The need for integrated healthcare has been increasingly recognised as health systems face mounting challenges from ageing populations, unhealthy lifestyles, urbanisation and subsequent proliferation of injuries and noncommunicable diseases (NCDs).¹ Fragmented modern healthcare exacerbates these challenges through inefficient resource use leading to inflated costs, poor quality of care and decreased patient satisfaction.¹ These challenges are particularly concerning in low-to-middle income countries (LMICs), which contain disproportionately high disease burdens with concurrent resource limitations.² The World Health Organization (WHO) global strategy on Integrated People-Centred Health Services (IPCHS) states, ‘The focus on hospital-based and self-contained “silo”: curative care models undermines the ability of health systems to provide universal, equitable, high-quality and financially sustainable care’.¹ Integrated health systems, defined as ‘the coordination of health services and the collaboration amongst provider organisations to establish an effective health system’,³ have been recommended to improve accessibility, affordability and quality of care, particularly for those with complex healthcare needs.⁴

A developing example of healthcare integration is collaboration between Emergency Medical Services (EMS) and palliative care.⁵ Palliative care itself is integrative in nature, as it applies a multidisciplinary approach to those with complex, life-limiting illnesses.⁶ The WHO has specifically recommended palliative care integration across multiple systems as part of its global response to NCDs to meet the increasing global demand for palliative care.⁷ Several studies have demonstrated the effectiveness of EMS and palliative care integration in this regard as it enhances patient satisfaction, improves quality of life, avoids unnecessary hospital admissions and associated costs and improves access to palliative care.^8,9,10,11 In LMICs such as South Africa (SA), where healthcare resources are constrained, integrating EMS with palliative care could improve accessibility while optimising limited resources.

In SA, these benefits have been noted by EMS¹² and palliative care providers¹³ as well as patients and family members.¹⁴ These stakeholder groups have recommended EMS and palliative care integration.^12,13,14 Despite these findings, EMS and palliative care systems remain ‘siloed’ in SA, and no clear guidance exists for integration. Thus, there is a need to develop implementable approaches facilitating integration. Given the resource constraints in SA, there is a further need to prioritise approaches with the greatest potential impact and feasibility. Therefore, the aim of this study was to develop and prioritise approaches facilitating EMS and palliative care integration within SA.

Nine experts participated in the meeting (Table 1), which lasted 2 h 27 min. Seven participants knew CG from the previous research participation in EMS¹² and palliative care expert interviews,¹³ and all were aware that the study formed part of his postgraduate studies. No participants dropped out of the study or refused participation. All participants completed each phase of the procedure. In total, 52 answers were generated and ranked (Table 2). Answers fell into 10 categories, as demonstrated in Table 3. Based on average impact and feasibility scores, ideas were plotted on a prioritisation matrix (Figure 1).

This figure includes the top 10 ranked ideas. A complete figure may be found in Online Appendix 4 Table A4-1.

Healthcare integration literature has identified several components within integration frameworks: Funding, Colocation, Communication, Community Engagement, Context, Culture, Governance, Defining Roles and Shared Goals, Stakeholder Management, Technological Connectivity, Awareness and Education.²² Although some differing categories were developed in our study, participant answers aligned well overall. Categories not explicitly developed in our study were Colocation, Culture, Defining Roles and Shared Goals and Technological Connectivity. However, elements of these were implied within specific approaches. For example, establishing cross-disciplinary communication and information-sharing would require technological connectivity and colocation to varying degrees. Furthermore, educational interventions have been previously recommended to impact EMS and palliative care cultures.^14,23 Additional categories noted in our study (Research, Policy Development, Alternative Pathways and Approaches) likewise contain similar elements as they would involve defining roles and shared goals. Thus, given their alignment with international healthcare integration frameworks and specificity to the SA setting, the categories developed here represent an appropriate foundation for EMS and palliative care integration in SA.

The approaches developed in our study may be achieved at macro- (national systems and policies), meso- (regional, district and organisational) and micro- (individual provider) levels (see Online Appendix 5 Table A5-1).^4,24 This was demonstrated in a similar study aimed at implementing ‘palliative paramedicine’ in Australia.²⁴ Within this Delphi study, 32 components for EMS and palliative care integration, divided into macro-, meso- and microlevel reached consensus.²⁴ Although several specific interventions differ between this Delphi study and the present NGT, all categories of approaches are aligned.²⁴

Considering the resource-limited LMIC context of SA, there is a need to focus on feasible, high impact and low-cost approaches to integration. Experts in this study identified several such approaches, which we highly recommend for immediate implementation: (1) enable EMS to administer already prescribed medications, (2) EMS undergraduate training in palliative care, (3) improve EMS recognition of signs of dying at the end-of-life, (4) palliative care awareness for the EMS community, and (5) palliative care awareness for in-hospital healthcare providers, particularly those in emergency medicine.

Currently, EMS providers do not typically administer medications that have already been prescribed, particularly if these medications fall outside of their scope of practice.²⁵ An example provided by one participant was that of a patient with oral morphine at home who has not self-administered because of a misunderstanding of when the medication should be used. Emergency Medical Services are then contacted because of the patient’s distress – a common reason for EMS and palliative situation intersection.^26,27 In this case, EMS should be empowered to assist with the self-administration of the oral morphine without subsequent conveyance to a hospital should the symptoms be relieved. This approach may allow many patients to be safely treated in the setting of their choice, which is frequently home.^28,29 Unnecessary costs to both the patient and healthcare system may be prevented through avoidance of inappropriate conveyance.³⁰

Educational approaches facilitating EMS and palliative care integration are the most frequently emphasised in the literature^5,31,32,33 and were the most frequently highlighted approaches in our study. Emergency Medical Services undergraduate training in palliative care has been recommended internationally²³ and in SA.¹³ In Australia, Juhrmann et al.²³ recommended this as an approach to facilitate cultural change within EMS from a curative approach to one which recognises patients with supportive needs in different contexts. A study interviewing SA patients and family members in palliative situations argued this cultural change to a person-centred approach would be beneficial, not only in palliative situations but also emergency scenarios.¹⁴ However, cultural change will not arise from simply receiving palliative care training. Rather, palliative care principles should be embedded in the approach to care for all patients. For example, incorporating the palliative principle of holistic care to the EMS mindset would be beneficial in both palliative and emergency situations. We concur with Juhrmann et al.²³ that undergraduate EMS training in palliative care should not detract from the EMS emergency response function, but rather enhance it. Such training should not be aimed at producing ‘paramedic palliative care providers’, but rather producing a cultural shift to person-centred care, which would enhance both emergency and palliative care provision.

Spreading awareness of palliative care among EMS and other healthcare providers, represents a simple, low-cost approach to service integration. One area in which EMS require assistance is identifying palliative situations.^34,35 Because of their training, EMS providers tend to view all situations from an emergency perspective and are often not aware of alternative approaches.¹² Thus, by spreading awareness of an alternative (palliative) approach, EMS recognition of palliative situations may be improved. This may be achieved through CPD training, dissemination of EMS and palliative care research, inclusion of EMS in palliative care conferences, meetings, strategic planning sessions and vice versa. We recommend each of these opportunities for awareness be explored and further innovations be developed.

While we recommend these highly impactful and feasible approaches, it should be recognised that even within SA, varying contexts exists between regions as some areas contain greater EMS and palliative care resources than others.^36,37,38 Thus, the feasibility of these approaches will likely vary dependent on area. This may explain much of the variance in feasibility scores awarded by participants as they function in diverse contexts (see approaches with s.d. > 0.75). As a result, there is a need for flexibility in the application of these approaches. From our findings, we suggest there is no ‘one-size-fits-all’ approach to EMS and palliative care integration in SA, but rather unique priorities may develop in various contexts. This is potentially counterintuitive to the current EMS system, which tends to apply a ‘one-size-fits-all’ approach, applying curative care principles regardless of situation type.¹⁴ However, while unique priorities may develop, the categories of approaches presented here remain a reasonable starting point. Interestingly, no approaches were ranked as having low impact. Thus, each approach may be beneficial and should be considered cross-contextually.

While discussing the integration of EMS and palliative care, participants cautioned against palliative care services simply ‘passing on their work’ to EMS. South Africa EMS providers have likewise cautioned against performing palliative care in isolation.¹² While integration between the services is necessary, the need to establish clear roles and boundaries is an important consideration³⁹ and has been highlighted in healthcare integration literature.^40,41 Future research is necessary to identify these roles and boundaries in various SA settings. Along with SA EMS and palliative care providers,^12,13 we suggest the EMS role in palliative situations is to identify palliative needs, provide initial containment and link patients with palliative care providers.⁴² Additionally, EMS and palliative care integration should not be viewed as a panacea, but rather as part of an approach to improve palliative care provision in the country.³⁹ Thus, ongoing research into EMS and palliative care integration must be performed to monitor its safety, efficacy and unintended consequences.

Our findings align with the WHO IPCHS strategy which recommends empowering and engaging people, strengthening governance and accountability, reorienting the model of care and coordinating services.¹ These recommendations take country development status into account and are aimed at creating an enabling environment for healthcare integration.¹ This further aligns with CAS theory, which views healthcare integration as emerging through self-organisation rather than central control.⁴³ Thus, rather than enforcing integration, broad guiding principles to foster a positive environment for integration are recommended.^16,44 According to a CAS approach, ‘top-down’ controls stifle creativity and negatively affect a health system’s ability to adapt.^16,44 This approach is pertinent in the SA setting. The need for health system adaptation to the increasing prevalence of NCDs and the growing need for palliative care is apparent. Given the diverse contexts present within SA, a central control approach to EMS and palliative care would be futile, whereas applying the findings of this study as guiding principles would encourage integration cross-contextually.

This study contains limitations involving generalisability as a purposive sampling strategy was employed, resulting in a small group of participants largely from two provinces within SA. However, these participants work in diverse contexts within their provinces in both private and state sectors, including HE, management and patient-facing roles. While experts from other provinces were unable to take part because of scheduling constraints, the high proportion of participants from the Gauteng and Western Cape provinces are reflective of the greater EMS and palliative care resources in these areas.^37,38 Study’s findings, including these contextual differences, have been discussed considering previous local and international research. Researcher bias may be present as the meeting facilitator knew many participants from the previous research and may have unintentionally influenced the group discussion through subconscious demonstration of personal opinions. However, researcher triangulation and member checking were performed to mitigate this. Finally, this study placed time constraints on participants and the findings of this study may not be comprehensive. Nevertheless, these findings align well with health system integration literature, represent the considerations of highly experienced SA providers, and therefore, remain applicable.

Through use of a nominal group, consisting of experts from both EMS and palliative care, this study aimed to develop and prioritise approaches facilitating EMS and palliative care system integration within SA, thereby providing guidance for implementation in the country. We recommend the following highest ranked approaches as a practical starting point for EMS and palliative care integration in the country: (1) enable EMS to administer already prescribed medications, (2) EMS undergraduate training in palliative care, (3) improve EMS recognition of signs of dying at the end-of-life, (4) palliative care awareness for the EMS community, and (5) palliative care awareness for in-hospital healthcare providers, particularly those in emergency medicine. These approaches represent high impact, low-cost interventions, which are needed in the LMIC setting of SA. The implementation of these approaches will bring together currently siloed EMS and palliative care systems to enhance holistic care for those with palliative needs. Future research should aim at establishing the safety and efficacy of these interventions.