ISRCTN Identifier: 08256118.

BackgroundGeneral practice in the UK faces continuing challenges to balance a workforce shortage against rising demand. The NHS England GPForward View proposes development of the multidisciplinary, integrated primary care workforce to support frontline service delivery, including the employment of paramedics. However, very little is known about the safety, clinical effectiveness, or cost-effectiveness of paramedics working in general practice. Research is needed to understand the potential benefits and drawbacks of this model of workforce organisation.AimTo understand how paramedics are deployed in general practice, and to investigate the theories and drivers that underpin this service development.Design & settingA mixed-methods study using a literature review, national survey, and qualitative interviews.MethodA three-phase study was undertaken that consisted of: a literature review and survey; meetings with key informants (KIs); and direct enquiry with relevant staff stakeholders (SHs).ResultsThere is very little evidence on the safety and cost-effectiveness of paramedics working in general practice and significant variation in the ways that paramedics are deployed, particularly in terms of the patients seen and conditions treated. Nonetheless, there is a largely positive view of this development and a perceived reduction in GP workload. However, some concerns centre on the time needed from GPs to train and supervise paramedic staff.ConclusionThe contribution of paramedics in general practice has not been fully evaluated. There is a need for research that takes account of the substantial variation between service models to fully understand the benefits and consequences for patients, the workforce, and the NHS.

BackgroundThere are approximately 60,000 out-of-hospital cardiac arrests (OHCA) in the United Kingdom (UK) each year. Within the UK there are well-established clinical practice guidelines that define when resuscitation should be commenced in OHCA, and when resuscitation should cease. Background literature indicates that decision-making in the commencement and cessation of resuscitation efforts in OHCA is complex, and not comprehensively understood. No relevant research from the UK has been published to date and this research study seeks to explore the influences on UK Emergency Medical Service (EMS) provider decision-making when commencing and ceasing resuscitation attempts in OHCA. The aim of this research to explore the influences on UK Emergency Medical Services provider decision-making when commencing and ceasing resuscitation attempts in OHCA.MethodsFour focus groups were convened with 16 clinically active EMS providers. Four case vignettes were discussed to explore decision-making within the focus groups. Thematic analysis was used to analyse transcripts.ResultsThis research found that there are three stages in the decision-making process when EMS providers consider whether to commence or cease resuscitation attempts in OHCA. These stages are: the call; arrival on scene; the protocol. Influential factors present at each of the three stages can lead to different decisions and variability in practice. These influences are: factual information available to the EMS provider; structural factors such as protocol, guidance and research; cultural beliefs and values; interpersonal factors; risk factors; personal values and beliefs.ConclusionsAn improved understanding of the circumstantial, individual and interpersonal factors that mediate the decision-making process in clinical practice could inform the development of more effective clinical guidelines, education and clinical decision support in OHCA. These changes have the potential to lead to greater consistency.and EMS provider confidence, with the potential for improved patient outcome from OHCA.Electronic supplementary materialThe online version of this article (doi:10.1186/s12873-017-0136-3) contains supplementary material, which is available to authorized users.

Introduction: More than half of all patients attended by the South Western Ambulance Service NHS Foundation Trust are over the age of 65. In 2017, 62% of older patients who were the subject of a frailty assessment were believed to have at least mild frailty (1/5 of all patients). Frailty is an increasingly relevant concept/diagnosis and ambulance services are well positioned to identify frailty and influence the 'care pathways' through which patients are directed (thereby influencing health outcomes). Throughout the South Western Ambulance Service NHS Foundation Trust, a mandatory training session regarding frailty was delivered to clinical personnel in 2017 and frailty assessment tools are available on the electronic Patient Clinical Record. Aim: To explore and gain insight into the current knowledge, practice and attitudes of ambulance clinicians regarding frailty and patients with frailty. Methods: Two focus groups of ambulance clinicians (n = 8; n = 9) recruited from across the South Western Ambulance Service NHS Foundation Trust were held in October 2017. Focus group discussions were analysed thematically. Results: Knowledge of conceptual models of frailty, appropriate assessment of patients with frailty and appropriate care pathways varied substantially among focus group participants. Completion of the 'Rockwood' Clinical Frailty Scale for relevant patients has become routine. However, conflicting opinions were expressed regarding the context and purpose of this. The Timed-Up-and-Go mobility assessment tool is also on the electronic Patient Clinical Record, but difficulties regarding its completion were expressed. Patient management strategies ranged from treatment options which the ambulance service can provide, to referrals to primary/community care which can support the management of patients in their homes, and options to refer patients directly to hospital units or specialists with the aim of facilitating appropriate assessment, treatment and discharge. Perceptions of limited availability and geographical variability regarding these referral pathways was a major feature of the discussions, raising questions regarding awareness, capacity, interprofessional relationships and patient choice. Conclusion: Knowledge, practice and attitudes of ambulance staff, with regard to frailty, varied widely. This reflected the emerging nature of the condition, both academically and clinically, within the ambulance profession and the wider healthcare system.