The paramedic–general practitioner relationship: a scoping review

Introduction

International demand for acute and non-acute health services continues to increase (Willson et al. 2022), with current models of health care provision considered unsustainable (Montgomery et al. 2017). Emergency departments (EDs) and jurisdictional ambulance services are frequently under-resourced and overstretched (He et al. 2011; Montgomery et al. 2017; Willson et al. 2022) – issues that are echoed in primary health care (PHC) (Mahtani et al. 2018; Eaton et al. 2020; Schofield et al. 2020). Up to 40% of lower-acuity ED presentations may be avoidable, providing the patient has suitable and timely access to PHC (Ismail et al. 2013; Willson et al. 2022). A high proportion of ambulance workload is made up of non-life-threatening concerns, potentially appropriate for management by PHC teams (Eastwood et al. 2016; 2020; Eaton et al. 2020).

The role of the Australian paramedic has evolved significantly over the past decade (Eastwood et al. 2016; Eaton et al. 2020). This expansion includes an increase in the scope of practice, introduction of professional registration and well-established tertiary education requirements (O’Meara et al. 2012; Eaton et al. 2020; Reaburn 2020). The paramedic caseload is increasingly comprised of low-acuity/PHC-suitable presentations, leading to changes in expectations of how paramedics assess and manage these patients (Eastwood et al. 2020; Eaton et al. 2020; Wagstaff and Mistry 2020). There is an increasing requirement for the paramedic role to encompass the confidence and competence to be selective with patient selection for transportation to EDs (Paulin et al. 2021), driven by EDs in Australia and abroad struggling with department congestion, long wait times and ambulance ramping (He et al. 2011; Finn et al. 2013; Willson et al. 2022). These challenges have driven a need for paramedics to, when appropriate, avoid patient transportation to EDs, utilising alternative patient care pathways, with the conveyance of all ambulance cases to an ED now considered an outdated and unsustainable practice (Blodgett et al. 2021; Paulin et al. 2021).

PHC services are also facing challenges in achieving adequate care for those in the community (O’Meara et al. 2012; Currie et al. 2020; Eaton et al. 2021a). There is a link between potentially avoidable hospitalisations and accessibility and effectiveness of PHC (Katteryl et al. 2012), and inappropriate patient transport to an ED may delay timely access to primary care (Eastwood et al. 2016). The combined pressures on both acute and non-acute health services have led to attempts to prevent unnecessary ambulance transport to EDs. Many organisations are trialling and implementing strategies, such as embedding paramedics within PHC teams or the implementation of paramedic referral pathways (Blodgett et al. 2017, 2020; Eaton et al. 2021a), the intent of which includes increasing patient satisfaction and reduction of burden on EDs. These novel approaches appear to increase collaboration between paramedics and those working in PHC, most frequently GPs (Bury et al. 2006). It is therefore valid to consider the importance of this professional relationship as an essential foundation to these strategies.

The cornerstone of safe and effective patient care relies on sound teamwork and communication (Manser 2009; Rosen et al. 2018); therefore, the relationship between paramedics and GPs can be considered critical to the safety and efficacy of these pathways. The paramedic-GP relationship is not novel – GPs have historically interacted with paramedics through paramedic attendance at PHC clinics for patients requiring emergency care and transport to an ED. Much of the relationship has therefore been under different circumstances to what is now occurring, with a shift towards joint patient care efforts for the non-acute patient. To overcome the challenges and optimise opportunities for best patient care, developing a robust understanding of the relationship is vital for future cooperation.

The aim of this scoping review was to describe and analyse literature that has examined the paramedic–GP relationship.

Methods

Results

Selection of sources of evidence

An initial search of three databases resulted in 6746 studies. Following the removal of duplicates, 4995 studies remained. After title and abstract review, 93 studies remained, with 15 studies remaining after full-text review. No further studies were identified through both grey literature searching and backwards citation searching of included studies. A study selection overview is shown in Fig. 1.

Fig. 1.

PRISMA-ScR flow diagram.

Discussion

In some cases, the value of the study to the Australian context was questionable. Scandinavian studies involved an Emergency Medical Services (EMS) configuration where paramedics and GPs work alongside each other in the community emergency response setting – an uncommon scenario within Australia. These studies found that staff reflected more positively on the relationship when compared with studies that investigated the relationship where paramedics and GPs did not work together in a single service (Forland et al. 2009; Hjortdahl et al. 2014; Mieritz et al. 2018; Nystøyl et al. 2018). Examining the experience of the relationship in a variety of settings is essential to best inform future collaborative efforts. The question of whether the two professions should be participating together in a single episode of patient care, and in what capacity, is unresolved and key to directing the future of the relationship.

An identified theme relating to transfer of patient care responsibility was complex to analyse. Multiple contributing factors included poor communication, and a lack of trust and understanding of each other’s scope of practice, collectively contributing to issues surrounding responsibility for patient care. It is reasonable to infer that if a GP perceives a paramedic to lack the necessary skills in patient assessment, they may feel uncomfortable receiving a paramedic patient referral and the transfer of the associated responsibility. Although there was a perception in the literature that understanding of scope of practice underpins interdisciplinary trust, there was no examination of the exact nature of the scope of practice knowledge issue with sufficient detail.

The importance of interdisciplinary training to improve interprofessional understanding and empathy was highlighted throughout the literature (Hjortdahl et al. 2014; Lazarsfeld-Jensen and Bridges 2014; Proctor 2019; Eaton et al. 2021b). Multiple studies specifically detailed the desire of paramedics to receive more feedback from GPs (Blodgett et al. 2017; Eaton et al. 2021b). The concept of paramedics providing feedback to GPs was not discussed in any examined literature. This may be indirectly attributable to entrenched medical hierarchy, based on the belief that the more extensive training of the GP makes it inappropriate for paramedics to give feedback. Effective feedback has been found to be one of the most important factors for improving multidisciplinary teamwork (Salas et al. 2018). Therefore, in any model of care that relies on the collaboration of two different professions, opportunities for two-way feedback are vital.

The importance and value of the paramedic–GP relationship is expressed through the notion that a singular negative encounter or interaction between disciplines can have lasting impact on future effective cooperation (Blodgett et al. 2017). Successfully establishing health care services that rely on collaboration between the two professions will be enhanced by addressing any existing challenges and barriers to a closer working relationship (O’Meara et al. 2015).

Ten of the studies were published in the UK and Scandinavia, which suggests that other countries have been more innovative in health service provision and expanded paramedic involvement. In the UK, one of the driving factors for paramedics working within PHC teams is workforce shortages within traditional PHC professions, including GPs (Montgomery et al. 2017; Eaton et al. 2021a). Australian demand for both acute and nonacute health care is also increasing at a concerning rate (FitzGerald et al. 2012; Currie et al. 2020). There are ongoing challenges associated with the unequal distribution of health professionals, including GPs, needed to meet rural/remote Australia PHC demands (O’Meara et al. 2012; Currie et al. 2020). As overall demand for PHC services increases in Australia, there will be the subsequent need for reform of models of care that may require further collaboration between paramedics and GPs. Key potential challenges for future paramedic involvement in Australian primary care will include ensuring that patient care does not become fragmented, that the quality and safety of PHC is not diluted, and understanding if and how GPs will be provided with time, funding, and appropriate methodology to mentor/supervise/educate paramedics.

Summarising the overall state of the relationship was limited by inconsistences in the literature and the absence of collaborative studies comparing acute and nonacute settings. The majority of studies evaluated individual experiences of the relationship in one setting; for example, both paramedics’ and GPs’ involvement in a referral scheme or paramedics embedded in a GP clinic. As such, the included studies lack the depth required to deeply understand the relationship, as it exists across multifaceted environments of clinical practice, whereby the groups may interact in the community, hospitals or a PHC – any of which might involve the care of acute or non-acute patients.

Significant variation in the training level and scope of practice of the paramedic is observed in the included studies. The search criteria included all potential terms pertaining to paramedic, including emergency medical technician/ambulance officer and so on, accepting that there are vast differences in the education standards for these roles. As Australia predominantly has a tertiary education entry requirement for state-based ambulance services (Reaburn 2020), it could be argued that some of the literature is not representative of the Australian paramedic–GP relationship. Another limitation of this review was access to full-text articles. There was a total of 16 articles that were not accessible in full-text version, and it is therefore possible that some relevant literature has been omitted from this review.

There is a need for an Australian-based study that examines the relationship between paramedics and GPs that would ideally investigate both perspectives. To achieve holistic understanding, there needs to be an investigation of how these two professional groups interact within and outside of PHCs. The findings of this research could inform the development of collaborative models of care that optimise relevant skill sets. Reform in this area could potentially improve outcomes for patients and health care services.

As models of care evolve, interest in the GP–paramedic relationship is increasing. This review found five main themes contributing to the relationship – the importance of communication, understanding each other’s scope of practice, leadership roles, responsibility for patient care and the significance of interdisciplinary training. Internationally, paramedic involvement in PHC is increasing, with an aim to avoid unnecessary ED transport and improve access to PHC for patients. Further investigation of the Australian context is required to optimise both current and future interdisciplinary collaborations and relationships.

Data availability

The data that support this study will be shared upon reasonable request to the corresponding author.

Conflicts of interest

The authors declare no conflicts of interest.

Declaration of funding

This research did not receive any specific funding.