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As the financial year comes to an end, PCNs are bidding for the additional roles underspend. We look at the scheme’s merits and what might come of the end-of-year rush. Emma Wilkinson reports
Speak to PCNs about local funding issues for the additional roles reimbursement scheme (ARRS) and you get a mixed bag of responses. Some have spent their slice or more. Some cannot get the staff even if they want to or can only access staff not eligible for funding. Some have regular conversations locally about how to use the money. Others have had limited communication with their integrated care board (ICB), despite trying.
This variation is also highlighted by the results of our Freedom of Information (FOI) investigation on the current underspend and plans for its allocation, which found ICBs taking very different approaches.
Our exclusive uncovered that at least £64m of the £1.02bn available for 2022/23 is currently forecast to go unspent and less than a fifth of that sum is set to be allocated to PCNs. Once again, money that was destined to be spent in general practice will seemingly be lost to the sector.
Yet GP leaders have warned clinical directors (CDs) to spend up in this final year of the contract or risk losing it. ‘Do all that you can’ to recruit and spend that money because once it’s embedded in the system it is likely to be retained, Dr Richard Vautrey, former chair of the BMA GP Committee and CD of Central North Leeds PCN told Pulse PCN at the end of last year.
The FOI responses on ICB underspend do suggest a significant improvement on the first two years of the ARRS scheme, when Pulse revealed that up to 40% of the available funding went unspent.
Figures from NHS Digital published in January show networks have hired nearly 4,000 pharmacists through the ARRS alongside 2,448 care co-ordinators and 2,345 social prescribing link workers.
But as Ben Gowland, director at think-tank Ockham Healthcare, pointed out in response to the figures, ARRS is by far the biggest part of PCN funding, so any underspend ‘represents an underspend against the promised investment in general practice’.
He also has concerns that PCNs are now starting to see the impact from the move from more primary care-focused CCGs to the ‘more distant’ integrated care systems (ICSs).
In theory, when funding through the ARRS scheme – the part of the network DES in which PCNs are funded to hire non-GP staff including pharmacists, physiotherapists, paramedics and (most recently) digital transformation leads – goes unspent, ICBs are able to invite PCNs to bid for the surplus, as was the case when CCGs were in charge.
Yet in reality, the information provided from ICBs under the FOI act suggests that with a matter of weeks to go before the end of the financial year, only 13% of the estimated underspend is set to be released back into primary care.
The small proportion of the money that will be reallocated, according to our data, will be limited to 14 ICB areas. Any unclaimed funding remains in the NHS England coffers.
In all, 36 ICBs responded to our request for information and only 21 of those are inviting PCNs to bid for money at all. One additional ICB received no bids despite inviting them.
At one end of the scale, Hertfordshire and West Essex invited all 35 of its PCNs to update their workforce plans, and is expecting to reallocate £1.7m, despite recording an underspend of just £54,647.
Likewise, Birmingham and Solihull ICB has approved 19 PCN bids and is planning to allocate £1.3m of its £1.7m underspend. Devon ICB approved the most bids of those who replied, granting £1.2m in extra cash for staff, despite estimating it will underspend by £800,000.
It became apparent that there is significant variation in the way systems are interpreting the PCN DES. Surrey Heartlands ICB did not open a formal bidding process and instead suggested funding should be reallocated by bringing forward planned ARRS recruitment.
Ultimately, in this scramble to make sure money is spent, there are fundamental flaws in the ARRS funding stream, say PCNs.
Putting in a bid – if that is an option – is one thing. Being able to fill the roles in time is quite another. Difficulties with recruitment, rigidity of the permitted roles, and the last-minute panic leave little room for long-term planning. And after the ‘worst ever’ winter the health service has seen, PCNs have little headspace to think strategically.
Ruth Rankine, director of primary care at the NHS Confederation, points out: ‘While many of our members have been able to access the ARRS underspend and recruit more staff, the funding is short term and has often come too late to have maximum impact this winter, which has been a theme across the NHS.
‘While any additional income in primary care is welcome, this still doesn’t address the historical issues that primary care has had with recruitment for certain roles.’
She adds: ‘Targeted support for those areas would be welcome, along with innovative approaches to addressing the capacity gap.’
Beccy Baird, senior policy fellow at The King’s Fund think-tank, says variation in the ability to recruit is a real problem for PCNs and she would rather see ICBs offering support to PCNs to overcome those problems and help them spend the money in the longer term as well as getting the roles properly embedded.
In some areas, she says, recruiting pharmacists is really hard. In others, mental health workers are particularly difficult. One size does not fit all and support from the ICB is key, she adds.
‘If you can’t recruit pharmacists, who can you recruit and what can we help you with? How are ICBs going to make an impact with this money, because it’s really important to everybody that we use the money.’
Variation in ICB support
If PCNs are not submitting bids, ICBs should be asking why, she says.
It’s not just about barriers to recruitment. There are other areas that PCNs are grappling with – such as having enough estate to house any new staff. There is also the issue of having the time to do the recruitment, training, supervision and integration with existing teams.
‘For me, that’s an ICB job – to work with PCNs and say what would it take, what do you need to be able to recruit these roles. They’re important, but just having them isn’t enough. You also need to be able to implement them properly.’
This should be a collaborative process between the ICB and PCNs because ‘no one wants that money lost, everyone wants to improve GP access’, she adds.
That support for primary care in ICBs is massively variable, she explains. Some areas, such as Sussex, have invested in primary care infrastructure but in other areas it simply does not exist.
‘How the ICB will support primary care is a wider question than just the ARRS roles but fundamental,’ she adds.
Five ICBs are currently or will soon start inviting PCNs to bid, including:
Northamptonshire ICB reported it had not had any applications for additional ARRS funding.
At least eight ICBs estimate they will have no underspend for 2022/23, including:
Derby and Derbyshire ICB also forecasts no underspend, but has reallocated funding regardless.
Dr Sarit Ghosh, CD at Enfield Unity PCN in north London, is among those who have had limited communication on the underspend. He fears the money will just be lost.
‘We have had no direction on this from the local system. We suspect the money will be clawed back by the centre,’ he says.
Dr Brigid Joughin, CD of Outer West Newcastle PCN, says in her ICB of North East and North Cumbria there is a large underspend and they have been asked to submit bids with no advice about a limit.
The main problem is that it’s so last-minute.
‘There are few roles that we can get in post within three months. It is very frustrating.’ She adds that it could be used to bring forward ARRS they have budgeted for in the following year.
‘But as it’s unlikely we can get anyone started before April, I’m not sure we can use any of it,’ she says.
One option the PCN has considered is to ask a voluntary organisation it already uses for link workers if it can redeploy someone to get an ‘extra three-months’ worth’ but that is probably all it can do.
It has been suggested there is likely to be an underspend again next year. ‘So we could employ on top of budget for next year and hope there will be underspend again to continue that additional role into the next year.’
As previously reported by Pulse PCN, some areas feel limited by the roles on offer and would prefer to hire other staff, including nurses. One CD for a Dartmoor PCN noted: ‘We see a lot of practices – particularly smaller practices – say they can’t use an ARRS role and would rather opt for a doctor or nurse. That’s probably where you’re getting underspend.’
Dr Nicholas Jackson, CD at Selby PCN in North Yorkshire, says ARRS underspend is a constant source of angst for him and the PCN manager.
‘The constraints on the staff groups and the recruitment environment mean that it has been almost impossible to come anywhere near using our allocation.
He adds: ‘Locally, I think there is one small PCN who has done so and the rest of us are watching tens or hundreds of thousands of pounds going back into NHS England baselines.’
Earlier this year, Dr Jackson approached NHS England centrally to ask whether the underspend could be released to fund winter resilience schemes, because ‘we predicted both a really difficult winter, and a reduction in the sums available to support winter access due to the pay award’.
‘That fell on deaf ears but seems a very short-sighted decision now,’ he says.
Humber and North Yorkshire ICB did not disclose to Pulse PCN its total underspend on ARRS roles but did say that one bid for £40,000 had been reallocated.
Dr Jackson is frustrated that they have not been able to access ARRS underspend for any other purpose. ‘If we can’t recruit to the ARRS staff groups, the funds are lost. We have recruited to roles outside of ARRS which are really important and adding value, for example a data analyst, an urgent care manager [who is a] nurse and an advanced nurse practitioner but because they are not in the additional roles scheme we have had to fund them ourselves and at increased risk.’
He adds: ‘We could have recruited advanced clinical practitioners as well, but because the candidates were from a nursing background rather than physio, pharmacy or occupational therapy, we weren’t able to fund them through ARRS. Some high-level skills and experience were denied to general practice at a time when we need them the most. Relaxation of the constraints on ARRS would be really welcome,’ he says.
The experience of Dr Geetha Chandrasekaran, CD of North Halifax PCN, highlights the varied approaches ICBs are taking.
‘We have a good relationship with our ICB and have frequent updates on ARRS underspend,’ she says. ‘We have not needed to bid yet and have not explored wider than just our place. Last year we tried to bring forward roles and look at place-based projects to enhance patient services.’ Her general view is that there has been no resistance to making use of any underspend and any projects PCNs put forward.
In Greater Manchester there has also been a collaborative approach, says Dr Faisal Bhutta, joint CD of Hyde PCN. Hyde has used its ARRS allocation and has a system to make use of underspend, he explains.
‘We have agreed other PCNs can put a business case to use this money if the original PCN can’t use it. There is a panel in Greater Manchester that decides,’ he says.
System-wide approach needed
Ms Baird says Manchester shows the kind of conversation that should be happening everywhere. She wants to see more collaborative engagement instead of PCNs having to work it out for themselves.
‘Implementing these roles is really difficult. In a trust you would have teams of people thinking about deployment and organisational stuff. Where’s the support for general practice to do this?’
‘At the moment there’s too much of a tendency to say “you’re independent contractors, just crack on”. I’d like to see more co-ordination across the ICB and ICS at place level but that requires people with the knowledge of general practice.’
It takes a system-wide approach to solve the problems. The resistance to funding nursing roles out of the ARRS comes from nervousness at NHS England that this would exacerbate nursing shortages elsewhere, which is understandable she says, but must be resolved.
The same was seen with mental health workers. Community mental health trusts were nervous about workforce shortages so were resistant to helping PCNs recruit under the joint scheme.
But with support from the wider system, these challenges can be overcome and that is what is missing for many PCNs, she says.
She points to the example of Bradford, where there was an ambulance paramedic shortage. To improve retention, they set up rotational posts through primary care and the ambulance trust. It is that sort of wider programme that PCNs need to overcome capacity and recruitment issues, she says.
‘It was a win-win for everybody. It kept people interested and motivated and gave them time off the ambulances and helped to develop their skills in long-term condition management because they were working primary care.’
Dr Emma Rowley-Conwy, CD at Streatham PCN in south London, said they have no significant underspend at place level but believe there may be underspend in the wider ICS. ‘We have been asking how we access this for some time, but still have no clear answer.
‘I think the issue is with finance and contracting as we had a spreadsheet a month or so ago that purported to be our ARRS spend and projected a 75% underspend, which all PCN CDs confirmed was absolutely not the case because we are projecting to only underspend a little.’
One challenge for CDs is that it is difficult to land a human resources budget on spend because you can’t predict staff leaving in the final month of the year, or vacancies you can’t recruit to, or spend on temporary members of staff, she points out.
‘You are not allowed to pay overtime to recruited staff. Even if we ask our third-party providers for additional capacity in the short term, they cannot recruit or find staff on this basis,’ she says.
Overall, it is a muddle, she explains. ‘Last year any underspend was allocated on basis of PCNs projecting an overspend, but we did not bid – the NHS England guidance was not followed. We never knew what the total spend was across the ICS and what any underspend was. In the last financial year, member practices were prepared to take a financial risk of up to £10,000 each of overspend. Then at the last minute we were given the overspend by the CCG,’ Dr Rowley-Conwy adds.
Yet those circumstances no longer exist. ‘Practices can’t do this now because of the financial pressures of staff pay and utility bills. They aren’t prepared to take the financial risk,’ she says.
Spending quickly is really difficult, agrees Ms Baird. ‘Again, that’s where I’d like to see systematic planning and conversation, whether that’s formal or not, so rather than a really complicated bidding process where someone has to write a thesis to request a position, there’s ongoing dialogue across primary care, within a place, about where we’ve got underspend and what’s going on.
‘[This would] manage the overall picture for the ARRS money rather than relying on very stressed-out CDs to try to make all those decisions individually.’