Transforming Primary Care through Specialist Paramedic Involvement Scottish Ambulance Service & Teviot Medical Practice Collaborative Project 2016 - Onwards

How did it all begin? Following a chance meeting between the SAS Area Service Manager for the Borders and the Associate Medical Director for NHS Borders Primary Care Services the project idea formed. A collegiate pilot scheme was developed, using PDSA improvement methodology, to develop a working model based on certified competencies. Initial feasibility meetings took place between Teviot Medical Practice (TMP) and Specialist Paramedics (SP), and both parties indicated a desire to test the pilot. It quickly became apparent that the most effective use of SP in the TMP model, would be in carrying out the daily urgent home visits.

Background Specialist Paramedics & Teviot Medical Practice Specialist Paramedics (SP) in small numbers since 2004 2 x SP in Borders at project start, now 4 with a further 2 qualified by Jan ’18 Nationally numbers of SP increasing with 50 currently in education, and a further 50 beginning education programme in Jan ’18 Teviot Medical Practice (TMP) - semi-rural, Hawick and surrounding area. Approx 11,000 patients, 10 x GP, 3 x nurses, care assistant & phlebotomist TMP operates a duty Doctor Mon-Fri (x 2 Mon AM) – target tele-consultations, walk in patients, minor injury clinic referrals and any urgent house or nursing home call. The SAS South East Division cover two health board areas, Lothian and Borders. By January 2018 there will be a total of 30 fully qualified SP within the Division. 6 within the Borders and 24 spread across the Lothian's (Edinburgh – 12, East/Midlothian – 6, West Lothian – 6).

The Pilot A 3 month trial period was set from January - March 2016 SP role was to provide cover for Duty Doctor (DD) during opening hours Mon-Fri, attending appropriate home visits. These were initially triaged by the DD, and discussed with SP prior to visit SP attended patient with copy of intermediate notes, carried out assessment, and liaised with DD by phone to discuss/ decide treatment options SP returns to TMP and completes call on EMIS, adding relevant information to patient’s electronic notes. It was decided that although SPs carry medicines the GP would issue, as per normal, so as not to confuse patient expectation SP available to Ambulance Control Centre (ACC) for Immediately Life Threatening calls unless actively treating a patient Prior to commencement of trial, the SPs shadowed a number of GPs in surgery, and were given basic training on their electronic data system. They were also given personal access to EMIS, DOCMAN etc.

Some Data - Jan-Mar 2016 During the trial 187 domiciliary visits were made by SP. SP visited up to 8 patients per day whilst working solely in Primary Care Case mix - 60 respiratory, 24 UTI, 44 acute pain and 15 cellulitis. The remaining 44 were for falls, anxiety etc 80% of all assessments were in patients over the age of 80. A third of visits were to patients over the age of 90 98% of visits involved phone contact with GP 10 patients were admitted to Borders General Hospital 80% spent 10 days or more in hospital

Outcomes Good inter-professional working relationship created and developed Working model established SP skill set in minor illness management consolidated and developed GPs more aware of SP and SAS standard Paramedic scope of practice Reduction of DD workload SP more aware of alternative pathways of care, historically only available to GPs SP involved in direct referral of patients to consultants at Borders General Hospital Provision of access to existing pathways and anticipatory care plans via Primary Care networks to our standard Paramedics

Current Position and Look Forward Cheviot Medical Practice, and Kelso are now involved, similar to Hawick model SP working with Out of Hours (OOH) based within Borders General Hospital during peak pressure times Qualified and student SP have weekly presence within both practices In partnership with OOH a ruggedised PC is being procured for SP remote access to patient records Further improvements in data sharing/access/recording needed SAS desire to widen the project to other GP practices meeting resistance

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