Another issue raised is the usefulness of ARRS staff who were brought in to increase access. It is still too early for long-term studies on the effectiveness of the scheme but a research paper, accepted for publication by the BJGP, found that there was a small increase in both perception of access and patient satisfaction associated with direct to patient ARRS roles.
These increases equated to around 210-350 (0.7%) more patients who were able to make appointments for each FTE ARRS role employed in a typical PCN (30,000-50,000), and 240-400 (0.8%) more patients satisfied with their care. The average number of FTE ARRS roles per 10,000 registered patients was 2.91, it added.
But for many GPs, even established staff are often not effective in easing workload, especially as they may need GP support in consultations. One GP partner in Salford says: ‘Apart from pharmacists and perhaps physios, I feel the ARRS funding has been a massive black hole that swallows huge amounts of GP funding for roles such as social prescribers that make little difference to workload.’
Others say ARRS staff can often increase workload. A GP partner in Warwickshire says: ‘I don’t want an advanced care practitioner on a high salary seeing a patient every 15 minutes for a single issue when I’m still legally responsible for them even though I’ve not seen their patients.’ The partner says the PCN-employed ACP is very competent, but ‘can’t prescribe and asks to review five patients a day with a GP’, adding: ‘I want a GP who can deal with complex cases, triage effectively, see non-differentiated patients safely.’
Another GP in a deprived area agrees: ‘ANPs are helpful but can often add another step to the management of a patient. Although a GP appointment can be more costly, it can mean fewer appointments are needed to sort out a problem, so money can be saved in the long run.’ The capabilities of ARRS staff are not uniform.
Furthermore, it is misleading to suggest these new staff are ‘free’ for practices. The funding for the ARRS doesn’t go directly to the practice, but to the PCN. A survey by sister title Pulse PCN of 276 GPs who have a say in their PCN’s decisions, found a mix in how ARRS staff are distributed across a network’s member practices.
And in exchange for this funding, PCNs – through their member practices – have to take on more work, such as enhanced care for care home residents. A practice manager in Yorkshire says: ‘We do have access to some ARRS staff including ANPs and paramedics. But in our view the vast sums spent on the ARRS care home team vastly outweigh the need – in cost terms, the money is wasted and would be better spent on our wider patient population by practices rather than PCNs employing GPs through core funding.’
The nature of the ARRS funding also means staff may not have the same commitment to a practice and, being part of the PCN, are less likely to be truly embedded in the practice.
A nurse team lead in the north of England says: ‘ARRS staff seem to be unaware of the QOF [Quality and Outcomes Framework, a scheme that incentivises practices to achieve set clinical goals] and its impact on practice finances. This makes the nurse team feel demoralised as we have to chase information to achieve QOF and bring in money. [ARRS staff] are less likely to be impacted by a poor QOF achievement as they’re not paid by the practice.’
A November 2024 study from London South Bank University supported these findings. It concluded: ‘There was positive impact on workloads from ARRS roles working in original scope, for example pharmacists’ medicine reviews. However, any benefit was offset by the increased workloads created by those new to general practice and/or working outside of traditional scope.
‘This ranged from a lack of resources to provide the support those new to primary care require to practise safely, the expectations of others that [practice nurses] will fill the gap in support and teaching to directly safety netting the work of others. There was a lack of consultation regarding a major workforce change, leading to feelings of devaluation. There are some significant equity issues highlighted particularly around pay and opportunity.’
Another recent study, published in the BJGP in December, found that ARRS has the potential to reduce prescribing rates in primary care. It looked at the general workforce minimum dataset and NHS Digital datasets across more than 6,000 practices, analysing their activity between 2018 and 2022.
It found that the use of ARRS staff was ‘significantly associated’ with lower prescription rates and higher patient satisfaction. The lower prescribing rates were particularly seen in mental health medications.
They said: ‘The lower prescribing rate could be attributed to the strong emphasis on adherence to guidelines in the training of advanced practitioners, and to the availability of a wider range of forms of help, which may reduce the need for prescribed medication. This is particularly consistent with the employment of a high number of clinical pharmacists.
‘By providing more time with a broader care team, ARRS staff may improve satisfaction, especially for patients with ongoing health conditions requiring regular monitoring and coordination.’
This implied that investing in ARRS roles, especially those supporting mental health and long-term conditions, may help to reduce prescribing and increase satisfaction, the authors said.
There is no doubt that the ARRS has been a game changer for general practice. Success of the various roles under the scheme it is not uniform and more recent additions will need further analysis as will the scheme and its efficacy as a whole. But the size of the endeavour will not be easily unravelled so while PAs are in a precarious position its not quite game over for the scheme as a whole.
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