ARRS: Bureaucracy and red tape are undermining a promising development

The Additional Roles Reimbursement Scheme (ARRS) was introduced in 2019 to expand the primary care workforce¹ in response to the obvious increasing pressure on it. It initially supported the recruitment of several professional groups, including pharmacists, physician associates, GP assistants, first-contact physiotherapists and paramedics. Notwithstanding criticism that the scheme did not initially cover GPs and nurses,² most of the appointments were well received.

Sophie Bartlett and her colleagues interviewed five practice managers, two GPs, three pharmacists and a business manager across Wales in a study that demonstrated that practice pharmacists have become virtually indispensable to the primary care set-up, managing medicines with far greater detail than doctors.³ My practice’s experience of ARRS recruits has been equally positive.

It is, therefore, regrettable that the more recent expansion of ARRS to nursing and medical recruitment has been beset by so many layers of bureaucracy and red tape that I believe it will prove unworkable. Advanced nurse practitioners were admitted in 2023,^4, but only those educated to MSc level are eligible.⁵

There are two obvious problems with limiting recruitment to such a (literally) exclusive club. Firstly, such well-qualified nurses are likely to be in stable employment, many, if not most, employed by practices that may have funded and supervised their education. I aver that far too few will be on the open market to satisfy need, and the scheme does not support those qualified nurses already in post. Secondly, the continued exclusion of practice nurses alienates a cadre whose appointment may be just as useful to practices and their patients and who may well develop professionally to the ANP level with in-house support.

ARRS and GPs

The recruitment of GPs, approved recently by the new Labour government,⁶ is, if anything, even more bewilderingly complex. It is restricted to those within the first two years of postgraduate qualification who have not held any substantive post and, as with nurses, excludes doctors currently employed by practices.

Quite apart from possible prima facie age discrimination, it prevents tapping into the large cadre of experienced GPs who may wish a new challenge, and who need less supervision that young recruits arriving straight from the relatively protected environment of vocational training. Above all, a further disincentive is that the monies available for this pale beside normal salary scales for GPs, so these will at best be transient appointments rather than substantive career posts.^6,7

Given that PCNs and not individual practices hold the budgets, I fear that the relationship between constituent practices may be damaged if what is available cannot equally fulfil the differing priorities practices may have. A very negative scenario would be that, faced with inadequate sums of money and excessively stringent recruitment criteria, practices may recruit staff they don’t require simply to spend the money and be left with uneven teams, understaffed in some areas yet bloated in others.

The contrast with fundholding, active from 1991 to 1998 and a scheme that genuinely improved services to patients for practices willing to embrace it,^8,9 could scarcely be greater, and I believe that it is timely for health service managers to turn the clock back and look at a revival of this, or a similar model. PCNs do not need dismantling, but, as with fundholding, individual practices should have license, within budgetary constraints, to recruit staff according to their populations’ priority without having to navigate pointless bureaucratic red tape.

Edin Lakasing, GP Trainer and Tutor, Chorleywood, Hertfordshire

References

1. NHS England. Network Contract Direct Enhanced Service: Additional Roles Reimbursement Scheme guidance. Updated 9 Dec 2019. https://www.england.nhs.uk/publication/network-contract-directed-enhanced-service-additional-roles-reimbursement-scheme-guidance/ (accessed 11 Oct 2024).
2. Mahase E. Government is refusing to include GPs or nurses in additional roles scheme, says BMA leader. BMJ 2024; 384:
3. Bartlett S, Bullock A, Morris F. ‘It’s the stuff they do better than us’: case studies of general practice surgeries’ experience of optimising the skill-mix of practice-based pharmacies in Wales. BMJ Open 2023; Volume 13, Issue 11. https://bmjopen.bmj.com/content/13/11/e073778 (accessed 11 Oct 2024).
4. Hacker J. Advanced nurse practitioners added to ARRS. Pulse, 6 Mar 2023. https://www.pulsetoday.co.uk/pulse-pcn/advanced-nurse-practitioners-added-to-arrs/ (accessed 11 Oct 2024).
5. NHS England. Additional roles: A quick reference summary. 16 May 2023. https://www.england.nhs.uk/long-read/additional-roles-a-quick-reference-summary/#:~:text=Advanced%20practitioners%20can%20be%20a,six%20where%20it%20is%20100%2C000. (accessed 11 Oct 2024).
6. Parr E. PCN DES update reveals ARRS GP eligibility and reimbursement rates. Pulse, 26 Sept 2024. https://www.pulsetoday.co.uk/news/breaking-news/pcn-des-update-reveals-arrs-gp-eligibility-and-pay-rates/ (accessed 11 Oct 2024).
7. Salisbury H. Funding GPs through the additional roles scheme won’t solve GP unemployment. BMJ 2024; 387:
8. Howie JGR, Heaney DJ, Maxwell M. General practice fundholding: Shadow project–an evaluation. Edinburgh: University of Edinburgh,1995.
9. Jones RW, Lakasing E. Practice-based commissioning: are there lessons from fundholding? British Journal of General Practice 2007; 57 (537): 328-329.

Edin Lakasing

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