4. Has the ARRS improved access?

As the THIS Institute and Health Foundation found, there had been more than 400 initiatives designed to improve access from 1984 to 2023. These have been through targets and incentives. In 2000, the New Labour Government introduced a target that patients should be able to see a primary care professional within 24 hours and a GP within 48 hours – yet, as now seems familiar, the Health Foundation found ‘People’s ability to see their preferred GP declined’.

Over the next few chapters, we will look at the major initiatives designed to improve general practice in the more recent past, predominantly in England. They will focus on efforts to increase the number of appointments available, attempts to reduce demand and initiatives designed to improve ease of access. The final chapter of this part will touch on what has been proposed in the current government’s 10 year plan.  

But without doubt, the most consistent policy designed to improve access has – quite reasonably- been around boosting staffing numbers. It's clear that an increase in the number of healthcare professionals in general practice improves access. But this seemingly bland statement has plenty of nuance that we need to explore, and this has implications for government policy.  

To understand this fully, it is worthwhile revisiting the previous Cogora report from January 2025 on workforce, which detailed the various failed attempts made to increase the number of full-time GPs in England. It was partly in response to these failures that the additional roles reimbursement scheme (ARRS) was introduced as part of the primary care network contract in 2019, providing these networks of practices covering roughly 30,000-50,000 with funding to hire certain staffing groups. It has only been since the Labour Government took power that PCNs have been funded to appoint GPs, with certain restrictions in place. But it has already recruited 42,000 full-time equivalent non-GP or nurse direct patient care staff across general practice as of July 2025. 

Of all the government policies to improve GP access, the ARRS been the flagship, with a £1.41bn budget a year. There has already been a lot written about whether it has helped improve access, with some claiming success and others saying it has failed. In 2023, a year earlier than planned, the Conservative government heralded its achievement of meeting its 2019 manifesto ambition to deliver 50 million more appointments a year by the end of that parliament. As we saw in chapter 1, appointments with non-GP staff have been responsible for the increase in appointments overall with GP consultations remaining fairly static (in part, due to the decrease in the number of FTE GPs). This would suggest that the scheme has been a success.  

But, as we explored in chapter 2, that hasn’t led to increased patient satisfaction. As the Institute for Government concludes: ‘The enormous expansion of the direct patient care workforce, the last government’s signature primary care policy achievement, has coincided with the largest drop in patient satisfaction on record. Our regressions also showed a negative relationship between the change in DPC staff and the change in satisfaction between 2019 and 2023. In other words, the larger the increase in DPC staff, the more likely it was that patients’ satisfaction with a practice would fall.’

These are the two most salient points – yes, the scheme has undoubtedly helped increase the number of appointments; but it hasn’t improved patient satisfaction. It both has and hasn’t improved access.  

The previous Cogora white paper on workforce concluded: ‘Other healthcare professionals have taken on some more of the work, and this has been valuable in cases such as nurses and pharmacists working at the top of their licences. But GPs have the skill levels and capability to take on the majority of the work in general practice and, in most areas of activity, are the only professionals who can take on the clinical responsibility. An increase in GPs would also mean less activity overall, because their experience and training mean fewer follow-ups.’ 

Much of the workforce report was based on how whether these staff were clinically appropriate and safe, and whether it alleviated the workload of the established roles in the general practice team – GPs and nurses. Of course, these themes are almost inseparable from the question of whether they improve access. But this chapter will focus solely on the access aspect of the scheme, and whether those working in general practice feel it has helped.  

Useful roles  

Cogora’s survey of around 2,000 primary care staff revealed that, of the most traditional roles included in the ARRS, practice pharmacists were considered most helpful in terms of improving access. However, even for pharmacists, the survey still revealed an average score of less than 3.75 out of 5.  

These figures should be treated with caution though. A number of respondents pointed out that it was too early to judge the impact of the ARRS GP and nursing roles. Meanwhile, the other option – physician associates – while not necessarily traditional, has been a source of great controversy over the past few years, with PAs not particularly popular among GPs, practice managers, practice nurses or practice pharmacists. Importantly, the Cogora survey didn’t provide a breakdown of ARRS roles, which was a mistake in hindsight. Also, despite the survey question clearly stating it was about impact on access, respondents may have based their answers on overall feelings about the scheme.  

Some respondents were pleased with how the ARRS had benefited access. One practice manager says: ‘We have a pharmacist who deals with minor illness who frees up GP time. Also, we have a qualified mental health practitioner one day per week plus a MIND worker. This has made great impact in terms of returning patients. We have seen over a 60% reduction for GPs in these types of appointments.’ 

In the survey question’s free text box, around 200 respondents specified the most useful professionals. By far the most commonly cited role was that of physiotherapist, or similar musculoskeletal (MSK) roles – with around half of respondents highlighting their utility.  

Many people said physiotherapists had been a ‘game-changer’, pointing out that having these professionals within the practice allowed patients to bypass what have traditionally been appointments with a GP. As one practice manager pointed out: ‘This frees up time for our GPs to undertake work that is more relevant to them.’ 

Other popular roles included paramedics and mental health workers, although the latter isn’t particularly common across general practice due to problems with recruitment.  

Broadly, respondents somewhat valued pharmacists, as the chart shows. But whether this necessarily meant they were useful for improving access is less clear. Respondents specifically cited long-term condition reviews and ‘managing cholesterol pathway, structured medication reviews, drug safety alerts and increasingly hypertension’, as one GP puts it.  

Other comments from GPs included: ‘We have used ARRS admin to set up a robust medicine monitoring recall system, this has not improved access but it has significantly improved patient safety and the quality of care we provide’; ‘Not improved access particularly but they have reduced some of duty workload’; and ‘ARRS pharmacists have been huge help to us, but not necessarily with access – more with prescribing quality/safety/projects/supervision of wider prescribing team/structured medication reviews etc.’  

ARRS staff can help improve areas other than access, say practice managers. One cites the GP assistants, who lead on managing patients’ appointments to secondary care and therefore reducing DNAs to the practice. Another says that social prescribers/care co-ordinators – another popular role among respondents (see case study) – ‘have been an absolute asset dealing with social issues like loneliness and support with helping patients accessing funding, especially when they don't have any IT facilities’. 

One practice manager in Bristol concludes: ‘It feels qualitatively as if the ARRS staff help, but it is virtually impossible to quantitatively measure that. GP appointments are still under huge pressure (which is what ARRS staff were supposed to help with) so have we just created additional work to be done in GP rather than freed up GPs themselves?’ 

The comments of our respondents offer another reminder that access isn’t the only factor when it comes to good general practice.  

Need for GPs 

Another major theme was that an appointment with a non-GP staff member may not necessarily be of the same quality as one with a GP.  Again, it is useful to look at the IfG report for a detailed analysis of how various workforce roles affect patient appointments and satisfaction.  

The report found that GP partners are associated with the largest increase in total appointments across the practice. An additional extra GP partner leads to an annual rise of 5,439 total appointments in a practice, and 4,256 GP appointments. Meanwhile, an additional nurse leads to 4,976 extra annual appointments across a practice, compared with 2,279 for other direct patient care staff – although the report points out that those staff also carry out other unmeasured activity. 

There are similar trends with patient satisfaction. The IfG found: ‘An additional GP partner in a practice is associated with a 1.4 percentage point increase in patients reporting a “good” service. Additional salaried GPs and nurses are also associated with an increase, but not to the same extent. Yet additional “direct patient care staff” are not associated with any increase.’ 

The benefits brought by additional GP partners have major implications for future government policy – which we will explore in more detail in Chapter 15.  

Respondents to the survey were clear that an appointment with a GP improved access more than an appointment with another member of staff, unless the presenting complaint was specific to, for example, a physiotherapist or a specialist mental health worker. One GP in the north east says: ‘Pharmacists needed a lot of supervision and training but are not very effective. For example, I do 90-100+ medication reviews each month whereas our aligned pharmacist can only do 16 max per month. Queries slow to answer and lots of checks back and forward with GP.’ For this GP, even the more ‘useful’ roles offer limited access benefits: ‘One extra GP partner in the practice could do the work of three to four ARRS staff roles themselves.’ 

A number of respondents referenced the workload implications of supervising ARRS staff, which has an effect on access, notably to GPs.  ‘With regards to all ARRS except GPs and pharmacists, they are lovely members of our team and I value their contribution, however they increase workload overall,’ says one GP in Sussex. ‘They cannot hold the complexity that GPs do, tend to over investigate… dilute continuity of care and are overall inefficient compared with GPs. This is not a negative comment on my ARRS colleagues’ abilities… but their roles aren’t right for undifferentiated first point of access GP care.’  

So while some roles are helpful in terms of patient care and access, there are opportunity costs involved too. First, as the Cogora workforce report made clear, PCNs struggle to hire the more popular roles, and sometimes recruit less sought-after staff to ensure they use their budget. Second, and on similar lines, the more useful roles tend to be in greater demand across the NHS and not just in general practice – the Cogora paper found recruiting pharmacists to general practice had a negative effect on community pharmacy. As one practice pharmacist in Northampton puts it: ‘ARRS physiotherapists, social prescribing link workers, paramedics and pharmacists when combined significantly increase access to care in general practice. It does however reduce access to the services they formerly worked in. The ARRS scheme is very useful, but it desperately needs to have clearer defined access and accountability.’ 

Third, and maybe most important, the workforce paper found the availability of funded staff had led to GPs being out of work. Practices facing a funding squeeze are more likely to hire funded staff even if they may not be as effective. There is often also a lack of premises space to accommodate ARRS staff. This can affect the number of GPs employed, but also the number of face-to-face appointments – which the IfG found was a significant factor in patient satisfaction (see case study). 

Structural issues with ARRS 

The structure of ARRS also impacts how the scheme can support access, primary care staff say. ARRS staff are employed by PCNs, not practices, and the way this works can differ between PCNs. A staff member might be based full time at one site, such as a hub, or a single practice that carries out the extra work required under the PCN contract. Indeed, some PCNs comprise just one practice, which makes the process of recruitment simpler.   

For most PCNs, though, ARRS staff work sessions for different member practices and in such cases practices may not see the benefit in terms of improved access. One practice manager in Leeds says: ‘Those working solely for one practice, in practices are invaluable.’ But, she adds, for those that work across practices, ‘we don’t know what they are doing’.  

This issue of shared staff was a major theme among survey respondents, who said it had an effect on the continuity of care practices were able to provide. ‘The problem with the ARRS is that each practice within the PCN has different needs.’ Says a Luton GP. ‘When the PCN needs to be a separate entity, then ARRS staff are shared between five practices and you often get poor continuation of care.’ Dr David Coleman, a GP in Sheffield says: ‘We have one ARRS GP in our PCN, but they are not based at our practice so no impact on access.’ 

ARRS Salaries  

Respondents also spoke of issues related to ARRS salary levels, which could be too high or too low, depending on the role. The salary for GPs under the scheme has been considered inadequate, with one respondent saying it is ‘difficult to employ a GP for the provided money’. A practice manager in Cambridgeshire says ARRS GPs are ‘not fit for purpose’. They add: ‘Funding is not enough to cover a salary and it will not solve the current unemployment crisis for GPs. Unfortunately, this will only be resolved by additional funding direct to practice to allow us to afford to employ them directly.’  

Another practice manager in Hertfordshire says: ‘The reimbursement doesn't cover the amount of sessions needed across PCN for equity so it is not having the impact it was meant to.’ 

The amount PCNs can claim for salaried GPs increased to £82,418 in 2025/26 from £73,113, which was the bottom of the salaried GP pay range. Despite this uplift, the salary still falls into the lower quartile of the range. 

For other roles, practices consider salaries too high. One GP from Devon says: ‘We use our ARRS staff for helping to provide holistic care, but they are overpaid compared with non-ARRS staff.’ A practice manager in Cambridgeshire adds: ‘Physio is helpful, care coordinators give additional admin support, but I do not agree with the pay range being higher than the practice team.’ 

As Cogora’s workforce report noted, the ARRS has also left practice nurses feeling insecure – especially with the introduction of nursing associates. Comments from practice nurses this time round included: ‘Nursing associates are great but make me feel insecure in my role’, and even more starkly: ‘Practice nursing has been left out in the cold.’ 

The main demand among respondents, however, was for funding to be with practices rather than PCNs, with dozens of comments along these lines.  

One GP in Gloucestershire says: ‘We have one day a week of an ARRS GP. This is helpful but would be better if funding directly to practice for this. We have no PCN nurses. GP assistant role has been good for us but again – why not just fund practice directly for this?’ 

A former PCN clinical director in Derbyshire agrees that money should be invested practice: ‘There are limited benefits to the ARRS, but we are duplicating management costs. This money would be better used and we would see more access if invested directly into the practices.’   

There can be a perception among the public that GPs are overpaid, and negotiators on the BMA’s GP Committee have often spoken in private to sister title Pulse about a reluctance to provide funding to general practice as a result of this. In a possible bid to counter this narrative, GPC England has floated the idea of the Government funding all costs for salaried GPs, as part of the wholesale renegotiation of the GMS contract in England. Negotiations should be taking place over the next couple of years for a likely implementation by April 2028, and this proposal is likely to be a major element of them.  

Commercial partner of this white paper: General Practice Solutions