Medium Integration, Medium Complexity example

A small semi-rural practice that operates with a small team of 4 GPs (2 partners and 2 salaried), as part of a PCN that shares employment of some supporting/back-office roles. The practice demographics are mainly working-age and retired adults, no substantial deprivation although some farming communities that are not as engaged with preventative health care as they could be. The practice is managing but busy; a reduction in GP sessions due to both partners approaching retirement means the workload has increased but not quite to the point that would justify appointment of an additional GP.

The PCN employs two paramedics to work across their sites. Each practice in the PCN has a paramedic for 2 days a week, on a fixed-day basis, meaning the same paramedic is on site at a regular time each week. This builds familiarity between the GPs, the paramedic and other members of the practice team. The paramedics have non-medical prescribing qualifications. The practice does not run a ‘duty’ service – instead each clinician has a series of pre-booked and a series of on-the-day appointments. Extras are shared out amongst the clinicians working on the day. The paramedics operate a similar mixed-model, triaging and seeing both acute and pre-booked patients (with some exclusions) on their allocated practice days. On one of the days, they contribute to the home visit pool, but only for patients they have triaged themselves. Paramedics undertake virtual consultations where appropriate and face-to-face clinics, with time allocated to a named GP to discuss any difficult cases.

Patients are sometimes surprised to be offered a paramedic appointment, as they may have previously seen the GP, and they are not always sure how the paramedic skills are matched to their need. However, if a paramedic appointment is available and they have an urgent problem, they are usually happy to see them if it means being seen quickly. Similarly for home visits. Sometimes patients prefer to wait a little longer for their appointment and pre-book with a GP instead. Some patients find that it can be a little disruptive to the continuity of care when they may sometimes see a GP, and sometimes a paramedic, particularly if urgent problems crop-up associated with their ongoing health need.

The GPs have needed a little time to work out what the paramedic is competent and confident to see, but have built a relationship knowing that the same clinician will be present at predictable and regular times each week. GPs recognise that providing time to supervise and discuss cases is necessary and takes time out of the day, and is not always easy to co-ordinate, but on balance feel this is balanced with the increased appointment capacity that a paramedic brings. Paramedics recognise it can be difficult to build a continuity of care relationship with patients when only working at each site for part of the week, but over time do feel more part of the practice team. It can be difficult to attend clinical and practice meetings and MDTs when these do not occur on the day(s) that they are allocated to that site, which does limit a feeling of involvement. However, paramedics and GPs have found a way to adapt to this by sending a summary of minutes and updates where possible.