics are really good.’ (Participant 7)
The value of paramedic referrals can be overlooked as a result of the anecdote, emotions, and frustration in other parts of the system
‘I think it's reasonable in an emergency response that mental health patients should be in ED.’ (Participant 1)
‘Paramedics would struggle to get either a mental health or social services opinion out of somebody in the timescale that they need it.’ (Participant 2)
‘It comes down to funding and we can't get away from it. If a paramedic makes a referral then who is going to pay for the admission etc?’ (Participant 3)
‘Appropriate referrals often depend on a tripartite agreement between the paramedic, the GP, and the patient, which can easily be broken if there is even any mild dissatisfaction with any party. The patient who is appropriate for primary care, quite often has ended up on the 999 step—not because they want to be there but because they already have a degree of frustration with primary care sometimes. They may have phoned 111 and then been put through to 999, and they may only phone 111 because the GP practice is shut or some other issue.’ (Participant 4)
‘More often than not, the paramedics have correctly identified that the patients are safe and often the call has initiated from NHS 111.’ (Participant 5)
‘NHS 111 is a major problem and hitch in the correct use of resources. One of the things I really worry about during out-of-hours is the amount of paramedics that are waiting for call backs. I am aware that if a paramedic doesn't get a call back, that is an ambulance off the road.’ (Participant 6)
‘Some patients don't need a paramedic, don't need to see a doctor, they don't need to do anything. NHS 111 has just sent an ambulance and the paramedic is just looking for somebody else to take responsibility—this is not a criticism of paramedics specifically. Within the NHS, if you don't have to take responsibility for anything then you don't. I remember when I was a junior doctor, every question I had I would pass it to somebody else, and over time you're pushed into a position where you're the one making a decision so the responsibility lies with you. If there is a pathway there for someone else to take responsibility, then I think it's human nature to get that someone else to take the responsibility.’ (Participant 7)
Need for skills development in paramedic practice to ensure referrals are more compatible with U&PC
‘Paramedics have one urgent care green response car on the Wirral and maybe we need more of those types of things.’ (Participant 1)
‘There are other examples across the country where paramedics are being used more in primary care. It takes the courage to say I think this could work.’ (Participant 2)
‘You have to be careful about the skill and level of the paramedic. We want paramedics if they review patients, to assess and manage them appropriately and try to keep them in the community.’ (Participant 3)
‘Paramedics working in primary care is the Holy Grail. We want paramedics to have really rewarding jobs where they can see they are making a big difference to a group of patients.’ (Participant 4)
‘They have the clinical background that just needs some tweaking to the skillset.’ (Participant 5)
‘For paramedics coming into the urgent care way of working, there is definitely a different skillset to learn.’ (Participant 6)
‘A lot of things paramedics see is primary care stuff anyway. If they are not comfortable with their skills, they should be out to develop those skills.’ (Participant 7)
Discussion
There is a baseline confidence from the GPs interviewed that paramedics can make appropriate referrals, but this faith also comes with caveats. Occasionally during referrals, paramedics can be insistent that some form of action should urgently take place.
Ang et al (2013) argue that communication skills influence health outcomes, adherence, and satisfaction, but measuring the quality of a conversation is difficult to scale. An amicable discussion is the principle point of a referral where often only advice is needed as opposed to GP visits, ED attendances, or other swift measures. Paramedics must accept this from a GP perspective as there needs to be an understanding not to use unnecessary resources. A pivotal factor in variability can depend on the type of dialogue between the paramedic and GP.
There are assumptions by some of the GPs that paramedics should take more responsibility for patient care. Conversely, paramedics should make it transparent to GPs what they take responsibility for, so there is clarification regarding roles, with consideration of scope of practice, risk assessment, and accountability. Liu and Buijsen (2016) illustrate the continual reliance of individual responsibility in a healthcare system. Paramedics can have preconceived biases around patient care. GPs may accept these referrals too readily without exploring all the facts or not knowing the paramedic's limitations. There are insufficient data or feedback on the reliability of a paramedic diagnosis; therefore GPs cannot be reliant on a paramedic's impression. GPs as recipients of referrals must realise the diagnosis is in their scope and decision-making.
Some interview participants who work in the OOH setting allude to the workload placed upon them. NHS 111 is very much perceived as the catalyst for this. There has been a high degree of patient satisfaction with NHS 111, but the impact on other health organisations has not accurately been assessed, with mixed views from other stakeholders (Pope et al, 2017).
Results have shown that parents of paediatric patients have mostly shared positive experiences, while getting what they needed and would use the service again (Burger et al, 2016). This optimistic view was not shared by some of the participants, who anecdotally are not reaping the benefits of NHS 111. Competent paramedic referrals are sometimes superseded by GPs' frustrations that an emergency ambulance response should not have been activated in the first place. GPs are under severe pressure to prioritise paramedic callouts in OOH settings. The merit of paramedic referral skills can be obscured, even when they have made an appropriate assessment.
There can be opportunities to develop paramedic capability in the future. Villareal et al (2017) concluded that ambulance service support by GPs enables more patients to avoid ED admittance, reduces costs, and improves quality of care for patients who are not in need of hospital services.
However, there is virtually unanimous agreement among participants that there is a current skills gap with some paramedics on the Wirral in the context of U&PC. Djalali et al (2017) surveyed that an increase in practitioners' confidence in relation to primary care can be testified to by an improvement in their professional, organisational, examination, and management skills, after a period of vocational training. Paramedics may feel stressed and anxious about making referrals to GPs because they do not feel they have the sufficient skillset. Appropriate referrals are synonymous with appropriate skills. Paramedics already possess a basic skillset for U&PC as some fundamental assessments overlap with emergency care.
Limitations
The limited sample in terms of size and geographical area, along with the number and subjective nature of views of the participants in the current study must be considered. However, the qualitative responses, which may or may not be reflective of a wider national picture, are of value.
Conclusion
Conversation skills between a paramedic and GP are a critical factor when making a referral. Paramedics should not be confirming a diagnosis as this is the responsibility of the GP. The credibility of referrals can go unnoticed, particularly if there has been an inappropriate response somewhere else in the system. Further research should scrutinise paramedic skill-bases to see how they can evolve and diversify for the challenges ahead.
Recommendations
Paramedics should convey messages to GPs in ‘neutral terms’. This means articulating an objective narrative to GPs based on reliable history-taking, symptoms, observations, treatment, and the patient response to any intervention, as well as any other relevant fact-finding, but falling short of confirming a diagnosis. GPs require time and opportunity to ask the appropriate questions and decide on the best care for patients involved. Paramedics must not undermine GP decisions but remain a strong advocate for the patient and address any concerns or risks during the referral in a respectful manner. A referral made by a paramedic to a GP is a skill in itself, and this practice should be cultivated to reduce the variability and improve quality.