How are paramedics working in primary care?

Formal

There is currently no formal, national, curriculum for paramedics to work in primary care. However, completion of education in the following clinical subject areas would prepare paramedics well to work in the primary care environment:

• Health assessment (history and examination)
• Minor Illness
• Minor injury
• Paediatrics
• Long term conditions
• Palliative and end of life care
• Independent prescribing

These modules are frequently part of Master’s degree programs in Advanced Clinical Practice.

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).

Community of Practice
The College of Paramedics has a designated clinical development lead for paramedics working in primary and urgent care, with a range of resources available to members, including CPD, involvement in special interest groups, and access to an e-portfolio to record clinical development. More information on the Community of Practice developed and supported by the College of Paramedics is available here.

Professional examinations
There are an increasing range of opportunities for national examinations for paramedics working in primary care. Professional examinations establish a standard for clinical practice and adherence to standards. This benchmarking process provides assurance to employers, employees, patients, and insurers that paramedics have attained the necessary standards to practice effectively in an environment marked by numerous challenges, including uncertainty and ambiguity. 

• College of Paramedics Diploma in Primary and Urgent Care
• The Royal College of Surgeons of Edinburgh Diploma in Urgent Medical Care

Primary care as a clinical setting is well used to the provision of supervision, given the emphasis placed on supervision in supporting General Practitioner speciality training (Royal College of General Practitioners and Council of GP Education Directors, 2022). However, whilst the provision of supervision for paramedics in primary care is encouraged by the College of Paramedics, as well as national workforce plans for England, Northern Ireland, Scotland and Wales, the role of supervision for paramedics (and other healthcare professionals) remains one of voluntary best practice.

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. Evidence highlights the substantial advantages of supervision, benefiting individuals, the broader team, service users, and the overall service.

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.

Paramedics working in primary care are encouraged to ensure they proactively seek clinical supervision to develop their clinical practice. The guidance below sets out a range of factors that will help to ensure that paramedics receive effective supervision that meets their individual needs and expectations:

• A focus within the practice setting on providing staff support, the sharing/ enhancing of knowledge and skills to support professional development and to improve service delivery.
• Ensuring there is employer support for protected time, supervisor training, and private space to facilitate supervisory sessions. This should be listed on job advertisements or in employment contracts.
• Flexibility in the fulfilment of supervision, both in terms of working patterns, as well as in adapting the mode of supervision to give the most support needed at the time.
• Providing the choice of, or access to, multiple trained supervisors with expertise matching the paramedics needs. Clinical supervisors do not necessarily need to be General Practitioners, nor do they need to be paramedics, but they must have the appropriate skills, knowledge, and experience to conduct the supervision being requested, and have received appropriate training.
• Scheduling regular supervision sessions tailored to individual needs, with ad-hoc sessions in cases of difficulty.

Supervision of other colleagues
Paramedics well 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).

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

Patients
Research has outlined that patients demonstrate openness to the role of paramedics in primary care when provided with a clear explanation that these healthcare professionals are integral members of the primary care team, available for specific consultations. Consequently, when paramedics utilize their extended appointment times to establish rapport and connections with patients, individuals express a willingness to have subsequent appointments with paramedics, appreciating the additional time during which they feel heard. Patients also exhibit understanding when paramedics collaborate with other healthcare providers for their care, recognizing the paramedic’s role within a broader healthcare team. Consequently, patients are agreeable to paramedics seeking advice and input from GPs. However, patients are not receptive to seeing a paramedic when they anticipate seeing a GP for their appointments – and communication with patients’ group when a paramedic is employed in the primary care practice is key.

General Practitioners
Research has shown that when GPs develop trust in the competence of paramedics, they consider them a valuable asset to the primary care team and actively advocate for their inclusion. GPs typically prefer paramedics with significant experience in the ambulance service, as they perceive them to be better prepared for primary care roles. However, if GPs do not perceive paramedics as independent clinicians capable of making diagnoses, they might limit their responsibilities to assessments or home visiting only, which is perceived to be a better fit for paramedics. GPs are more likely to offer clinical supervision to paramedics when they have available time during their workday and are acting within a specific supervisory role.

Employers and wider health service
In England, employers are more likely to bring paramedics into their workforce when they receive financial reimbursement from NHS England. Generally, paramedics are actively sought after in primary care when their knowledge and experience gained in the ambulance service are considered valuable for the primary care workforce. However, paramedics with limited education and clinical experience may secure employment in home-visiting roles, as employers may perceive them to lack sufficient clinical expertise for more complex decision-making.

Implementing rotational employment models, where paramedics alternate between primary care and ambulance services, has the potential to enhance capacity in the primary care workforce while retaining paramedics in ambulance service roles. When paramedics improve patient access to healthcare, their role is highly appreciated by both primary care teams and patients.

Nevertheless, research has demonstrated that when legal or policy constraints prevent paramedics from addressing the entire spectrum of conditions encountered in primary care, it leads to frustration for both paramedics and other healthcare professionals, limiting their ability to make meaningful contributions to the primary care team.

Primary care providers (also called General Practices), contracted by NHS commissioners for generalist medical services, are typically small to medium-sized businesses. While some are operated by individual GPs, most in England function as GP partnerships involving two or more GPs, potentially with additional staff. These partnerships jointly manage business aspects, pool resources, and share ownership of the practice. GP partners, as independent employers, set their own pay and contract conditions, leading to variations in salary, leave, benefits, and contributions compared to the rest of the NHS. This section aims to guide Paramedics considering primary care employment on essential elements for discussion with employers prior to working employment in primary care.

Hours of the working week
The standard hours of all full-time NHS staff is 37.5 hours, excluding meal breaks. Working time is calculated exclusive of meal breaks, except where individuals are required to work during meal breaks, in which case such time should be counted as working time.

Salary
Unlike ambulance services and secondary care settings, primary care does not follow a ‘banding’ structure. The general salary principle is if capability is proven, renumeration for that level of practice should follow.

The below table outlines clinical level, corresponding education level, years of clinical experience and the associated pay range:

Employment models and contracts differ, and paramedics are encouraged to        check whether they will receive annual pay increases, and such increase in    renumeration is usually discussed at contracting.

Sickness

Each contract should state:

• How much sick pay is
• How long sick pay can last
• Any rules the employer has for using sick pay

If the employee is eligible for statutory sick pay (SSP), the employer must pay that as a minimum. Statutory sick pay is £109.40 per week. It can be paid for up to 28 weeks.An employer does not have to pay statutory sick pay for the first 3 qualifying days of sickness absence. These 3 days are called ‘waiting days’.

Statutory sick pay is the minimum amount employers must pay. Some employers might pay more. If they do, this must be written in the contract or workplace policy. It should also say in the contract or the organisation’s policy whether the first 3 days of sickness absence are paid or unpaid. It may also be written in the contract that employees get more than statutory sick pay. This can be called ‘company’, ‘contractual’ or ‘occupational’ sick pay.

NHS Employers also set out recommendations regarding a scale of allowances to supplement statutory sick pay to provide additional payment during absence due to illness, injury, or other disability. Primary care practices have no obligation to adopt this scale, however some may do so – and this is set out below:

Annual leave
Every employee in the UK is entitled to paid holiday, known as ‘statutory annual leave,’ regardless of whether the employment contract is full time, part time or under a zero-hours contract.

The number of days individuals may receive is contingent upon:
– Weekly or hourly work commitment
– Any additional agreements in place with the employer

Holiday accrual begins from the first day of work, even during periods such as:
– Maternity, paternity, adoption, or shared parental leave
– Probationary periods
– Sick leave

Contracts may stipulate a holiday entitlement exceeding the statutory requirement, referred to as ‘enhanced’ or ‘contractual’ holiday entitlement.

NHS Employers also set out recommendations regarding entitlement to annual leave and general public holidays, as set out below:

Local arrangements to consolidate some or all of the general public holidays into annual leave may also operate.

Maternity and Paternity leave rights
Paramedics in primary care are encouraged to check their contracts regarding their maternity or paternity entitlement, as this can be significantly different in primary care employers who only provide statutory maternity or paternity pay and leave, compared to NHS trusts following the NHS Employers scheme.

Indemnity
Professional insurance or indemnity cover aims to provide financial compensation in the case of negligence or mistakes on the part of healthcare professionals. Paramedics working within the scope of their employment in primary care should ensure their employer has appropriate indemnity arrangements in place to cover both the primary care provider, as well the paramedic.

State-backed GP indemnity schemes
In England, the Clinical Negligence Scheme for General Practice (CNSGP) and in Wales, the General Medical Practice Indemnity (GMPI) were introduced as state-backed GP indemnity schemes. All GPs and their staff delivering NHS services are automatically included in the schemes, and so this eliminates the requirement for paramedics to organise and finance their individual clinical negligence coverage.

However, some paramedic may work across various practices or for different NHS organisations, without being directly employed by an individual practice. This situation raises concerns about potential vicarious liability for claim arising from such work. The legal standing in such cases is not always clear, and a claim could potentially be directed at the individual, the practice where they were working at the time of the incident, and/or their employing body. It is strongly recommended that paramedics seek advice and guidance regarding the potential benefits of additional corporate or vicarious liability coverage if they are employed across several primary care providers.

The devolved governments in Scotland and Northern Ireland have not introduced a state-backed indemnity scheme for primary care providers.

College of Paramedics
The College provides full members with the following Medical and Public Liability insurance as a benefit of membership, subject to members being ordinarily resident in the United Kingdom, Channel Islands or Isle of Man. However, notable exclusions for this policy include activities funded or commissioned directly/indirectly by the NHS or claims arising from members main employment.

Therefore, paramedics working in primary care may be required to purchase separate cover. James Hallam* provide independent Medical Malpractice & Public Liability cover for Paramedics in the United Kingdom. This is the only product recommended by the College of Paramedics.

*James Hallam Limited is a Subsidiary of Seventeen Group Limited. Authorised and regulated by the Financial Conduct Authority.

Pension
The NHS Pension Scheme covers retirement pensions and early pension payments due to ill health. Typically, individuals employed within the NHS or in GP practices under GMS, PMS, or NHS Standard Contracts can have membership under NHS Pension Scheme. This may be an opt-in option, depending on the employer. In addition, those under APMS contracts or involved in sub-contracting, clarification on pension scheme eligibility should be sought from the employer, scheme regulations, or even the NHS Business Services Authority.

Patients emphasise the significance of being informed about the possibility of encountering a paramedic in the primary care setting and having the ability to identify when they are being attended to by a paramedic in primary care. This can be achieved by:

• Clear job titles, that include the word ‘paramedic’ in them.
• Wearing a visibly different scrub colour to GPs, nurses and other members of the primary care clinical team.
• Inclusion of the paramedic role within the relevant staff section on the primary care practice website.
• Use of posters (printed or electronic) within practice waiting areas.
• Use of usual communication methods used within the primary care practice (eg. newsletters, social media) to introduce and outline the paramedic role.
• Engagement with the primary care practices’ ‘patient participation group’ (if this exists) to assist in the dissemination of the paramedic role in the footprint of the practice.
• Information given to them by the receptionists or care co-ordinators when booking an appointment in primary care, or when they reach out to the primary care practice for advice on their condition.

Paramedics can play a significant part in communicating about their job role to patients they may encounter within their clinical work, and are encouraged to take ownership of this aspect of within the scope of their employment.

There are several basic systems paramedics will need to be set up with in order to work in primary care and, with many different types of systems on offer, these vary across primary care providers.

An example induction check list offers a standardised sequence of procedures to provide all staff in primary care settings with an efficient induction. Paramedics new to primary care can use this template to ensure they gain the right information to integrate into the primary care and start building confidence in their new role.

As well as set-up on systems, the induction should be used to clarify the expectations around the role expected to be performed, responsibilities, and consideration to patient groups considered suitable based on prior knowledge and experience.

Based on theories of transition, a model to support the transition of paramedics in primary care is recommended below: