Changing models of care, prompted by the push for integration, create both challenges and opportunities for ambulance providers looking for better ways to manage demand on their resources within a context of workforce pressures, including recruitment and retention. The Carter review of operational productivity and performance in English NHS ambulance trusts found that sickness absence among ambulance trust staff stands at an average of 20 days per year. There is significant variation in staff retention among trusts, ranging from 9% to 17% staff turnover per year and there is an acknowledged gap in workforce capacity as with other clinical specialties.
Among efforts to make best use of staff across the NHS workforce, initiatives to rotate advanced paramedic practitioners into GP practices can support both ambulance trusts to reduce conveyance rates and 999 demand from GPs, as well as pre-empting patient needs for urgent and emergency care at home. Paramedics working in primary care settings can take on home visits and administer medications, further reducing pressure on GP time, and also potentially reducing calls to the ambulance service itself.
Having flexibility in the workforce has been helpful. We have been situating paramedics in primary care settings, who then do some of the home visits and work with a portfolio of patients. The benefit of this has been to see patients earlier so if they need conveying to hospital it can be done earlier in the day where a GP might not otherwise have seen the patient until later. This also improves flow in the hospital. They can also refer to community teams and they have equipment and medication that GPs don’t have immediate access to.
However, rotational workforce models need, by definition, to be rotational, facilitating a flow of skills and experience from other disciplines into ambulance service delivery too. Many ambulance trusts now have nurse practitioners working on the frontline alongside paramedics. Those trusts we spoke to highlighted the need to find balance and demonstrate the benefits of flexing the workforce in this way to prevent increasing pressure on an already stretched paramedic workforce by losing them to bolster the primary care workforce.
Bringing other health professions into ambulance service control rooms/CAS also helps to diversify the role of ambulance services within an integrated care setting. The smooth transition of patients dialling 999 or 111 to talk immediately to advanced practitioners, GPs, midwives, mental health nurses, pharmacists, dentists and even social care staff within the ambulance CAS, can both ensure that patients are advised by the right person first, free up paramedic time for the most urgent cases who need to be seen, and equally can alleviate demand on those community teams at the point of access.
Here, the benefit of ensuring ambulance trusts are included in conversations about care transformation is clear. Those piloting ‘shared workforce’ initiatives have taken different approaches to managing the risks - some providers have collaborated with other local organisations to offer paramedics ‘portfolio’ careers who then rotate through sectors, ensuring a healthy supply of paramedics is available to the emergency services. Other providers have developed alliance arrangements within their ICS to place their clinical staff in the ambulance CAS settings, physically or remotely, thereby reaping the benefits, often reducing demand on, for their own services by being able to assess patient needs at their point of contact with the health system (via 999 or 111).