Assessing the impact and success of the Additional Roles Reimbursement Scheme

Foreword

The NHS has been through a lot since 2019, when primary care networks (PCNs) and the Additional Roles Reimbursement Scheme (ARRS) were introduced. The achievement of exceeding 50 million appointments and beating the 26,000 new staff recruitment goal cannot be overstated. In spite of the challenges, primary care has recruited over 34,000 new patient-facing staff and met the target to provide an additional 50 million appointments four months ahead of schedule. The success of the scheme is more than simply delivering on the ambitions, but primary care consistently going above and beyond to deliver for patients. 

However, to build sustainable general practice and deliver on the new ambitions of the NHS Long Term Workforce Plan, progress cannot stop now. Primary care still faces challenges from high levels of demand, unfit estates and the race to get the right digital infrastructure in place. 

As a network, we are committed to supporting primary care to maximise its impact on patients and drive change. As part of that work, we have considered the broader future of the additional staff in primary care and their potential to support the delivery of integrated care.

Professor Aruna Garcea 
GP and Chair 
Primary Care Network

Background

The Additional Roles Reimbursement Scheme (ARRS) was launched in 2019 as part of the government’s manifesto promise to improve access to general practice. The government committed to funding an extra 50 million general practice appointments by 2024 and to increase the staff available across primary care to increase capacity to deliver the additional appointments. 

This report reflects on the success of the ARRS against its original aims

In addition to clinical staff, the manifesto included aims to extend social prescribing, which would support patients struggling with the wider determinants of health, such as housing, poverty and isolation. The ARRS addressed this promise by including social prescribing link workers as one of the first roles available as part of the scheme. These additional staff would be able to connect primary care to other local organisations and bridge the gap between community, charity and local authority services, bringing together health and wellbeing within a general practice setting. 

As primary care prepares for the 2024/25 GP contract, this report reflects on the success of the ARRS against the original aims and its progress towards overcoming existing challenges in primary care. It provides a set of recommendations for how the scheme can develop beyond 2025.

Setting the right goals

As stated in our vision for at-scale general practice, the success of any plan for the future of primary care depends on its ability to positively impact workload, to diversify and retain the workforce while also tackling physical and digital infrastructure challenges. To achieve this, any scheme should target these areas and their enablers.

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.

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.

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.

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.

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.

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.

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.

A whole-system approach to workforce planning

Recruitment is a key challenge for many providers, with significant variation across the country. While key indicators like deprivation and rurality affect recruitment to GP roles, there is limited evidence for what impacts ARRS staff recruitment. This suggests that further research into what influences shortages of particular roles within a system would enable each system to identify, and potentially address the issue at scale rather than leaving each provider to tackle the problem in isolation. Furthermore, ongoing implementation of the recently published NHS Long Term Workforce Plan should actively consider the needs and capacity of the ARRS workforce. 

ARRS has introduced new roles to primary care, but they do not exist in a vacuum

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.

The trend towards increased flexibility and autonomy should continue

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. 

ARRS staff have been eligible for pay rises in line with AfC pay uplift

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. 

Clinical supervision by a GP offers development and learning opportunities

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. 

Data collection needs to be improved to accurately assess activity, demand and capacity

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.

Conclusion: the future of the ARRS

Ultimately, the ARRS scheme has met its key targets and delivered improvements to access, workforce pressures, and the range of services available direct to patients. The benefits of the scheme are evidence that the new roles have a place in the future of primary care, but continued success requires more than simply renewing the scheme. 

The new roles  have a place in the future of primary care

Primary care and its partners have adapted to the new ways of working required to make a success of the new roles, but they are working against challenges that, if resolved, would enable further progress. The sustainable future of primary care, as envisioned by our network, will require further workforce development to be supported by policy which recognises its interconnected enablers and focuses on sustainability.

Creating conditions for success: our recommendations

• Ensure increased ARRS flexibility to allow primary care to determine their workforce needs within the funding available, including the number of practitioners that are funded and the flexibility to contract and deploy where most appropriate.
• Future funding models should include provision for the supervision, training and ongoing personal development required to retain and improve the workforce.
• Greater investment in primary care capital for estate and digital as part of the upcoming national estates plan and ongoing commitments to improved capital funding.
• Further work is required to align primary care contracts and funding to the rest of the NHS to ensure that primary care remains equipped to support a greater shift to out-of-hospital care. This would also ensure that primary care is seen as an attractive employment prospect in line with the benefits and pay uplifts available in the wider system.
• At-scale HR and employment support for ARRS staff has been a demonstrable success and providers should be encouraged to explore potential at-scale support in their area.
• Expand support to commission digital solutions at scale to enable integrated working across the health service and reduce unwarranted variation. 
• Raising patient awareness of, and confidence in, multidisciplinary primary care is essential. The national education campaign on the roles available in primary care should be continued and integrated care systems supported to increase tailored campaigns at local level. 
• Develop the primary care workforce dashboard to support tracking workforce development including staff turnover on a national scale.
• Shared funding commitments for roles like mental health practitioners should be evaluated and, where necessary, enable alternative contracting and funding arrangements co-designed between primary care and mental health providers.