ARRIVE: Ambulance paramedics Responding to urgent patient Requests In general practice for home Visits - Evaluation development

Background:

In response to rising demand for health care and limited availability of GPs, paramedics are increasingly working in general practices, most commonly to carry out home visits. UK policy supports this change which involves role substitution across professional groups and sectors of care. In Wales, schemes have been introduced over the past few years, with various configurations, employment and governance arrangements, but we do not know the risks and benefits of Paramedics working in Primary Care (PPC), or which model works best. As well as effects at individual patient level, potentially on outcomes such as safety, acceptability, efficiency and costs, this interface-crossing innovation may have an impact on workforce issues including professional role development and 999 service availability. There is an urgent need to better understand the PPC innovation. We propose to investigate this emerging area and undertake a feasibility study to inform the planning of a full, UK-wide evaluation.

Aim:

To describe the evidence base, theoretical underpinning and current initiatives, and determine the feasibility of undertaking a definitive evaluation of PPC in order to produce generalisable evidence to inform policy and practice.

Objectives: 

To describe the:

1- Research evidence related to PPC, including experience of stakeholders (patients, carers, paramedics, GPs, managers); safety; costs; and effects

2- Delivery arrangements and rationale for new PPC models

3- Feasibility of undertaking a fully-powered UK wide evaluation of PPC Research questions and methods WP1.

What is already known? Systematic review of evidence related to PPC WP2.

What is currently happening? Survey of UK ambulance services (n=13) and GP practices with new paramedic models of care (up to 3 per service), by email with telephone follow-up as necessary. We will describe PPC models which are currently in use or planned. WP3.

What benefits and risks are expected and what are the mechanisms for change? What outcomes are important to include in an evaluation?

How will we decide whether to progress to a full evaluation? We will hold a stakeholder event to:

a. Present a synthesis of review and survey data

b. Develop a logic model underpinning this innovation in service delivery and its evaluation

c. Determine outcomes of importance

d. Agree progression criteria for deciding whether to go forward to a full evaluation of safety, clinical and cost-effectiveness WP4.

Is a fully powered 'natural experiment' evaluation in sites across the UK feasible? We will undertake a controlled 'before and after' feasibility study comparing new models of care with standard practice (no paramedics) across three GP practices in Wales using routine anonymised linked outcome data, patient satisfaction questionnaires, and qualitative methods to capture views and experiences of stakeholders including paramedics, GPs, service managers, patients and carers.

Potential benefits to patients and the NHS will be both short and long term. Outputs from the ARRIVE study will include a final report to Health and Care Research Wales.

An application to NIHR HS&DR programme to undertake full evaluation, if progression criteria met; - scientific and user-friendly (policy, practice and public) write up of: systematic review, stakeholder workshop (including logic model), feasibility study findings including qualitative findings related to the views and experience of stakeholders