Medium Integration, High Complexity example

A large coastal practice, with a high number of nursing and residential homes, retirement homes and supported extra care living. Demographics are average deprivation, older than national average adults and few young families. Visit burden is quite high on the practice, and there are some pressures on residential care placements due to the large numbers who retire to the region. A substantial proportion of patients have complex multi-morbidity and the practice has to invest significant effort to maintain QoF performance, particularly around medication reviews and prescribing rationalisation. A high number of palliative care cases at any one time.

A number paramedics are employed, through the PCN, as part of a rotational development post to provide clinical support to GP surgeries within the PCN, and maintain a commitment to the ambulance service. Paramedics undertake blocks of 3 months in surgery, 3 months on the road, swapping between them every 12 weeks. The paramedics are on a Frailty Advanced Clinical Practitioner development pathway, with the aim of bringing primary care experience to their ambulance roles, and acute care experience to support primary care. Paramedics have already completed their non-medical prescribing qualifications and use these skills in both roles, and are able to undertake medication reviews with the support of the PCN pharmacist, with whom they work closely.

During their 3-month practice blocks, paramedics undertake both proactive and reactive frailty care. Paramedics have nominated residential and care homes within the PCN, and will generally undertake all visit requests that the practice receives for those homes each day. The paramedics have particular interests in working with patients with dementia, and have some working relationships with the community dementia nurses. Paramedics can always discuss cases with GPs, although this may not always be the patient’s named GP who is most likely to know them best.

Patients do at times voice that they would like to be able to see more of their GP, but after clear explanation (including through written literature from the practice about the paramedic roles, sent to them with their chronic disease clinic reminder letters) patients generally appreciate that the paramedic is qualified and appropriately supported to manage their complexity. Occasionally, GPs will continue to visit the most complex cases, including for end-of-life care where continuity is seen as most imperative. Some patients are unsure, with the significant demand on rural ambulance services, if paramedics are best placed in surgeries or on the ambulances, but do appreciate being seen by whoever can help when needed.