Additional roles reimbursement to primary care networks: an uplift or downfall of general practice partnership?

Introduction

In the UK, the general practice (GP) partnership model that pre-dates the NHS is based on self-employed general practitioners (SeGPs) as dedicated medical doctors and highly committed business partners to deliver cost-effective primary care.¹ Today, the partnership model remains a cornerstone of UK healthcare provision, and its value is acknowledged.¹ Success of the GP partnership model relied on NHS payments, through the then clinical commissioning groups (CCGs), which commissioned GP services. The NHS payment ensured optimal running costs, and, most importantly, appropriate overhead payment. However, SeGPs continued to suffer inadequate funding,² and remuneration could not be made in line with the new agenda for change. This led to the experience of staff being overworked and of low morale.³ The birth of primary care networks (PCNs), which was followed by the introduction of the Additional Roles Reimbursement Scheme (ARRS), was aimed at improving primary care.⁴ In this article, we analyse the effect of ARRS, in the hope of eliciting the critical thinking required for the future of GP partnership.

ARRS and its impact on GP practices

The ARRS is an automatic funding stream for any established PCNs comprising 30 000 to 50 000 patients. It was implemented in 2019 to support recruitment and employment of non-GP health professionals for service provision of the directed enhanced services (DES).⁴ The intention was to increase non-GP health and social provider capacity, with the ultimate aim to solve the GP workforce shortages.⁴ In anticipation of increased complex health and social needs, the reimbursable roles under ARRS increased from the original six to the current 19.⁵ For the purpose of this analysis, GP practices are categorised based on the following patient list sizes:

1. Giant-sized practices: ≥30 000 patients;

2. Large-sized practices: ≥20 000 to 29 999 patients;

3. Medium-sized practices: 10 000 to 19 999 patients;

4. Small-sized practices: 5000 to 9999 patients; and

5. Micro-sized practices: ≤4999 patients.

To enhance the clarity of the analysis, micro-sized practices and giant-sized practices that are on the extreme of the continuum of GP practice sizes are used for comparison and to elicit contrast for the purpose of discussion.

The ARRS guidance stated the condition that ‘reimbursement through the new ARRS will only be for demonstrably additional people’.⁵ This principle of ‘additionality’ assumed that core practice staff were not able to fulfil the PCN DES contract. The introduction of ARRS was therefore to recruit new non-GP individuals to complement core GP staff work. In the context of understaffed and overworked GP practices, presumably the ARRS scheme would boost staff morale.

While the principle of ‘additionality’ in the Network Contract DES Specification must be observed,⁶ clinical pharmacists in GP and Medicines Optimisation in Care Homes Schemes were given the privilege to transfer across as PCN pharmacists. Time was even given for the migration, so that those who failed to migrate by 31 March 2020 had a second opportunity to do so between 1 April 2021 and September 2021.⁶ ARRS was, therefore, a good opportunity for GP practices, or the then CCGs, to transfer their employers’ responsibility to the PCNs. Giant-sized GP practices that could establish themselves as one single PCN seized the opportunity to quickly assign the original salary budget to the PCNs via ARRS. The ‘demonstrably additional people’ rule had financially benefited SeGPs from any giant-sized practices. Through the ARRS, they could easily afford to give a pay rise to core staff to increase staff morale. By using the same strategy to benefit from the ARRS funding, additional staff could be employed to replace certain GP role functions to relieve the workload of core staff. Unlike their giant peers, smaller-sized practices usually operated with a group of GPs supported by practice nurses, phlebotomists, and non-clinical administrative staff.⁷ They were not likely to have any pharmacists to transfer across to the PCNs. They, therefore, stayed peripheral to the initial benefits of the ARRS.

Smaller practices being part of their PCNs continued to take up additional DES work, but without the benefits of extra PCN ARRS funding. They could never mirror their giant peers in their pay scale of ARRS, which followed the new agenda for change.⁸ In fact, salaries of core practice staff remained much lower than PCN peers. The pay gap is further enlarged by reimbursements for travelling costs and longer protected learning time for ARRS staff.⁹ The fact that these benefits were alien to core practice staff, including the SeGPs themselves, meant the ARRS risked lowering core staff morale and threatened staff rentention.¹⁰ As part of the backdrop of these ongoing disparities in staff costs and employment benefits, there was the recent announcement about increasing core contract funding to ensure a 6% pay rise for core practice staff.¹¹ By default, employer on-costs (national insurance and pension) would follow the 6% rise. However, the increased core contract funding did not include the salaries of the SeGPs. In this regard, the increased funding was not enough to catch up with the escalated running costs, let alone ensure a 6% pay rise. In order to close the pay gap between core practice staff and PCN staff, it is not an exaggeration to say that many SeGPs are no longer just overworked and underpaid, but are also very likely to be out of pocket.¹¹ In order to survive, even when ARRS staff remained far from being able to complement certain GP practice role functions,⁹ many smaller practices were left with no choice but to discontinue employing GPs, giving rise to the phenomenon of unemployment among GP locums.¹²

As mentioned, the list of ARRS has expanded to also include care-coordinators and GP assistants.⁵ These two role responsibilities mirrored the care-navigating and administrative functions of core practice staff. The introduction of these two roles again benefited giant-sized practices in that the recruitment would simply help fill any vacancies of a single-practice PCN. In smaller-sized practices, expanding the ARRS list to include care-navigators and administrative staff had a different effect. It unavoidably instilled the negative atmosphere of staff redundancies at practice level, and the consequential fear of possible disbanding of the GP partnership model. These heightened the already low staff morale grounded in pay disparity.

Another employment issue relates to the appropriateness of PCN staff. As we know, the emphasis of recruitment is on economy of scale rather than individual care needs. The profile of PCN staff that may be fit for purpose for one single-practice PCN may not necessarily be suitable for the needs of PCNs comprising several smaller practices. Take, for example, a PCN pharmacist who is capable on specific items, and would be able to half-complete a structured medication review (SMR). Pharmacists who lack a wide breadth of clinical expertise and engaged in incomplete SMRs may be deemed adequate for giant-sized practices. This is because the incomplete SMR by the pharmacist is expected to be followed up by nursing health professionals or a GP. While such patient care upholds the ethos of collaboration within a PCN, it delays the care. In the case of smaller-sized practices that already have a GP or a non-medical prescribing nursing staff member to complete SMRs in one single face-to-face patient encounter, pharmacists with limited clinical knowledge and skills would still gain employment in smaller-sized practices’ PCNs. This would be the case even if the employment of the pharmacist meant destabilising the existing work pattern of core staff and a shift from holistic care to compartmentalised care, simply because, as part of a PCN, every GP practice is expected to collaborate.¹³

Further issues surrounding employing new people through ARRS is the allocation of working hours to each practice as PCN members. To observe fair and equitable distribution of ARRS staff, allocation of hours is likely to be based on patient list size. Take one full-time equivalent (FTE) in a 30 000-patient PCN, for example. On a weekly basis, an individual is likely to spend 37.5 hours in a giant-sized practice, 18.8 hours in a 15 000-list-sized practice, and 3.1 hours in a 2500-list-sized practice. Based on this analysis, it can be appreciated that giant-sized practices are not affected in the slightest, but smaller practices, especially the micro-sized, are severely impacted. Not only is it impossible to have anything done in a short 3-hour week, but also, due to shorter attachment, job satisfaction and organisational commitment of these non-GP PCN staff are lower and quality work is less likely to be established.¹⁴ The negative impact then filters down to core practice staff, leading to feelings of frustration for having to continuously piece together the fragmented care left by PCN peers.⁹ This exacerbates the lowered staff morale, which affects patient care and the consequential decreased patient satisfaction.¹⁵

Conclusion

PCNs were established on the basis that GPs would take control of their direction, and the introduction of ARRS was with good intentions to address GP appointment oversubscription.¹⁶ Our analysis indicates that this reassurance might have materialised, but is somewhat limited to giant-sized practices, which are large enough to form single-practice PCNs. Smaller GP practices as a small part of a PCN are experiencing the detrimental effects of ARRS (Box 1). This includes but is not limited to disparity in funding allocation between PCNs and individual GP practices, and the increasingly fragmented care due to inadequate work–hour allocation of the skilled ARRS, and irreplaceable GP role function by PCN staff. These further exacerbate the already low staff morale within overworked and underfunded GP practices. While quality care may not be associated with practice size,¹⁷ the short span of control in micro-sized practices allows for more effective human resource management, which can be translated into high-quality primary care.^18,19 There is already evidence that smaller-sized practices, especially the micro-sized ones, when operated based on the existing core team, were better at continuing care,¹⁶ and had higher patient satisfaction.¹⁹ In addition, smaller-sized practices, especially micro-sized, are economical to operate. When SeGPs own the premises, the rent is usually no more than 1/10th of that in the giant-sized practices. Ensuring sustainability of GP partnership in smaller-sized practices is therefore critical. It may be time for funding that was filtered from practices to support the PCNs to be returned to individual practices¹⁶ to take control in employing staff they deem appropriate (Box 2). Otherwise, in the pursuit of using ARRS to uplift GP practices, the GP partnership model of smaller practices risks becoming merely a proud moment of history in the primary care service, as opposed to being continually enhanced as was initially intended by the ARRS.

Box 1.

Unintentional harm by ARRS

Additional Roles Reimbursement Scheme (ARRS) risk disrupting holistic care and delaying care. ARRS hours based on patient list size, when allocated to smaller-sized practices, led to unnecessary duplication of efforts, ineffective working, and fragmented care. ARRS funding widened the disparity in payment of staff salaries between core practice team and PCN staff. Employment benefits to PCN staff risk introducing unfair employee treatment to core practice staff. The ARRS expansion to include care-navigation and administrative functions has unintentionally created an ominous atmosphere of looming redundancies for core practice staff.

Box 2.

Strategies to address the unintended harm

Reallocate primary care network (PCN) funding to individual practices to ensure fair treatment and payment to core practice team. Individual practices receive adequate funding to regain the autonomy to ensure appropriateness in staff employment for holistic patient care based on effective healthcare costs. Individual practices, based on adequate funding, to employ GPs so that timely medical care is provided to ensure patient safety and increase patient satisfaction.

Provenance

Freely submitted; externally peer reviewed.

Competing interests

The authors have declared no competing interests.