A whole-system approach to workforce planning

ARRS has introduced new roles to primary care, but they do not exist in a vacuum. Rather, each member of staff comes from a pool of potential staff shared with other sectors, including community pharmacy and mental health. For each new staff member recruited to primary care, there is potentially one less available to other parts of the system. This has created local challenges and tensions in addition to widespread operational pressure in community pharmacy. 

Workforce sharing and joint recruitment has its challenges. For example, the mental health practitioner (MHP) role has been beset by challenges including workforce shortages, difficulties navigating the requirement for 50 per cent of funding to come from a mental health trust and supporting a large patient population as the sole practitioner in many cases.

The funding requirement was introduced to deliver a more integrated approach to out-of-hospital mental health care. This was among the first measures to mandate this level of collaboration. While some areas have found the process challenging, others have reported the benefits of the time and effort to get the right arrangements in place. Setting up the support available for MHPs and ensuring the job requirements are correct is often a joint consideration and requires good working relationships between the trust and primary care. 

As there is a shortage of MHPs available to trusts and primary care, and the funding requirement is not always feasible for one or both partners, tensions have arisen when funding or staff have not been available, and in those areas the relationship between primary care and the trust risks being eroded. In these scenarios, alternative solutions are required. Members have reported the success other roles have had, including health coaches, occupational therapists and social prescribers, in supporting a patient’s mental health. Ultimately, however, they recognise that access to an MHP has the greatest impact. Exploring alternative methods of employment such as rotations, building integrated cross sector teams, and other solutions co-designed with the local context in mind would reduce pressure on staff to cover a large area alone, and reduce potential complications around funding and recruitment.

Now that there is a growing and diversified workforce pool in primary care, it is essential that this is better connected to other system partners. This would support the growth of multidisciplinary teams into teams of teams that provide wraparound care to the local community. PCNs and GP federations that already have ARRS staff working across a neighbourhood footprint have developed the blueprints for this kind of integration, but they need to be supported by the freedom to develop flexible contracts and design services that enable effective integration beyond the boundary of primary care.

While the number of available roles has grown, caps on the number of certain practitioners which could be employed has felt arbitrarily restrictive as it does not account for local need, or availability of that workforce. Each year the increase in the number of advanced practitioners which could be employed has been welcomed, and the 2023 decision to remove the cap on the mental health practitioner role has allowed providers greater flexibility and autonomy to build MDTs around the available staff and the needs of patients. This trend towards increased flexibility and autonomy should continue to support wider MDT working.

Finance

The ARRS has a fixed budget with indicative pay bands for each role. PCNs have pay flexibility within the band to balance skills and experience with cost to get the most out of their allocation of the fund. Providers that recruit at the top of the pay bands often do so to provide a financial incentive for roles which are in short supply in their local area. This often solves the immediate recruitment issue, but can increase competition between providers. 

Moreover, in recent years, ARRS staff have been eligible for pay rises in line with Agenda for Change pay uplift. Funding for these uplifts has not kept pace with inflation and has remained within the five-year contract uplift – as a result PCNs that have recruited at the top of pay bands, and those that have used their whole ARRS allocation, struggle to meet the additional costs. Where an organisation has used their full allocation, employers have to find funds from elsewhere by cutting other services or reducing investment in improvements. Centrally funded increases to NHS salaries outside of primary care has led to recruitment challenges within the sector and could be addressed with the inclusion of pay uplift clauses in the PCN Direct Enhanced Service. 

Furthermore, the current scheme does not provide provision for benefits such as maternity or sick pay, meaning many potential staff are discouraged from moving to primary care. Larger PCNs and federations are more likely to be able to optimise scale to offer greater benefits, but the disparity between larger and smaller providers risks exacerbating a growing two-tier system for staff in primary care with different terms and conditions. For primary care to continue to attract new staff, there should be support to achieve financial and contractual parity with the rest of the NHS and address the challenge of financial resilience within current contracts. 

While employment costs for the additional roles are covered, many employers have found that they face further costs such as IT provision (both kit and extending licenses), as well as ongoing training. This can pose a disproportionate financial challenge to smaller providers with a lower overall budget and fewer contracts for additional services. 2023 was the first year that training time for first-contact practitioners was included in the scheme and members received this support with enthusiasm as it took pressure off already stretched budgets.

Supervision

NHS England guidance on ARRS explains the GP supervision requirements for each role to ensure patient safety and provide support to ARRS staff. However, this support takes time to do well and is inadequately reflected in the funding allocation. In a small organisation, it can be difficult to find additional funds or available staff for supervision, and practices in deprived areas experience disproportionate GP shortages which would compound the issue and leave them less likely to be able to meet the supervision levels required to take on new staff. 

Including provision for supervision in future funding models would ensure that ARRS roles are embedded effectively, lead to improved patient care and provide job satisfaction for individuals. This provision also presents an opportunity to improve GP retention, as members have shared their success in retaining GPs in supervision roles as an alternative to retiring. This keeps them in the workforce and reduces the number of hours of GP clinical time that are lost to supervision. 

Not only is clinical supervision by a GP a requirement, it also offers some development and learning opportunities. For all staff, working with mentors (whether this be GPs or other more senior practitioners) supports their development and illustrates potential career pathways. This is particularly the case for roles like paramedics and MHPs that often find themselves the sole practitioner in their PCN. Mentorship or supervision from a practitioner within their discipline would reduce professional isolation and provide peer support. Ensuring that all roles which provide mentorship and supervision are recognised in ARRS guidance will be key to increasing the provision of this offer across the country.

Estates

A key challenge of successfully implementing ARRS from the outset has been the lack of infrastructure to support the additional staff. The most significant infrastructure limitations have been estates and IT as many providers have struggled to house their new staff and ensure they have effective IT solutions to connect to the wider team. 

In May 2023, the RCGP reported that nine in ten practices did not have enough consultation rooms and two in five staff who responded to the survey believed that their premises were not fit for purpose. Our members have also shared their own difficulties in providing sufficient consultation space, influencing our network’s ongoing recommendations for prioritising primary care inclusion in any future national estates plan. ^*  To combat these limitations, employers are working creatively to introduce hot desking or hybrid working solutions which allow staff to rotate through available space or work remotely where appropriate to do so. While these solutions can improve the issue in the short term, some are unsustainable in the long term and the NHS Confederation has already called for improvements to capital funding and investment in urgent areas such as estates. Primary care estate investment has lagged behind other sectors in the last decade and was not addressed as part of the access recovery plan.

Data and digital innovation

To embrace innovation and deliver increased options for patients, our members have reported that digital innovation and IT improvements have proved vital to the implementation of the ARRS. Digital infrastructure for virtual appointments, working across practices, can optimise hybrid working, enable relevant practitioners to access patient records, and expands the access options available to patients. This must also be supported by improvements in triage which ensure patients get the right support first time and in a way that is simple for patients to understand and access. 

Primary care data remains problematic with inconsistency of recording and under-reporting. National systems like the GP Appointments Data (GPAD) Dashboard do not track the full scale of activity in primary care. To accurately assess activity, demand and capacity, data collection needs to be improved with greater consistency in how activity is recorded in systems. Data improvements are also required to support continued workforce development and planning, for example, the ability to have data on attrition rates of ARRS staff. Developing the current primary care workforce dashboard to provide additional information, such as attrition rates, would enable issues to be addressed at a national level.

Patient education

The introduction of new roles into primary care has required a cultural shift not just for staff in primary care, but for patients. While there are many models for delivering primary care, they have all traditionally been GP led and patients often still expect to see a GP first. For patients and practices, the role of a GP remains vital to providing clinical leadership, supporting patients with complex symptoms, and providing continuity to those who need it. 

However, with the development of MDT working and the growing skill mix in primary care, patients are often unaware that they can see a different practitioner more suited to their needs. Engaging patients in the development of new services, and ensuring they understand the pathways available will help patients make informed decision about their own health and care needs and strengthen the trust between professional and patients.