Low Integration, Medium Complexity example

A medium sized practice in an inner city area with a high level of deprivation, racial diversity and a demographic mainly comprising young families, students and migrant workers. The area has specific challenges with health literacy and engagement in preventative care, with a number of social prescribers and community outreach link-workers. The practice runs a full range of services catering to the needs of the local population, including a busy family planning service and a drug and alcohol treatment service. The practice is struggling to attract and retain GPs due to the deprivation and complexity, and there are challenges with engaging patients in chronic disease management, with the majority of care reactive. Demand fluctuates quite unpredictably.

The PCN employs two paramedics to deliver sessional support to each of the practices in the PCN, several of whom are in similar circumstances with the same challenges. Paramedics rotate between practices in the PCN to give a more diverse training opportunity. Paramedics have been working for a couple of years in primary care, are not yet non-medical prescribers, but are working towards developing some additional skills in areas of chronic disease management. One of the paramedics has some additional interests and experience in asthma care, and supports the delivery of a monthly asthma monitoring clinic, according to established review protocols as part of the practice’s QoF programme. The practice nursing team deliver other chronic disease monitoring clinics (hypertension, diabetes, cardiovascular disease). Another of the paramedics has interests in developing skills in sexual and reproductive health, and delivers the fortnightly family planning clinic alongside the practice nursing team. Both paramedics rotationally have a morning same-day clinic for urgent minor illness cases which are booked by the duty triaging GP. Both paramedics undertake home visits in the afternoon, again allocated by the duty GP. There is protected time to discuss cases with the duty GP.

Patients are aware that paramedics are part of the team, but are not always sure how they fit in with their care, sometimes seeing them in acute ‘minor illness’ appointments, and sometimes in chronic disease clinics. They value the chance to build a relationship in their chronic disease management, but struggle with continuity between long-term and acute problems. In general, these reservations are offset by improved appointment access, particularly for ‘on the day’ issues.

Paramedics can find it challenging to get access to a GP during a busy clinic when a patient needs a prescription, which can mean some loss of efficiency. It can be difficult to protect enough time to have ‘case discussions’ about acute on chronic cases, and GPs are aware of this and try to schedule this into the day, although demand can curtail this. Additionally, relationships between paramedics and the GP are not very well developed, due to the limited time the paramedics are allocated to each practice, and the varied nature of who is the duty GP amongst quite a large GP team (the duty GP being the primary point of contact on the day). However, the paramedics value the opportunity to develop some areas of chronic disease/preventative care expertise, and look forward to their regular specialist clinics. Paramedics can work well to the pre-agreed care protocols and, with a little experience, can titrate up- and down- treatments within these limits effectively.