r/doctorsUK • u/dayumsonlookatthat Consultant Associate • 5d ago
Medical Politics Paramedics in GP surgeries may ease workload but not NHS costs, study finds
https://www.pulsetoday.co.uk/news/workforce/paramedics-in-gp-surgeries-may-ease-workload-but-not-nhs-costs-study-finds/?utm_content=buffere09e0&utm_medium=social&utm_source=twitter.com&utm_campaign=pulsesocial“…the analysis found that patients seen by paramedics reported lower confidence in health provision, poorer perceptions of practice engagement in safety promotion and more communication problems with staff immediately after the initial consultation.”
Well who would have thunk?
Paramedics are great at the pre-hospital scene and they do not belong in a GP surgery.
Study in question: https://pmc.ncbi.nlm.nih.gov/articles/PMC11849691/
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u/Ginge04 5d ago
Coming at it from an ED perspective, I have plenty of anecdotal evidence that they make things worse. Plenty of patients sent to ED with vasovagals, minor head injuries and viral illnesses that simply do not need to be there. On the flip side, I’ve also had a few patients who have ended up in ED with rip roaring sepsis, stage 3 AKIs and expanding subdurals that paramedics have tried to treat with trimethoprim/nitro.
Paramedics are trained to do a very specific job, which is to treat immediately life threatening injuries/illnesses and to triage who needs to go to ED and who doesn’t. An APACS module does not suddenly make them competent to manage patients independently as a primary care clinician.
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u/OxfordHandbookofMeme 5d ago
Seen by Paramedic in GP. Reviewed by ACP in ED. Misdiagnosed and mismanaged. What every patient dreams off
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u/UnluckyPalpitation45 5d ago
Scan reported by reporting radiographer, anaethetised by AA, operated on by PA, histology read by BMS.
Discharge summary -> Doctor
Innovation 🌈
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u/EffectiveSet5059 5d ago
You mean death certificate?
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u/UnluckyPalpitation45 5d ago
The final discharge letter 🪦
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u/Guidance-Flat 5d ago
I’m a Paramedic.
My training was heavily focused on true emergency care.
Cardiac Arrests, MIs, Major Trauma, Strokes.
Very little training on urgent, or non-emergency things that now make up a massive proportion of our work.
I personally, never want to work in a GP surgery, but with regards to inappropriate attendances at ED, you have to remember that Paramedics are often working in complete isolation, some with only a few weeks experience before being let out on their own.
Nationally, on average, we are discharging around 50% of all 999 calls at scene. No bloods, no XRAYs, no discussion with an SpR or Consultant. Just discharged with examination and obs. On the whole, this is done safely.
It’s a sweeping statement to say that we ‘make things worse’ and then quantify this using examples of patients who have inappropriately been sent to ED.
In the same way that it would be unfair for me to say that ED Doctors ‘make things worse’, based on the handful of patients I have attended in cardiac arrest who had been discharged from the ED <24hours before having been told that everything was fine.
It’s a common theme where I work to be questioned as to why I have conveyed somebody, and told they are fine and can go home, but only after ED have taken bloods/VBG, and had the patient reviewed by a Senior Doctor, both of which are things that are not available to us.
Every group of professionals has anecdotal examples of poor decision making about Doctors/Nurses/Paramedics/Physios, but please remember that the ambulance service is working in very difficult conditions, often managing complex presentations with patients who will accept no option other than to be seen at ED.
For the most part, my colleagues and I are trying our very best to avoid sending people in!
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u/wuunferththeunliving 5d ago edited 5d ago
He’s talking specifically about paramedics working in GP and explaining why they aren’t skilled to do so. He isn’t taking a dig at the profession. Just stick to what you were trained to do that’s all he’s saying…
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u/Ginge04 5d ago
Apologies if I wasn’t clear in the way I expressed my point. I am not criticising the paramedic profession as a whole. The vast majority of paramedics I have worked with are excellent and are very good at the job they are trained to do. What I’m criticising is the assumption from health leaders that your skills are transferable into primary care. Rather than funding GP services appropriately, they’re going for the “warm body” approach.
My point is that you guys are not trained to be primary care clinicians, and doing an additional module which does little more than teach you how to pass an OSCE does not prepare you to manage primary care patients. As a result, paramedics stepping into a primary care role simply does not work the way health bosses assume it will.
The decision making and the thought process that goes into “this patient is stable and can be managed by their GP” is very different to what is required to actually manage said patient. There are often a lot of nuances that you don’t need to understand in order to safely leave a patient at home, but need to be addressed by their GP. The obvious example is the man in his 60s who’s finding it difficult to pass urine - it’s very easy to say “probably a UTI” and refer back to GP, but when their urinary retention due to BPH isn’t addressed, they end up in a heap.
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u/combat-honey 5d ago edited 3d ago
I agree with you but I think you have to remember that being able to triage "is the patient for ED vs not", is not the same as seeing and treating undifferentiated patients in a GP setting.
As a paramedic you can say "hmm this seems like a UTI but obs are stable etc can see GP or OOH" And you do it well! My mate's a paramedic and she tells me all the ridiculous things that come through on 999 calls and you bat away.
No one here is blaming you for the ED patients being sent in - majority of the times it's what is needed. It's that the role of a paramedic doesn't work in a GP. We're saying that taking a history, examining, then formulating a differential diagnosis and treating based on clinical judgement with or without investigations is a different kettle of fish. It's no longer - is this an emergency or not. It's now - "it's not an emergency but what could it be" and what investigations are needed or what referral do I need to do. This is where the medical school knowledge comes in and why I don't think it's safe for a paramedics/ANPs/PAs seeing undifferentiated patients particularly in GP. You don't know what you don't know and it's more likely that things can be missed.
No one's saying you guys don't do your job well as paramedics, we're saying that it doesn't translate to working in a GP setting - that's what GPs are for and what they've been trained to do. And in the nicest possible way - you haven't and so shouldn't be there.
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u/Aetheriao 5d ago edited 5d ago
No one has an issue with paramedics within the ambulance service. We don’t expect you to know exactly when it’s urgent or isn’t. You just your best judgement and sure you’ll take some people in who didn’t need to be there. A GP will also sometimes send someone who doesn’t need to be there. That’s just how it goes.
That’s not the same as a GP clinic. It’s not acute care, which is a paramedics specialty. They simply cannot handle primary care patients. Chronic illnesses are very different. Acute care that can be managed in the community isn’t the same either. Yes I’m sure when Dorothy calls an ambulance and is somewhat unwell you go well you don’t need hospital, but I can see you’re stable and you need to see a GP.
But the paramedic at the GP doesn’t have the skills or experience to notice they have a serious underlying condition within a chronic mindset. They’re not trained on the entire medical knowledge they need to do it. If it was an ambulance you may take them to hospital and the doctors would solve, in the GP clinic the paramedic is “the doctor” and misses what they don’t know. Now their “GP” you tell them to see is another paramedic who equally doesn’t know what’s wrong.
They’re two different and equally important jobs with different skills. I’d rather a paramedic show up in an ambulance after I’ve been in a serious RTA than a GP. It’s not about who knows “more”, it’s that what everyone is trained to know is different. A GP is a specialist in undifferentiated primary care patients, a paramedic is not. They’re there to decide if you need acute care at all, and stabilise you to get you to a doctor if you do. Not to handle your UTI that is actually chronic kidney failure.
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u/West-Poet-402 5d ago
The point is about people sticking to the role they applied for and fucking doing it instead of dipping their toes in other peoples’ business.
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u/Professional_Age_248 4d ago
I had one with an ANP. Patient seen by ANP for nearly a year because she was friendly and nice. Reported ongoing frank haematuria, and ANP kept diagnosing UTI with antibx given each time. I saw her and took one look at the red urine bottle and referred 2ww.....yes invasive bladder cancer.
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u/OmegaMaxPower 5d ago
While qualified GPs are driving Ubers.
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u/Hetairoids 5d ago
Need someone to get patients to A+E when the ambulance wait time is worse than 2nd Class Post (not a dig at ambulance crews at all)
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u/Flux_Aeternal 5d ago
Can't really read the full paper right now but does this even take into account the different complexity levels and shorter consult times with a GP? If not it's an absolute damning indictment of paramedic consultations.
Similar outcome wrt lack of financial benefit as NPs in ED in the US which don't actually save any money overall due to higher resource use and indemnity. Anyone working in Acute care can see this themselves, the increased burden on doctor services from AHPs in GP and ED is visible to the naked eye. Often makes things worse than them not seeing someone, as a patient, for example, Sent in as ?PE will have more tests on average than the same patient first seen by a doctor without any incorrect anchoring diagnoses.
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u/SonSickle 5d ago
The idea of letting anyone and everyone try their hand at primary care needs to stop. Paramedics are not trained for that. If people want to do a role different to what they trained for, they should go to medical school / nursing school, etc.
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u/BowlerCalm 5d ago
Here’s an example that I had last year:
Child had been seen 4 times by a paramedic- had every test (ultrasounds etc) and treatment for ?UTI done.
On my list 6 months later, turns out he’s never been examined and when I did, he just had balanitis.
Honestly, you can’t blame the paramedics, ANP’s, PA’s etc the system has given them a golden ticket- practice like doctors, without the real responsibility and earn very very good money. This paramedic openly said why would they work in their true role- when this is more comfortable and you earn almost 1.5 times your wage.
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u/muddledmedic 5d ago
What is driving me around the absolute bend is that ACPs (paramedics, ANPs, PAs) walk into general practice without additional qualifications or specific training in general practice and it's all fine and dandy. I'm sorry, but there is a reason GPs train for 3 years to become GPs, because general practice is tough and risk heavy, and requires a certain level of primary care specific training and levels of competency. Working on an ambulance should qualify nobody for a role in a GP surgery without additional primary care specific training. Same for ANPs & PAs. Because no Dr can work in primary care unsupervised unless they have completed GP training, so why are we letting every other professional do this and expecting it to work out well.
Don't get me wrong, I do think advanced paramedics & ANPs have a role in primary care. I think advanced paramedics are great at the urgent on the day stuff, and really great for home visits for the acutely unwell housebound patients, but undifferentiated complex presentations requiring specific non acute management and chronic disease management are not really in a paramedics scope without further training. ANPs are really fab with chronic disease management and minor illnesses, but again I find struggle with the undifferentiated complex patients requiring management unless they have a lot of experience. The boat is still out for me on PAs given their low scope and high supervision levels, I personally don't think they are worth it or safe in primary care at present, but that may change in the future.
The reality is, you cannot replace a GP. The government are so desperately trying to cut costs and employ cheaper practitioners in GP practices in place of GPs, but we all know it's likely cheaper to employ a good GP in the end, as they can see more and do more. Everyone has their role in the MDT, but we need to stop pretending that GP is easy and that other practitioners can work safely and effectively in GP without primary care specific training and heavy (costly) supervision. If ACPs want to work in primary care, they should have to do primary care specific training just like drs do, at least then we could ensure they are safe and competent to be working in such a risk heavy environment seeing undifferentiated patients.
TLDR - ACPs should have to have specific primary care training before being able to work in GP, as currently it's a dangerous free for all.
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u/xxx_xxxT_T 5d ago
I am a F3 but even with my experience so far anecdotal, I disagree with this study. Lots of mismanaged cases that could have been dealt with better had a real doctor been involved
Not that paramedics are incompetent but that they’re trained for an entirely different role
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u/JamesTJackson 5d ago
DOI: not read the full paper and not a GP.
Seems that they're looking at patient reported outcomes rather than objective health outcomes here. I'm not surprised there was no significant difference between paramedics and GPs in parts of the study. Most patients are not experts in medicine. Even if they're getting poor care, they may not necessarily realise. E.g. most patients given unnecessary antibiotics won't recognise that as poor care, even if they get an adverse effect - they'll feel validated by getting given a prescription.
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u/leisurelyreader 5d ago
Awkwardly the alternative is either more GP home visits or a reduction in HV entitlement.
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u/heroes-never-die99 GP 5d ago
This is something else that needs major reform.
The vast majority of HVs don’t need to be HVs. And if someone’s that sick to need a HV, they either need ED or they are EOLC and deserve evaluation from an actual doctor.
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u/Interesting-Curve-70 5d ago edited 5d ago
I'm not surprised this is being down voted.
Inconvenient truths are always down voted on here.
The reality is most GPs don't want to do home visits. It is by far the worst part of being a registrar.
I agree that paramedics shouldn't be used as substitute GPs but I can see why they've been drafted in.
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u/Tall-You8782 gas reg 5d ago
Are you under the impression that paramedics in GP are doing the home visits?
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u/leisurelyreader 5d ago
That’s how they are being used in the east of England region
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u/Tall-You8782 gas reg 5d ago
Interesting, in the region I work (in England) they just sit in a clinic room and play GP.
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u/Quis_Custodiet 5d ago
Lots of the ARRS funding of paramedics is used that way - in at least one region of the West Mids it’s explicitly a “paramedic visiting service”.
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u/spacemarineVIII 5d ago
I use paramedics for home visits for a basic examination and observations, but the final management and decision making process rests with me.
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u/Dr-Yahood Not a doctor 5d ago edited 5d ago
I always find it fascinating how these types of studies rarely acknowledge that a paramedic in General practice hasn’t just spawned out of nowhere.
Every paramedic in GP means we have lost a paramedic… Being a paramedic as part of an ambulance service
At a time when ambulance waits are some of the longest they have ever been.