Supervision & training
We found that appropriate initial training and ongoing quality supervision are essential for paramedic working in general practice to be safe and effective.
We found that appropriate initial training and ongoing quality supervision are essential for paramedic working in general practice to be safe and effective. Although the role of the paramedic in UK general practice has been introduced over a period of 20 years, it is still developing and there is a lack of clarity for general practices, paramedics and patients, about what the role involves. There was enormous variation in the experience, skills and qualifications of paramedics we learned about during the study. This ranged from paramedics starting a role in general practice ‘straight off the road’, meaning they had no experience beyond their role in the ambulance service, to paramedics with extensive qualifications related to a general practice role, including non-medical prescribing. This lack of standardisation may lead to paramedics inadvertently working outside of their scope or requiring extensive supervision when transitioning into the role to ensure safe practice. This can be compounded by the sometimes limited understanding of a paramedic’s scope of practice before entering a role in primary care, leading to a mismatch of expectations.
I think if I’m honest, I think that the doctors thought they [paramedics] might be more help straight away… I think you always underestimate the time and commitment for anybody coming, that requires training and support takes.Practice manager
Furthermore, matching the skill sets of supervisors to paramedics was a challenge for some practices. The need for quality supervision is now widely recognised; paramedics are advised to be guided by a named doctor, particularly when completing certain advanced practice modules. However, the supervision workload on GPs or other advanced practice staff is difficult to quantify. It is important to understand how the GP role is evolving, considering their ongoing responsibility for patient care, supervision of multiple AHP roles, and the high workload for GPs in the NHS. It might be that outsourcing paramedic supervision to educational institutions could relieve some of this burden on GPs and other practice staff.
For a lot of the PCNs [Primary Care Networks], [supervision] is also an issue, because they don’t know how best to support the roles. You can’t have this brand new, huge new workforce, and expect the GPs to do all the supervision because that just adds to their workload and they’re not necessarily the right people to be doing it either . . . “System leader interview
There is increasingly recognised a distinction between providing mentoring and support around professional development for a paramedic in general practice, and clinical supervision for complex cases requiring clinical oversight. Acknowledging the interrelatedness but distinction between these issues – and finding a practical solution to address both – emerges from our data as a challenge. The former may be best provided by an experienced paramedic or advanced practitioner with detailed insight into the particular complexities of transitioning professional competencies to a primary care setting. The latter continues to require supervision from an experienced GP.
Providing induction and supervision can become very complicated when paramedics are involved with multiple practices. Therefore, outsourcing some of the supervision needs may be a viable option for low integration models.
However, we found that in many high integration models, ‘in situ’ supervision was favoured as teams were working closely together and there was more opportunity for spontaneous conversations and cross-learning about the paramedic role.
[I have] daily supervision, daily case-based discussions and then regular monthly supervision meetings as well.Paramedic
There is some variation in supervision requirements depending on the complexity of patients that paramedics are seeing. In some low complexity models, we found that if paramedics take on the simpler cases (e.g. minor illness), GPs’ workload can become challenging because they are both dealing with more complex cases and managing supervision demands.
In general, paramedics working in high complexity models tend to be qualified to ACP level and therefore require less day to day supervision. However, this is not always the case and we did identify some concerns that paramedic-led care for complex patients requires a high level of supervision beyond the initial training period. It is important to note that advanced paramedics are not doctors and they do not have equivalent training in pathology and physiology.
Our findings indicate that both professionals and patients consider adequate supervision and education of paramedics to be crucial components of safe paramedic care and acknowledge that there are significant resource implications.