Assessing the impact and success of the Additional Roles Reimbursement Scheme
Measuring success
Access
In 2019, access was identified as a growing issue for patients and stretched staff within general practice. 308 million appointments had been delivered in 2018, rising to 312 million in 2019 when the manifesto and ARRS were announced. This large growth in appointments indicated a rise in demand, just as patient satisfaction was decreasing. Therefore, it was vital to target access to relieve the growing pressure on the workforce. Workforce is a key enabler of improving access, so the scheme was welcomed by primary care providers.
But tackling workforce issues in isolation meant an opportunity was missed to build a comprehensive plan. The Fuller stocktake has since emphasised the importance of estates and digital (in addition to workforce) as the enablers for creating the capacity for wider improvements led by local decision-making. Our work on designing the future of primary care through our Design Groups has recognised access as an outcome of enablers, including workforce. The ARRS was not a standalone solution to this problem.
The increase in skill mix has allowed new services to be provided in primary care settings.
Increasing the primary care workforce through the ARRS has improved access to general practice, providing over 50 million more appointments in 2023 than in 2019. While demand and pressure remain high, an additional 31,000 roles joining primary care has allowed providers to run additional appointments and extend existing services. The increase in skill mix within primary care teams has also allowed new services to be provided in primary care settings for the first time. Across the country, patients can now access services such as menopause, learning difficulties and asthma clinics staffed and supported by ARRS practitioners. The number of additional clinics vary across the country and challenges such as estates and workforce shortages prevent some providers from expanding their offer.
The new roles have also supported access improvements by simplifying pathways for patients. The increase in first-contact staff, who can see patients without a GP referral, alongside improved triage through the introduction of care coordinators and digital services in general practice, allows patients to book directly into appointments with the right practitioner for their needs. Where this is done well, and supported by effective triage and staff training, patients can see the right practitioner at the right time without needing to be referred by a GP. However, first-contact practitioners and care coordinators alone cannot create improved pathways. For providers without effective triage procedures and tools, this process can lead to inappropriate bookings and waste more time.
Case study: Well Up North PCN, Northumberland
Well Up North PCN employs five first contact MSK practitioners who work across ten practices and provide appointments which patients can book into directly by ringing their practice or using the e-consult service. Prior to the establishment of the service, only one practice had MSK provision and patients would require a referral to other services.
This service streamlines patient experience without compromising patient safety because of the robust supervision, note-taking and communication protocols in place that ensure any patients who do need to see a GP are referred as soon as possible. Patient and staff feedback is positive and the service delivers over 1,000 appointments a month which would otherwise need to go through a GP for referral.
At a time when access pressures are extremely high, additional direct-to-patient services provided by ARRS roles are reducing unnecessary GP appointments and making it simple for patients to see the right practitioner as soon as possible.
Multidisciplinary approach to patient care
In 2015, general practice was facing a GP shortage and the government pledged an additional 5,000 GPs to bolster the workforce. However, GP numbers continued to decline and the 2019 commitment to supporting general practice with non-GP staff was an innovative approach to increasing appointments and addressing the pressures on the GP workforce. Moreover, the design of the scheme to allow primary care leaders to select which of the available roles to recruit was a positive step towards letting local leaders lead and tailoring services to local demand. It is through local knowledge of the population and service design that innovation and population-focused care can thrive. The ARRS is a key example of setting policy which empowers local leaders to build teams and services which meet local need.
The design of the scheme was a positive step towards letting local leaders lead.
ARRS staff bring a new range of skills and expertise to primary care which can be used to support patients with a diversity of care needs. For example, they have contributed to the expansion of bespoke multidisciplinary teams (MDTs), including frailty teams, mental health and wellbeing, and long-term conditions. These MDTs improve patient care and support peer learning by bringing practitioners together to share knowledge, expertise and design person-centred care plans. This can also reduce GP workload as GPs are able to act as an expert generalist providing oversight for any care plans created as part of MDTs. When supported by strong lines of communication back to the GP, this can enable effective management of a patient’s health without additional GP interventions.
Our members are also exploring how they can learn from MDT models in countries like Brazil and the Netherlands to build on the range of skills provided by the ARRS staff. By taking inspiration from global models, our members are broadening the horizons of holistic, patient-centred care and redefining the relationship between clinical and non-clinical care.
To maximise the diversity of skills and learning potential of MDT working, the importance of building a cohesive team cannot be overstated. Without a genuine team culture and cohesion between those involved, the team will experience significant strain and have limited positive impact on staff and patients.
Case study: Leyton Collaborative PCN, London
Leyton Collaborative PCN uses its ARRS staff to support frailty-focused MDTs which aim to proactively manage the PCN’s Ageing Well cohort who experience mid to mild frailty. Once the cohort has been identified, the MDT delivers interventions by reaching out by telephone to potentially frail patients and following up at one, three, six and nine weeks after the initial contact. An additional call is made at 12 months to ensure that a patient’s long-term health is also supported.
They have established a multi-agency and multidisciplinary team including care coordinators, social prescribing link workers and health and wellbeing coaches employed as part of the ARRS. The MDT reviews patient needs and helps them to access services and manage their own health and wellbeing. Each role in the MDT supports a different area of the patient’s health, wellbeing and experience of the health and care system, ensuring that they receive effective and holistic care which takes into account the full context of the patient.
Strengthening collaboration across sectors
While the ARRS has increased competition and concerns about the availability of practitioners including paramedics, pharmacists and mental health practitioners, it has also provided opportunities for greater collaboration. Rather than viewing other providers as competitors for a small and in-demand workforce, some of our members have shared their success in creating shared workforce arrangements and developing relationships with system partners. These relationships support the sustainability of employing additional roles in primary care and lay the foundations for further integration.
The ARRS has provided opportunities for greater collaboration.
Some of the most successful agreements see staff rotate through primary and secondary care at agreed intervals to prevent the workforce being depleted. These agreements work best at scale where the interface between primary and secondary care can be simplified, with at-scale primary care providers providing a single point of contact, and a smaller workforce can be deployed across a larger area, reducing duplication. However, these arrangements are still rare and can be challenging to establish.
Case study: Valens PCN, Northumberland
Workforce has always been a priority in primary care and Valens PCN saw the potential in extending multidisciplinary working to include system partners. The PCN had recruited heavily into ARRS roles and dedicated time to developing MDTs and partnerships with local organisations that could support their ARRS staff to support patients.
Working with key partners in adult social care, mental health and in the community has enabled Valens PCN to collaborate on the delivery of new multidisciplinary models of care. For example, a daily frailty MDT has been in operation since late 2020 to provide a proactive approach to managing the care of elderly patients and reducing hospital readmission. In this model, care is retained in the community or transferred from secondary to community-based care within a structured framework and supported by robust pathways. This structure allows the team to feel connected and supported to flourish, leading to true integrated, collaborative working as well as supporting future workforce development by using PCN additional roles such as social prescribing for maximum benefit.
Case study: Merton Health Limited and London Ambulance Service, London
Having identified the need to recruit paramedics to deploy within their PCNs, in 2020 Merton Health Limited (MHL) reached out to London Ambulance Service (LAS) with a proposal to recruit and subcontract paramedics to the federation. As a result of discussions with LAS they agreed to recruit 12 0.5 WTE band 6 paramedics (six WTE) across six PCNs as part of a six-month pilot during which the paramedics would work 50 per cent of their time for the PCN and 50 per cent with LAS on two-week rotations.
With 12 paramedics, there was always one paramedic available to the PCN as part of this rotational model. Once the paramedics were recruited, LAS provided monthly peer support and supervision, as required by the ARRS reimbursement specifications, as well as maintaining responsibility for annual leave and rota management.
The pilot saw a 50 per cent reduction in rapid response visits and a 50 per cent reduction in referrals to the CLCH rapid response service during the same period.
The pilot was a success. MHL and LAS have continued to develop the rotational paramedic model and expand into new services.
Integration and progress towards integrated neighbourhood teams
In our vision for primary care, we stated that: “Integrated neighbourhood working requires partners across a community to come together – with local citizens at the centre – to find solutions to local health and care needs, looking beyond the medical model of care to wider determinates of health”. One of the key steps in bringing partners together is building a shared workforce. This collaboration can then develop into successful integration as staff are no longer siloed, but part of a larger, cross-sector team to provide wraparound care across a geographical area.
Staff such as clinical pharmacists, mental health practitioners and paramedics present opportunities for building integrated teams with system partners, while non-clinical roles like social prescribing link workers are already forging relationships beyond the health service and with citizens to bring new expertise and valuable community level insight into the design and delivery of better care. These connections represent a vital step towards integrated teams at different scales by building the relationships necessary to forge new ways of working.
Case study: Alliance for Better Care – social prescribers supporting communities
In Surrey and Sussex, the Alliance for Better Care, a GP federation, has recruited 20 social prescribers to work across all their PCNs to liaise with patients to understand their needs and deliver personalised care. They explore the wider determinants of health alongside their patients to help make improvements and offer support where it is needed. This includes:
- A bereaved men’s group in response to social isolation and bereavement from the pandemic. This is a peer support group that meets once a month.
- An initiative aimed at tackling neighbourhood health inequalities, by focusing on young families. The aim is to ensure families are aware, and make best use, of all the health and support service that are accessible to them.
- Offering wider wellbeing support offer to refugees and asylum seekers in hotels around the area. This has included personal training in hotels as well as planned trips to Crawley Football Club.
Optimising economies of scale
The ARRS was established to provide staff to work at PCN level as the at-scale benefits to resource sharing were already recognised. Moreover, growing the primary care workforce at neighbourhood and place is key to improving the resilience of primary care. Initially ARRS staff were expected to operate at the 30,000–50,000 population level. However, in response to local need, to improve equity of access, and strengthen career opportunities, many areas have been able to optimise ARRS by deploying them into services at a bigger scale across a place level. This increase in scale improves equity of access to ARRS appointments by providing the same service to a larger area and reducing the impact of a shortage of specific roles in some PCNs. Where some PCNs have found it difficult to recruit into certain roles, sharing staff at place level improves access to the full skill mix available in the scheme.
An at-scale approach to employment reduces the administrative burden of recruitment, HR and management.
One of the shortfalls of the scheme is the lack of built-in career progression for additional staff. The ARRS itself does not support upskilling staff and/or career development and it is most likely that staff will move to new roles with other providers. At-scale providers like GP federations and larger PCNs can draw on the strength of a larger team with more opportunities for learning and develop in-house career pathways. Some members have even benefited from upskilling existing ARRS and moving them into higher bands where they could provide supervision support to new staff members.
An at-scale approach to employment also reduces the overall administrative burden of recruitment, HR and management by having a single employer which manages the needs of all staff within that patch. Many GP federations have been providing this service for a number of years thereby freeing up PCN resources.
Case study: Bolton GP Federation
While the ARRS is structured in such a way that all staff recruited as part of the scheme must be employed by a PCN, many PCNs have partnered with their GP federation to employ ARRS staff on their behalf and deploy them at a greater scale. Bolton GP Federation supports seven PCNs in Bolton and has demonstrated several innovative methods of supporting their PCNs through subcontracting and managing their ARRS staff.
The federation coordinates the enhanced access provision for their partner PCNs and is able to coordinate the workforce required by drawing from the full range of ARRS employed across those PCNs. Each PCN determines the skill mix they require for their portion of the enhanced access offer, and the staff are managed and deployed into the service by the federation. This frees up PCN time and reduces duplication of effort, in addition to reducing variation in service for patients.
Moreover, in 2022, following a successful bid for some ARRS underspend in the system, the federation was able to employ physician associates (PA) to deliver a cardiovascular disease quality improvement project. Each PA conducted their project at PCN level so that each PCN would have results tailored to their population and needs, but the overarching programme was coordinated by the federation.
Easing pressure in secondary care
The increased capacity and skill mix that the ARRS has brought to primary care has supported patients to receive care close to home when they may otherwise have had to be referred into secondary care. Moreover, many of our members have demonstrated that this has reduced the pressure on secondary care and freed up capacity for patients who require those services. The additional appointments provided by the ARRS staff also provides patients with more opportunities to access primary care, which can reduce the number who present at emergency departments.
Case study: Central Thistlemoor PCN, Peterborough
Central Thistlemoor PCN engaged in a population health management project to identify high frequency primary and emergency care users and to identify potential interventions to reduce A&E attendance. The PCN identified 400 patients who accessed emergency departments (EDs) more than twice a year and general practice ten times or more but had no long-term conditions.
On review this cohort on average contacted the practice 20 times a year and attended ED five times a year. The team reached out through text messages and phone calls to help engage the cohort and provide support. A team of staff who were trained on motivational interviewing spent around an hour with each patient finding out what mattered most to them. Patients who engaged are now supported by a variety of practitioners, including their GP, health and wellbeing coaches and social prescribers who are supporting them with their health and wellbeing.
Forty-five per cent of patients who engaged with the PCN were referred to social prescribers, who signposted them to services which offer non-medical support. Presentations at ED by this cohort dropped by around 30 per cent and general practice attendance by 75 per cent.
Ongoing challenges
While the ARRS has successfully met its targets, providers have experienced challenges and limitations in engaging with the scheme. To build on the success of the first five years, future policymakers should learn from the experiences of primary care leaders and address the wider determinants of successful workforce expansion and the challenges of introducing new roles into a traditionally independent sector.