A total of 6765 citations were identified through database searching (see Supplementary Figure S1 for details). Following screening of titles and abstracts against the inclusion and exclusion criteria, 202 full-text studies were retrieved. After applying inclusion and exclusion criteria, 24 relevant full-text studies were identified. No new studies that had not already been considered were found upon screening the reference lists of these studies. The main reasons for exclusion were studies that reviewed practice outside of the UK (n = 137); where the paramedic was working within the ambulance service only (n = 22); and where the population could not be identified as being a paramedic because of the term ‘emergency care practitioner’ encompassing both nurse and paramedic disciplines (n = 14). There was complete agreement on inclusion/exclusion decisions from independent screening against eligibility criteria at the full-text stage.
Charting the results
For the characteristics of the 24 included studies selected for review (all of which were published in English) see Supplementary Table S1. Study design varied across the included studies, with seven including primary research,13–19 two of secondary research,20,21 and the remaining comprising either a case study (n = 4),22–25 commentary (n = 4),26–29 report or strategic plan (n = 6),5,30–34 or protocol for future research (n = 1).35
Key findings were iteratively grouped into the following headings:
description of the clinical role;
clinical work environment;
reduction in GP workload;
patient satisfaction;
clinical activities in primary care; and
education and training.
Description of the clinical role
Across the studies, the job title of the paramedic working in primary care differed, either being ‘paramedic’,16,23,27–30,32,34 ‘specialist paramedic’,18,19,24 ‘paramedic practitioner’,14,17,22,36 ‘emergency care practitioner’,14,21,26,35 ‘advanced paramedic’,32,33 or ‘community paramedic’.5,31,33
The variety of titles was reported to be confusing for patients in two studies,13,17 as well as other clinicians within primary care,19,21,29 with concerns relating to the role, scope of practice, and autonomy of these paramedics.
Clinical work environment
In addition to variation in title, variation in clinical environment, in which paramedics were deployed, was also found. The studies reported paramedics working in commissioned home-visiting services,14,17,18,25,30,35 minor units15,20,21,24,30 (including first aid units, minor injury units, minor departments in hospitals, and walk-in- centres), general practice,5,14,15,19,22,27,28,31,33,34 and out-of-hours.13,16,24
In some studies, paramedics retained the ambulance service as their main employer and rotated through primary care settings.15,18–21,24,29
Reduction in GP workload
All studies reviewed reported the paramedic contributing to the primary care workforce through working within a multidisciplinary team. In some cases, the role of paramedics in primary care settings was specifically reported to decrease GP workload by assessing and treating urgent, non-complex patients.5,18,22,23,27,28 However, two studies highlighted that patients may still prefer to see their registered GP, rather than a paramedic.17,18
Another two of the included studies raised the issue that patients may not have a straightforward consultation with a paramedic if treatment needed to be clarified with a medical doctor,14,15 thereby adding an extra step to the patient journey. In some areas, there was an expectation that the paramedic report to a more senior clinician for all patient cases.23,26,33 Such referrals were reported as lengthening consultation time with little gain to the patient, and the paramedic role in these cases is of more limited value.
Other studies highlighted that the time paramedics spent with patients was generally longer than their physician or nursing counterparts within primary care,13,15,16,19,21 and so researchers questioned the benefit of their attendance from an economic standpoint. The slightly longer home-visits by paramedics was deemed a positive by patients in one study.17 Another study21 showed that the length of patient contact differed between clinical settings, typically being longer when paramedics were employed by ambulance services rather than in primary care. Reasons for this were not explored in the study, but it is worth noting that the pressure to see patients within a specific timeframe does not exist in the ambulance service, unlike in primary care.
Only one study associated paramedic roles in primary care with an overall cost saving,15 although this finding was an estimate and the study was authored in 2006; therefore, its relevance to today’s NHS is ambiguous.
Patient satisfaction
Three studies used retrospective comparators37 to record patient satisfaction following treatment by a paramedic.13,17,18 Although these studies document high satisfaction levels from patients who were visited by a paramedic in their home, in two studies a small minority of patients remained keen to be assessed by their GP,17,18 and other patients remained unclear about the purpose of the assessment undertaken by the paramedic.13
Clinical activities in primary care
The role of the paramedic in primary care varied little across studies, highlighting that paramedics who undertake roles in primary care (under whichever title) generally undertake similar roles that focus on the undifferentiated, undiagnosed patient. These include minor injury and illness clinics,15,19,22–24,28,33,34 home-visiting,14,17–19,22,23,25,28,30,33,35 and using paramedic-specific skills (such as 12-lead electrocardiogram [ECG] interpretation) to assist in general health assessment.22–24,28,29,31,34 There was no mention of paramedics providing high-acuity care within these settings, but it was acknowledged that one of the advantages brought by paramedics was their ability to provide high-acuity or emergency care.23,24,27,28
Four case studies14,22–24 and one report34 presented typical days for paramedics working in primary care settings of GP surgeries and a rural first aid unit. The type of work undertaken across these case studies is similar, indicating that paramedics working in clinical primary and urgent care roles tend to adopt a similar working day.
Education and training
Education standards for paramedics working in primary and urgent care were explicitly mentioned in eight studies.14–16,19,21,26,34,38 However, none of the publications by NHS England5,25,31 considered elements relating to education for paramedics working in primary and urgent care. Postgraduate education was outlined as a requirement for paramedics to work in primary and urgent care,14–16,19,21,26,34,38 in line with the guidance outlined by the College of Paramedics;39 however, there was little detail on the specific competencies required to work in these settings. One study16 highlighted the importance of supervision and mentoring for paramedics as they entered primary or urgent care roles, whereas another22 outlined how paramedics may also be used to provide mentorship to training physician assistants and nurses (for a brief summation of these findings, see Supplementary Box S3).