Using the pandemic to enhance the role of the paramedic
Adam Layland, National Head of Commissioning at Health Education England and Consultant Paramedic at Coventry and Rugby GP Alliance, outlines how paramedics are crucial in supporting primary care and reducing hospital admissions.
Throughout the coronavirus pandemic we have witnessed the extraordinary efforts of our healthcare professions, who go above and beyond the call of duty. This sense of duty is instilled in our healthcare workforce and while we often consider staff to reflect the values of the NHS, it has actually been the opposite during the pandemic: our staff are automatically leading the values themselves.
However, throughout the pandemic we have also experienced a change in patient behaviours, perhaps from fear of exposure or from contracting the virus, or that they are empathetic to the preparedness of the NHS. Whatever the cause, it has been noticeable in the patient demand and activity we are used to encountering. This has inevitably had an impact on service needs and delivery, providing organisations with an opportunity to review provision, reallocate staff or transform services.
One would question whether these changes can remain in place, as we have a rare opportunity to pause, reflect and think within some services, despite an ever-increasing demand on public health, and now on restoring services.
A shifting landscape for primary care?
Primary care, in particular, has had a noticeable drop in demand. There are several apparent reasons for this, some mirroring the above-mentioned patient fear or empathy, but others due to services shutting with no alternative access. We may never know the true impact that this has had on the health of the population, notwithstanding the severe and tragic impact the virus has already had. Primary care has, anecdotally and historically, rejected the need to improve access to patients through digital means and in the not-too-distant past has demonstrated this very strongly when the GP at Hand app was introduced by Babylon.
Things are now changing. Faced with an unprecedented challenge primary care has, finally, acted to allow a more responsive and accessible service to patients, and long may it continue. The benefits of this are astounding for patients but it has also raised awareness of the need for more visiting services – this is where paramedics stand in the spotlight. When you consider a paramedic you automatically think of an ambulance and 999, seldom do you consider the high level of training and autonomy that paramedics require to deal with any and every emergency you could imagine.
The luxury of an on-call system or a more senior colleague being close, as in a hospital setting, is more or less non-existent prior to arrival at hospital. Furthermore, the skill set of a paramedic is often misunderstood, as a high proportion of 999 calls are predominantly related to primary-care needs or exacerbations of long-term conditions. Therefore, paramedics have a unique skill set across both emergency care and primary care, and combining these naturally results in hospital avoidance. Readers may be thinking: “my emergency department is always full of ambulance patients”; however, this is not always a result of a lack of autonomous high-level care. Rather, it can be pinned to cultures and inappropriate protocols and, more often than not, a lack of services available to patients to help support them in their own homes.
We must utilise paramedics’ expansive skill set
Throughout my own experiences, however, I have never once seen a patient be discharged from an emergency department without being provided with treatment that is not completed in the pre-hospital environment. It could be argued that offering some of these diagnostics such as phlebotomy and ultrasound scans would further reduce attendances at emergency departments, thereby improving patient care, and reducing unwarranted exposure of risk when attending hospital.
Therefore, paramedic services are increasing within primary care, not only as a method to undertake home visits for GPs, but to offer a comprehensive diagnostic service, treatment plan and ongoing care for patients in their own homes. This in turn releases GPs from care needs for patients that can be successfully fulfilled by a paramedic and allows them to have more time and concentration with patients who have complex or palliative care needs.
I undertook a review of one such service operating across a city with a large acute university hospital. This service was specifically designed for paramedics to attend patients on behalf of a GP, who had already triaged the patients and determined that they would very likely need to be admitted to hospital. Astoundingly, 85 per cent of the patients seen did not need hospital care and were either treated by the paramedic in their own homes, or services were put in place to support the patient to remain at home.
In other words, for the 15 per cent of patients who needed treatment, only one per cent actually needed hospital admission, and the other 14 per cent needed an intervention from a GP such as a prescription or referral for further diagnostics. This service is now expanding its operations and undertakes admission avoidance cases as well as routine and pre-booked patients, all to support primary care in the delivery of high-quality, safe and effective services to the community.
There is also an increase in the skill set of the paramedics with reviews under way to include prescribing, additional diagnostics and referrals for imaging. This may result in primary-care paramedics offering a more comprehensive support service to a cohort of patients, on behalf of a GP.
Further expanding the skill set
Paramedics now have the opportunity to receive extended training for primary care. Some advanced training has been available for several years, however none has really focused on the specialism of primary care. This is due to a focus on emergency care and paramedics operating more in emergency departments and minor injury centres.
While the fundamental skills of emergency care prepare a paramedic for primary care, and this experience is absolutely necessary for paramedics going into the primary-care environment, an emerging skill set of developing longer-term treatment plans, ongoing care support and regular multi-disciplinary working for a patient is driving the paramedic profession into new levels of autonomy and holistic care.
This approach focuses the skill sets of the most appropriate person to support patients, and paramedics are experts, above all other healthcare professions, in assessing, diagnosing and treating patients in their own home – no other healthcare profession does it more often or is primarily trained to deliver care when the patient needs it, and at home.
We know that over the coming months and years, whatever the aftermath or ongoing nature of Covid-19, patients will need support, care and treatment. There is already a backlog of care needs, which in turn may cause added complexities in conditions or an increase in long-term condition management for patients, which inevitably worsen from time to time.
Despite the speed at which primary care is now coming to terms with a new service model digitally, I can only envision two options for patients who will require a home visit. Both utilise the paramedic profession: a paramedic in primary care offering a comprehensive service to patients on behalf of a GP, or accessing 999 and ultimately attending a hospital. You may question why 999 paramedics cannot have a parity of service with primary care, but the reality is not having the same method of access to the support of a GP and the autonomy provided in primary care, above that of an emergency ambulance response service.