Paramedics and Primary Care Teams

Paramedics employed in primary and urgent care settings have the opportunity to take on diverse roles, including:

• Competently applying the medical/biopsychosocial model to assess, examine, treat, and manage patients of various age groups with acute undifferentiated and chronic conditions.
• Conducting patient triage, performing telephone consultations, engaging in face-to-face consultations, and conducting home visits, including those to residential and nursing homes.
• Requesting, reviewing, and taking action based on laboratory results.
• Referring patients to specialist services or specific investigations when deemed appropriate.
• Attending to patients with acute or urgent (same-day) issues, offering pre-booked and routine appointments.
• Providing mentorship and supervision to students from diverse health and social care backgrounds.

The level of competence exhibited by paramedics in primary and urgent care depends on their skills and experience, as well as those of the practice team. It is crucial for paramedics to be cognisant of their clinical competency levels, identify areas for development, and operate within the limits and scope of their practice. Given the variability in the management of general practices and urgent care providers, the role of paramedics in primary and urgent care may vary across different practices or urgent care settings.

For this reason, where a curriculum provides a broader framework for learning and often encompasses various subjects or areas of study, clinical examination and procedural skills is a more specific document that outlines the practical tasks or procedures relevant to paramedics in primary care. CEPs are systems-based, and generic across patient groups.

Despite the generalist background of paramedics, research has highlighted patient groups that are commonly not seen by those working in primary care. The most common clinical presentations not seen by these were those relating to women’s health (including intimate examination, pregnant patients with directly related pregnancy issues, sexual health or menopause). This could be due to a creep into the paramedic role of nursing policy, which emphasises that nurses should refer women who are pregnant to midwifery or physician care if they are not registered in this area. Other common patient groups not seen by paramedics included children, particularly under the age of two. This may be due to a lack of clinical exposure in this area in the ambulance service, where clinical practice guidelines for paramedics in ambulance services are to convey all children under the age of two to emergency departments, and children under the age of five must be seen by a physician if non-conveyed.

However, paramedics may undertake further specialist training in areas such as the FSRH Diploma, as well as additional postgraduate courses in paediatrics, palliative care, management of long-term conditions, and mental health.

Research that has looked at the work paramedics in primary care undertake has produced this indicative CEPs document, which may be a useful guide to define the scope of role for paramedics working in primary care.

Unlike training for General Practitioners, there is no national education pathway for paramedics to work in primary care. This section brings together some of the key components primary care employers and GPs may find useful prior to employing a paramedic in primary care.

Two key questions for primary care providers prior to employing a paramedic are:

• What level of educational experience does your paramedic(s) have?
• Is the level of their educational experience appropriately matched to the service you are asking them to deliver?

Education pathways
Since 2021 paramedics have been required to have a BSc(Hons) to register as a paramedic, however paramedic undergraduate education has been in existence since the late 1990’s – and many paramedics will have undergraduate degrees.

Registration sets out the core concepts paramedics must know in order to gain (and maintain) professional registration, and this is summarised in the Standards of Proficiency for Paramedics. Whilst Section 12 in these Standards outlines specific key concepts of physical, life and clinical sciences – the extent to which this is studied can vary across education providers and may often be in relation to paramedic practice within an ambulance service role, rather than in primary care.

For paramedics in primary care, displaying proficiency in Masters level learning (FHEQ 7/SCQF level 11) is crucial as it indicates that the paramedic possesses advanced academic knowledge ready to be applied in clinical practice.

Research has demonstrated that paramedics can fulfil an increased clinical scope of role in primary care when they have a higher level of education combined with additional experience by virtue of their work in the ambulance service. Paramedics who lack in clinical experience or knowledge may still contribute to the primary care workforce through an assessment-only role (‘eyes and ears approach’) – where they report to a GP for decision making.

Newly Qualified Paramedics
In 2019, the NHS Staff Council Job Evaluation Group published the ‘newly qualified paramedic’ pathway for paramedics immediately post-registration. The pathway consists of a consolidated learning period, where NQPs work with additional support and guidance from senior colleagues, for a period of up to 24 months, before moving into an autonomous paramedic role (which is typically renumerated at a higher salary). Currently, most NQP learning programmes exist in ambulance services, however there is no reason why this could not be undertaken in primary care. Principles of the newly-qualified paramedic consolidation of learning programme are outlined here and this article outlines some considerations for primary care providers to support NQPs to transition into primary care.

Professional curricula
There is currently no formal, UK-wide, curriculum for paramedics to work in primary care.

FCP/AP Framework (England)
In England, NHS England Workforce Training and Education (formally Health Education England) has set out a roadmap of education for practice when paramedics are moving into First Contact Practitioner (FCP) roles, and onward to Advanced Practice (AP) roles in Primary Care. The roadmap is a standardised educational training pathway for all AHPs in primary care with specific supervision and governance to ensure patient safety that has been agreed by all national and professional bodies and with patient participation.

This document outlines the following:

• The definition of First Contact roles, along with their corresponding training processes and educational pathways.
• The definition of Advanced Practice roles, including their respective training processes and educational pathways.
• Guidelines for constructing a portfolio of evidence for both FCP and AP roles.
• Recommendations on supporting training through appropriate supervision and governance, with a connection to Health Education England’s Centre for Advancing Practice.

The framework is available here.

CPD
As registrants, paramedics must uphold the HCPC standards of continuing professional development, regardless of where they work. Paramedics annotated as prescribers also have the additional requirement to ensure any professional development undertaken has a specific focus on their practice as a prescriber (Royal Pharmaceutical Society, 2022).

Professional examinations
There are an increasing range of opportunities for national examinations for paramedics working in primary care.

College of Paramedics Diploma in Primary and Urgent Care

The Royal College of Surgeons of Edinburgh Diploma in Urgent Medical Care

Education and Employment under ARRS in England
Stage 1 of the FCP roadmap involves substantiating the "academic" aspect of competencies, while stage 2 focuses on translating that knowledge into practice through supervision, work-based assessment, reflective practice, and Continuing Professional Development (CPD). Ideally, the paramedic should have completed at least one Level 7 module in either clinical examination and/or history taking and diagnosis during this process.

ARRS sets out the following pathway for education (and employment) for paramedics:

• >4 years of post-qualification experience (comprising 2 years as a Newly Qualified Paramedic and a further 2 years as an autonomous paramedic)
• Demonstrate learning at Masters level* (FHEQ 7)
• Complete the FCP Portfolio within 6 months of individual reimbursement (extendable to 12 months with commissioner agreement where appropriate)
• To be eligible for salary reimbursement at Band 7: FCP – Demonstrate completion or ongoing progress in both Stage 1 and Stage 2 of the FCP portfolio
• To be eligible for salary reimbursement at Band 8a: ACP – Demonstrate Level 7 proficiency across all four pillars as per requirements for Advanced Practice accreditation or completion of a taught HEI MSc in Advanced Practice or an equivalent.

In summary, paramedics with higher levels of education and clinical experience, including independent prescribing capability, can effectively assume an expanded clinical role in primary care, allowing them to conduct a wider range of consultations.

Research has outlined that paramedics are more inclined to pursue careers in primary care when they believe that their education and prior experience in ambulance service have adequately prepared them for this transition. Paramedics are motivated to transition to primary care to enhance their clinical skills, leveraging their prior experience in ambulance services as a valuable foundation for work in this setting. Additionally, paramedics who engage in rotational roles between ambulance service and primary care find it easier to transfer their skills between these two environments.

They find the transition smoother and more supportive when they have access to clinical supervision and structured educational opportunities. In cases where formal education is lacking, paramedics acquire knowledge through practical experience in primary care. Clinical supervision plays a crucial role in honing their capabilities and fostering confidence in their new roles. As they transition, paramedics expand their scope of practice, adapting to different clinical conditions from those encountered in the ambulance service, which can lead to variations in the paramedic role due to a lack of standardisation.

Paramedics who are confident in their clinical roles and their contributions to the primary care workforce tend to experience fewer frustrations in this setting. However, managing their time efficiently in a primary care setting can pose challenges – and support to reduce appointment times is often the biggest learning curve for paramedics entering primary care.

Whilst primary care is well used to the provision of clinical supervision in supporting General Practitioner speciality training, the provision of supervision for paramedics in primary care remains one of voluntary best practice – although it is encouraged by the College of Paramedics, as well as national workforce plans for England, Northern Ireland, Scotland and Wales.

The provision of high-quality workplace supervision is crucial for paramedics in primary care, irrespective of their career stage. This includes those transitioning from other clinical settings, those progressing toward advanced clinical practice, and those already established in primary care. Various pieces of evidence highlight the substantial advantages of supervision, benefiting individuals, the broader team, service users, and the overall service (Rothwell, Kehoe, Farook and Illing, 2020). The development of paramedics in primary care is contingent upon clinical supervision within the primary care setting, which supports paramedics in developing their clinical acumen. Research has shown that paramedics who receive clinical supervision feel better supported, are satisfied with their job, and have a demonstrable increase in their clinical scope of role.

While dedicated, scheduled time for supervision is crucial, the perceived effectiveness of supervision for supporting paramedics relies on its quality rather than quantity. The frequency and duration of high-quality supervision should align with the demands of the setting and the developing capabilities of the paramedic. GPs have outlined that a lack of protected or additional time to support supervision of paramedics is one of the biggest barriers to providing clinical supervision to this professional group – and something that therefore adversely affects their workload.

Below are some considerations for GPs and primary care teams when creating supervision plans and providing supervision to a paramedic:

• It is the responsibility of the practice, at the outset, to delineate how core skills required for the role will be undertaken, and to ensure that the paramedic is competent and confident in performing these clinical skills before allowing them to practice independently.
• The amount of support and supervision provided should be commensurate with the scope of role the paramedic is being employed in. For example, a novice paramedic in primary care may benefit from a period of direct supervision, opportunity to discuss patients prior to finishing the consultation, seeing a narrower range of patient presentations, and working within longer appointment timeslots. Similarly, a paramedic employed in an Advanced Practice role who can independently prescribe medicines will require less direct supervision, but it is likely that the clinical risks undertaken will be significantly greater – and so they may benefit from indirect supervision or debriefing.
• Paramedics who lack in clinical experience or knowledge may still contribute to the primary care workforce through an assessment-only role (‘eyes and ears approach’) – where they report to a GP or other senior clinician for diagnosis and decision making. However, such roles may contribute to workload of GPs, rather than relieve it.
• Whilst paramedics need to understand aspects of physical science prior to registration, biochemistry interpretation will be new to most paramedics moving into primary care form the ambulance service, and clinical supervisors will need to ensure a paramedic understands blood test (request and interpretation) prior to incorporating this into their scope of practice.

Supervision under ARRS

The Network Contract DES specifies the minimum supervision requirements for staff hired through the ARRS. The table below outlines the recommended minimum frequency for supervision meetings and identifies who can provide this supervision. Each clinical supervision session should last at least one hour.

These recommendations are based on the Network Contract DES requirements, professional regulatory standards, and expert guidance.

More information can be found in NHS England's' supervision guidance for primary care network multidisciplinary teams.

Paramedics acting as supervisors
Paramedics established in primary care may provide clinical supervision for junior staff members across different professions. Paramedics working in a supervisor role should have undertaken the necessary training to be able to do so, depending on the requirements set out in the relevant national workforce plan (England, Northern Ireland, Scotland and Wales).

Paramedics are one of the most rapidly developing professions in the UK. Paramedics are required to hold professional registration with the Health and Care Professions Council and the title ‘paramedic’ subsequently protected in law though Article 39(1) of the Health Professions Order 2001. Whilst undergraduate honour’s degrees have only recently been mandated for paramedics to enter registration, paramedics have undertaken undergraduate degrees since the late 1990’s. The last decade has also seen the profession achieve the ability to undertake independent prescribing, including a limited formulary for controlled drugs since 31st December 2023.

At the point of registration, paramedics are autonomous clinicians. They are most commonly associated with working in the ambulance service, where they gain experience in assessing and treating a range of undifferentiated undiagnosed patients, as well as managing specific emergencies (such as cardiac arrests or major trauma) and specific episodes of care (such as acute exacerbation of COPD).

In the UK, the professional body for paramedics is the College of Paramedics, who have a primary and urgent care development lead and publish guidance for members.

This article encapsulates the some of the challenges presenting the paramedic profession in the UK, as well as gives more background to their professional development: Addressing the challenges facing the paramedic profession in the United Kingdom.