Home visiting is an unpredictable activity with an unknown outcome for health professionals. Ferguson (2018) states that home visiting constitutes a distinct sphere of practice and experience in its own right, as it is a deeply embodied practice in which all the senses and emotions come into play; practitioners apply home visits by skilfully enacting a series of transitions from the office to the doorstep, then into the house, where complex interactions with service users and their domestic space occur. Winter and Cree (2015) relayed the idea of home visiting as an ‘invisible trade’, as it happens behind closed doors in the most secret, intimate spaces of people's lives.
An advantage of home visiting is that practitioners witness patients' first hand in their own innate surroundings, which can uncover health and social care needs of ill and vulnerable people. Home visiting discloses many aspects of people's way of life and can stimulate wider thought processes for practitioners in comparison with consulting in the static confinement of hospitals or medical centres.
Templates for primary-care home visiting have traditionally been led by GPs in the UK. National Institute for Health and Care Excellence (NICE) (2018) guidelines state that GP home visits can help prevent unplanned hospital admissions when supported by appropriate diagnostic back-up with access to patient records and history, and enabled by referral options and shared decision-making.
In the UK, home visits are generally provided to primary care for patients who are chronically or acutely housebound (Abrams et al, 2020). However, GPs nationwide have followed trends in other countries that may leave high-risk housebound patients more vulnerable. Theile et al (2011) said that in the 21st century across Western Europe and the United States, home visits by doctors are no longer part of standard primary care. Mitchell et al (2020) highlighted that NHS workloads in primary care have risen. This, combined with an ever-increasing rise of elderly people with frailty and multimorbidity, has increased pressure on the GP workforce, making it more difficult for GPs to urgently attend patients at home when needed.
Political developments to change GPs' relationship with home visits eventually came to a head in the UK. At a British Medical Association (BMA) conference in November 2019, 54% of delegates voted to lobby NHS England to remove home visits as part the GP contractual responsibility, with 74% voting for a separate acute service for urgent visits (Lacobucci, 2019). Salisbury (2019) campaigned against the vote, saying that, although home visiting services were already undertaken by paramedics, there will still be an indication for GPs to visit if there are continuing complex health needs that require medical attention, including end-of-life care.
The BMA votes are a symbol of the ambivalence of the GP profession towards home visiting. The arguments for and against also illustrate the polarisation that divides doctors over this practice. It reveals that home visiting has a leadership vacuum—in other words, there has been a lack of ownership from GPs, which has opened unoccupied space that another profession can inhabit, and then design the future of home visiting in primary care.
The case for paramedic-led acute home visiting in the 2020s
First, a brief analysis is required to understand the paramedic profession's journey from their traditional background in ambulance services to working for primary care providers.
Government literature had begun to acknowledge that paramedics were becoming more autonomous professionals. Publications such as Peter Bradley's Taking Healthcare to the Patient (Department of Health and Social Care (DHSC), 2005), Professor Sir Bruce Keogh's urgent and emergency care review (NHS England, 2013) and NHS England's (2014)Five Year Forward View all accepted that the scope of paramedics was expanding.
However, these reports mainly expressed a theme of ambulance services overseeing paramedics' professional development and growth, which was ultimately a misplaced expectation. Newton et al (2020) explained that, in the midst of an exponential rise in educated paramedics, NHS ambulance services lagged behind and failed to create enough career opportunities. Consequently, this hampered practitioners' ability to make full use of their skills, which manifested in low morale and high rates of staff turnover (Newton et al, 2020).
The perception of ambulance services as slow-moving and complacent has helped to build a platform for an emerging jobs market within the primary care. Brooker and Voss (2019) advocated that GPs should employ paramedics, who have the skills to undertake home visits, manage minor illnesses and provide same-day urgent primary care. Home visiting may well become a cornerstone and a permanent fixture in primary care paramedicine.
While paramedicine is in its infancy in primary care, home visiting schemes are already commonly associated with the profession. Eaton et al (2020) discussed the roles of paramedics, pinpointing acute home visiting for patients with undifferentiated and undiagnosed conditions.
Acute care is longstanding practice for an occupation that is already well embedded in home visiting. Paramedics already lead successful acute home visiting services (AHVS) that are integrated into a network that reduces GP workload, free up GPs' time for care planning, improve the identity and skillset of paramedics, decrease unnecessary hospital admissions and enhance patients' confidence if paramedics are working collaboratively with GPs (Barker et al, 2020). Many other professions may assume that home visiting is part of paramedics' natural habitat. Therefore, a somewhat existing confidence in paramedics could inspire widespread belief that they are capable of leading AHVS.
The advent of a new decade saw government proposals to reform and modernise the NHS primary care system. The NHS Long Term Plan (NHS England, 2019) highlighted that, during the 2020s, primary care networks (PCNs) will be able to fund additional staff, including paramedics, as part of an expansion of multidisciplinary teams. The same white paper discussed AHVS, which are already in place and can be implemented on a national scale, with paramedics playing a key role. A paramedic-led AHVS that delivers urgent visits increase the number of patients that can be managed at home while reducing the number of unnecessary hospital admissions, and allows GPs to spend more time with patients who have complex needs (NHS England, 2019).
Nonetheless, studies suggest there is a long journey ahead for the profession to establish itself within this arena. Proctor (2019) concluded that more information should be provided to the public to increase awareness of primary care paramedics, and further research should be carried out to examine the value and productivity paramedics offer to general practice. Notwithstanding progress made by paramedics, the evolution of practice may be slow and drawn out despite steady increases in PCN resources, infrastructure and capacity.
Changing the culture of the home visiting system
Employees in primary care can feel overwhelmed when an influx of calls needs to be managed and this can lead to tension with service users. High public expectations and demands amid heavy duties are prominent concerns for the general practice workforce (Baird et al, 2016). The NHS Constitution (DHSC, 2012) set out principles, pledges, responsibilities, values and rights for both patients and staff.
Under the NHS Constitution (DHSC, 2012), members of the public cannot insist on a home visit and will be visited only if their GP practice deems their medical condition as requiring one and/or it is of an urgent nature.
It is imperative that GPs and AHVS feel in control to ensure acute patient care is delivered in a timely and efficient manner. Metaphorically speaking, the dog should wag the tail—not the other way around. There is a danger that AHVS could become ambulance services 2.0, with AHVS effectively being used as ‘dumping grounds’ for inappropriate calls if stringent measures are not in place.
Improvements in the home visiting system are encouraged by instructions and regulations. NHS England (2016) stipulated that general practices must have a system in place to assess patients who may require an urgent home visit, while ensuring all clinical and non-clinical staff involved in the process are aware of their responsibilities.
The Care Quality Commission (2017) reiterated its auditing of GP practices to determine how they decide whether a home visit is necessary, how a practice prioritises home visits, and what they do if the urgency is so great that a home visit is not appropriate. Reception teams have often considered requests which have then been dispersed to GPs for visiting, typically at lunchtime. However, home visits triaged by receptionists can be held up by unpunctual morning surgeries, causing delays in 999 calls needed for some patients and a greater impact on the afternoon workload (Charles and Das, 2016). An absence of clinical triage could mean home visit referrals are inappropriate, because either patients do not require a visit or treatment is delayed for patients who need earlier examination and hospital admission.
Remote operations are key if AHVS are to be successful. The BMA (2020) says remote clinical assessment and triage are crucial in the first instance when a home visit is requested; home visits should be considered if telephone or video consultations cannot be done, or if a physical examination is essential and patients are unable to attend an appropriate medical facility. Detheridge (2020) found that remote triage by GPs and nurses reduces the number of patients who were seen face-to-face.
Effective clinical triage relies on having the relevant patient details with a presenting complaint and succinct narrative. Referrals to AHVS should come with a specific reason for an urgent visit, where attending their home could change an outcome. This decision can also be reviewed by a member of AHVS and re-triaged if need be. The focus should always be on same-day appointment acute calls (i.e. sudden worsening of conditions requiring intervention). Alternatives should be sought for emergencies, chronic reviews and non-essential visits that will not change outcomes. Investment in effective triage could decrease unnecessary home visits, 999 calls and hospital admissions, which in turn increases equity and capacity within the overall system.
Clinical leadership in acute home visiting services
The professional body for paramedics offers guidelines on leadership roles in primary and urgent care, which can provide support for niches such as AHVS. The College of Paramedics (CoP) (2019a) has issued a framework for advanced paramedics, which specifies that they must demonstrate complex decision-making skills and competence in their area of practice, based on research, leadership, clinical practice and education.
Health Education England (HEE) (2017) has made it clear that advanced practitioners are care professionals educated to a master's degree (level 7 higher education or equivalent) in clinical practice and have developed the skills and knowledge to allow them to take on an expanded scope of practice when caring for patients.
The Health and Care Professions Council (HCPC) (2021a) has identified the regulatory challenges and risks in registrants advancing their practice, with an appreciation that the terminology for advanced practice is variable. There are semantic inconsistencies concerning paramedic titles and positions, but terms such as advanced paramedic practitioner or advanced clinical practitioner promote roles for educated professionals in advanced roles predicated on clinical leadership. Highly educated and clinically qualified paramedics are integral to AHVS credibility and leadership.
Clinical examination and diagnosis are flagship skills in advanced practice and one of the prime differences between the advanced (MSc) paramedic role and newly qualified (DipHE/BSc - Hons) paramedic role. Innes et al (2018) stated that clinicians need to develop their assessment techniques and serve their patients as diagnosticians; this involves clear history-taking and examination for better detection of clinical signs and diseases, pattern recognition, knowledge of pathophysiology, spot diagnosis and predicting prognosis.
Japp and Robertson (2018) emphasise that the core skill of history-taking is a mainstay of making a diagnosis; differential or final diagnoses can then be made with probability and risk. AHVS clinical assessments centre around history-taking, with dynamic examinations based on cardiovascular, respiratory, gastrointestinal, nervous, renal, and musculoskeletal systems. Clinical diagnostic and investigation skills can include urgent venepuncture blood sampling (with the ability to request and interpret results), swabs, mid-stream urine sampling and urinalysis, requests for imaging (e.g. x-rays), and end-of-life care planning. The vast majority of AHVS patients are elderly and housebound so advanced practice has a broader context in specific situations including frail, deteriorating and dying patients.
Paramedics working in AHVS can benefit from gaining advanced skills, building on the core transferable skills they already possess. Skills for Health (2019) supports the role of paramedics who specialise in advanced practice, expressing their capabilities in clinical assessment, diagnosis, investigations, treatment, advice, prevention and collaborative working.
A merit of advanced practice in AHVS is that they provide swift, appropriate care for patients who require it, while showcasing paramedics' array of skills, knowledge base and leadership in primary care. Paramedics can also undertake non-medical prescribing courses to practise as independent prescribers (CoP, 2019a). Independent prescribing should be exercised in AHVS as a form of treatment to manage acute conditions in the community.
AHVS can make extensive referrals to several settings, such as secondary or elective care in hospitals, or multidisciplinary services in the community such as rapid response teams or district nurses. Once all avenues including self-care have been explored, the options of referring to GPs, emergency departments and ambulances can be considered.
Acutely ill patients require paramedics to come to their homes, be able to maximise their advanced skills, identify problems and find a solution without overburdening other resources.
Record-keeping, clinical risk and governance
Paramedics are regulated and accountable for record-keeping. They have a professional responsibility to maintain patient records that are clear and accurate so information can be shared with colleagues, service users receive appropriate treatment, legal requirements are met and evidence is provided for decisions should these be later queried or investigated (HCPC, 2021b).
AHVS can operate with paperless documentation supported by technology. EMIS (2021) is a digital clinical system that gives access to primary care services to help practitioners make informed clinical decisions with secure access to crucial patient information and shares expertise between different areas of the NHS and social care. Not having access to platforms such as EMIS means AHVS would have no digital evidence of significant patient details, necessitating more reliance on potentially inaccurate service user narratives.
De Hoon et al (2017) explain that a deficiency in record-keeping results in poor communication between health professionals and an increase in adverse medication events. Dixon (2019) promoted EMIS as an accessory for paramedic independent prescribers working in primary and acute care.
The absence of digital records, such as a lack of information on allergies and medication, makes it difficult to safely prescribe drugs required immediately. AHVS access to health software makes record-keeping safer and enables urgent decisions for care in patients' best interests.
AHVS and paramedics must be able to demonstrate a preparedness to accommodate risk. The World Health Organization (WHO) (2009) states that clinical risk management addresses the safety of healthcare services by identifying circumstances that put patients at risk of harm, then acting to prevent or control those risks.
One of the issues that AHVS need to manage is handling a multiple caseload of high-risk patients. If there are several acute home visits to carry out and these are started early in the morning, it could still be mid-afternoon before a practitioner arrives on scene. During the period between triage and the home visit, there are potentially a few hours of uncertainty regarding the patient's condition, which can lead to many possible permutations.
Fenn and Egan (2012) note that health services have inherent risks with unpredictable consequences, which should indicate that practitioners need to be perpetually aware of risks to both patients and staff. On remote assessment and triage, patients must be made aware of rapid decline that may require an immediate 999 response and hospital admission before a home visit takes place. Risks also apply after a home visit if the patient has remained in their community setting. Advice on deterioration needs to be given in the context of the patient's condition.
For example, for a severely frail and deteriorating patient who may be approaching the end of life, an intervention may not be indicated while the paramedic is on scene. However, over the next few hours or days, there is a risk of this patient rapidly declining and dying. The patient may not require an ambulance if this has been deemed appropriate but may need urgent support from other services. Therefore, all potential risks and advice for family and other service users should be communicated.
A balanced and proportionate level of response to clinical risk should be advocated by AHVS without being overly risk-averse, which can be detrimental to patient care.
AHVS must be underpinned by robust clinical governance which can be provided by senior GP partners in primary care. Pearson (2017) highlights that clinical governance should ensure safe, effective, responsive, and well-led care. Van Zwanenberg and Harrison (2018) argue that clinical governance principles are uncomfortable as they implicitly accept that health professionals do not invariably provide patients with the best quality of care.
AHVS should engage in clinical audits which should be passed on to PCNs or NHS clinical commissioning groups. Clinical audit data can include the numbers of home visits, 999 calls and hospital admissions, as well as the type of advice to patients, community referrals and prescriptions. Active participation in clinical governance meetings at the general practice is useful as it allows paramedics to discuss any mistakes, accidents, near misses or incidents for future learning with GPs.
Appraisals to assess competency and areas of improvement or continuing professional development are essential for governance. AHVS can receive patient feedback via the general practice, and address queries or points of view expressed by the public. AHVS can assign development opportunities, e.g. providing trainee advanced practitioners or trainee independent prescribers with mentorship in primary care. AHVS leadership and governance should ensure competent paramedics are recruited and have suitable job descriptions and objectives, with good working conditions that allow staff to flourish.
Purpose, vision and philosophy of primary care paramedicine
AHVS are secondary to a much bigger picture of paramedicine. Attentiveness and contemplation can be used to explore a higher purpose for the existence of paramedics in primary care.
The CoP (2019a) promotes the idea that the paramedic profession will continue to develop across a wide range of health and care settings, with its growth and direction supported by education, clinical practice, research and leadership.
O'Meara et al (2017) wrote that paramedics across the UK have a shared desire for self-regulation, in which changes to clinical governance arrangements can support them to be more autonomous professionals.
There is a growing appetite from contemporary paramedics, who have been influenced by higher education institutions to exercise their ability to make knowledge-based decisions, to be more independent. Givati et al (2018) identified that newly qualified, university-educated paramedics were experiencing their decision-making in ambulance services being undermined because they felt overwhelmed or intimidated by colleagues with greater seniority or a longer time served.
A deeper meaning and fulfilment for primary care paramedicine can be founded on two main principles: professional freedom and autonomy. There is an impassioned call for freedom for the paramedic profession to depart from micromanaged, hierarchical cultures and realise its potential within a supportive and collaborative network.
Primary care engenders a sincere belief that a greater level of independence and decision-making can be determined by progressive paramedics in healthcare settings such as general practice.
‘Our vision is to inspire and enable all paramedics to participate in the profession within an environment based on safety, collegiality, inclusiveness, mental and physical wellbeing, and innovation—a vision built on what you see for your future in a profession for life’
Primary care paramedics may wish to apply the CoP's (2019b) vision—an aspiration to work individually and collectively in an environment that is committed to improvement and accomplishment—and tailor it to their own imaginations and domains.
Iliopoulos et al (2018) suggested the presence of an intrinsic link between job satisfaction, good performance and regular workplace learning. This may motivate paramedics to look for work and remain in post at general practices that appear dedicated to training.
Paramedics may also be eager to engage in several settings with different tasks. Bench et al (2018) highlighted that advanced practitioners enjoyed operating in hybrid roles. A primary care vision can include paramedics operating on hybrid templates, including a rotational system of online, video or face-to-face consultations, care home ward rounds, remote triage and home visiting.
Philosophical viewpoints from paramedics may well change during the profession's expansion in primary care. Schofield et al (2020) conclude that paramedics' contribution to general practice has not been fully evaluated, with little evidence on safety, cost-effectiveness or models of working to understand the benefits and consequences for patients. The lack of establishment in this field puts the paramedic profession in uncharted territory, so it should not be dogmatic when expressing hypotheses. It may take a long period before practitioners are operating optimally within a suitable model, which should allow time for critical thinking and carefully addressing problems.
Primary care paramedicine has an opportunity to be innovative, shaking off risk-averse algorithms and protocols for more enlightened practices. Paramedics who are employed by primary care providers should not assume a passive role but seek to lead the profession's pursuits in a productive workforce.