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Five PCN CDs joined Pulse PCN editor Victoria Vaughan on Microsoft Teams to discuss how the additional roles reimbursement scheme (ARRS) is working in their areas
Dr Sarit Ghosh, clinical director (CD) Enfield PCN, north London
Dr Sajid Nazir, CD Viaduct PCN, Huddersfield, West Yorkshire
Dr Sachin Patel, CD Harness North PCN, north-west London
Dr Partha Ganguli, CD South Ribble PCN, Lancashire
Dr Monica Alabi, CD Titan PCN, Bedforshire
Victoria: Let’s discuss whether the ARRS is fit for purpose.
Sarit Yes it is fit for purpose because from an NHS England perspective, it’s to get primary care to employ a range of additional role staff in a funding model that ensures efficacy. So, from the NHS England perspective, it is an effective model. Is it the right model for primary care? I would say no. From a primary care perspective there are lots of complex reasons why it’s not the best model.
The NHS England view is: ‘We’ll give you this funding, you employ these staff, and everything will be hunky-dory.’ But actually, there’s so much governance involved. Recruitment and retention are a major challenge. When you recruit these staff there’s a lot of training and supervision needed to make them effective. That doesn’t lead to the outcome that we want – more access for patients, and better quality care. It may do in five to 10 years, with the right support and infrastructure at PCN level, but it’s not there yet. At the moment it’s not fit for purpose as a programme for primary care, but that doesn’t mean that with the right tweaks that it can’t be. And I think the new white paper, in terms of the integrated care system (ICS), has mentioned PCNs as key place-based stakeholders so I think there’s an opportunity to shape PCNs more to primary care’s needs, instead of [using them] just as an employment vehicle [via the ARRS].
Sajid Certainly the idea behind ARRS is good, and there are benefits from some of the staff that are coming through. But in terms of receiving these staff – whether it is training, employment, even space – we are struggling.
We have some providers stepping up to say they can provide these staff, others are employing them directly – and that’s even within one town. We have a different level of skill within one town, [and] I’m sure that’s replicated nationally. It feels [as if ARRS] was rushed through without much planning. But at the same time we maximised our ARRS last year, and you know, practices saw benefit from that.
Sachin I agree that if we’re looking at a population level across the whole system, and nationally, and we know that we’re facing a GP workforce shortage, and we’re never going to hit the Jeremy Hunt target of 5,000 extra GPs, we have to look elsewhere.
And actually ARRS is the right vehicle, but it sometimes feels like a Trojan horse. We’re given an opportunity with benefits and funding, but beneath that lies all the challenges of bringing a whole new workforce into general practice, which is ultimately what it is. There are massive benefits from having additional roles, but there are significant challenges. I think as CDs our task is to go with enthusiasm and encourage our colleagues that there will be future benefit from the additional roles, but also acknowledge it is a journey, and a clinical pharmacist or a pharmacy technician won’t come in knowing how to be completely functional within primary care, because it’s a new field for them.
Partha No [the ARRS is not fit for purpose]. I feel that GPs have been adaptive from the first time QOF came in, and all the changes that happened in primary care. We GPs have adapted to that very well. And when this opportunity came for getting some workforce, we all adapted and used it to our benefit. I would say [the ARRS] was [done] in a hurry to just put some money to general practice.
Monica The management hasn’t been thought through. We recruited a PCN manager as soon as I took on the [CD] role. We couldn’t afford a full-time manager because [there isn’t enough funding allocated for management costs]. We are now recruiting a business apprentice as well to support her [as it’s a big task for which there isn’t enough resource]. The challenge for the ARRS is having enough management time to support the other people, to co-ordinate the roles, making sure the staff sharing agreements are in place, [and] the contracts, making sure that we can listen to their complaints. [Additional roles are]a whole industry, not something you can just throw into primary care and expect to be done, and expect the CD who’s resourced for one day a week to manage and understand it all.
Victoria: You’ve all mentioned the challenges of space, recruitment and training. Have any of you have found a way to tackle those in your PCNs?
Partha Yes, Covid has changed our way of working. We used remote consultations more. Our ARRS pharmacist is working part time from home, and part time from surgery premises. We are doing the musical chairs with our rooms better – but still we are struggling with estates at the moment.
Sarit Yes, the estate problem is interesting. As one of the largest PCNs in the country, and in London, we perhaps find it even more challenging. There are two factors with space – one, there isn’t enough, and two, it’s not in the right place. The challenge is, how do we provide an equitable service on a weighted list size basis for each of our practices? If practice one has no rooms, how do we give its patients access to an ARRS service?
That hasn’t been an easy conversation, but our strategy is to self-fund remote consultation suites. The plan is to have a big room full of lots of ARRS staff with GP supervision, providing a service to each of our practices on a weighted list size basis, because that’s the only way we can have a fair and equitable service with enough supervision to make it work.
That’s a while away because we will have to build, and to get that through NHS England governance took about a year, even though we’re funding it ourselves. We have to jump through lots of hoops to just get that model approved.
But I think that will set up other PCNs for similar things once we’ve done this. That’s the only solution we could find.
I’m not saying it’s the right solution [for everyone], but it’s the most effective one for us.
Sajid Covid possibly helped with the influx of staff because people were working remotely but now we’re finding they’ve not really integrated with the teams. The staff don’t know them very well. One example is the social prescriber who has been working remotely, but some practices are not referring [to her] because they don’t really know her. That’s an issue to consider with remote working.
Sarit Yes, people still have to go into practices to do face-to-face work, so it’s a blended model, you’re absolutely right.
And the other feedback we’ve had – and we’ve had relatively decent retention – is that people like working in teams. So, even though they’re working remotely, if they’re sitting next to some of their peers , that team building has a value as well.
Victoria: What about the training? How are you managing training ARRS recruits?
Sachin Training overall needs a substantial amount of planning to ensure there are suitable GP supervisors.
Our journey with additional roles started before the PCN came in because we were part of the NHS England pilot for clinical pharmacists to come into general practice. Our aim in our two PCNs was to build an academy that trained itself. I think that was probably the best thing we’ve been able to achieve.
Sarit We appointed two GP training leads, who take an overarching view of training and provide online training that they develop on a weekly or biweekly basis.
From a generic perspective, the bigger challenge is how to provide effective supervision on a regular basis, because that’s time consuming. There’s a physician associate (PA) preceptorship programme, which specifies how you deliver that. And again, that’s resource intensive but it comes with funding, so it is beneficial for people to use for PAs who are quite early in their careers and don’t have much clinical experience.
Victoria: PCNs varied in whether they managed to spend the ARRS budget. If you didn’t spend all your budget, can you elaborate on why?
Partha First of all, the challenge was time, waiting for the [details and the CCG criteria]. Then once we started the recruitment process, we didn’t get much response. We are up north and recruitment is difficult. We got one pharmacist and then the pharmacist moved out of the post, so we had a problem with retention. We looked for PAs and couldn’t get any of them into our network.
We struggled to attract appropriate candidates. Some were quite good but their banding was not [compatible with the requirements], and we would have had to put in extra money if we had to retain them and that was another issue.
There wasn’t enough support from our CCG because we said that whatever money was left over, we could use it in a slightly flexible way. And NHS England said: ‘You can’t do this. You can’t do that.’ We couldn’t get short-term pharmacy technicians or pharmacists because it had to be a long-term contract, the CCG said. We wanted to use [these staff] for our vaccine work but we couldn’t employ short-term with the extra funding we had. These were the problems we faced.
Victoria: If you did spend all your budget, how was that possible?
Sajid We were lucky in that, the year before, the very first year, we recruited a pharmacist. Most of our recruitment was not done by advertising, it was done by word of mouth. We had one pharmacist and then two and they enjoyed working with our practice as we gave them a good induction. We didn’t really need to advertise, so we currently have 10 pharmacists and one pharmacy technician.
[We focused heavily] on clinical pharmacists, although they’re doing different things. Some have little experience in general practice but we were able to use [our experienced pharmacists] to train them without disrupting service too much.
The other two staff we recruited are a social prescriber [and a first-contact physiotherapist. The social prescriber was] recruited [and employed] through our local authority. Our first-contact physiotherapist was employed through the local hospital trust, so we haven’t needed to advertise jobs yet.
Monica We also spent all [our ARRS budget, except in] the first year because we didn’t have time. We got our pharmacist in the first year, 2019, and our social prescribers very early, so we had a little bit of an underspend and that wasn’t given back to us, which was annoying, so we made sure that the second year we used all our money.
We are recruiting based on what we want as a PCN, so we’re very social prescriber heavy. There’s a lot of restriction on how you employ. We are very lucky, we’ve never struggled for staff. I put [the job ad] on my LinkedIn feed, on Twitter, everywhere. We’ve never had any problems recruiting. But there is a ceiling. We have to pay above and beyond for some of our staff, because we want to recruit the best, we don’t want to get people who we’ll have to be hand-holding. So that’s one of the challenges, this cap, and not going high enough for the best roles, and then not having enough in the pot to make up the gap.
Sarit London weighting only came into play recently, so [before that] we couldn’t compete with [posts in] inner London that were often offering more wages but we used all our funding.
We changed our strategy a bit. We’re pretty big. We’ve got 20 pharmacists, 10 PAs and a number of other staff, but we realised we couldn’t compete salary-wise, so we decided to give a better package, offering training. In the pharmacy team we have three or four senior clinical pharmacists who provide peer support and structure and that’s quite attractive for pharmacists. For PAs, we’re developing relationships with universities, so they attend for education when they’re trainees and when they qualify. That introduces them to primary care, so there are lots of strategies [apart from] salary that make you more attractive as an organisation.
Victoria: Do you think the ARRS will improve care?
Sarit Does ARRS improve care? It improves, potentially, access, which, in itself, will improve care. If a patient gets seen by an ARRS staff member, that could free up time for the GP to do some other work. But as we’ve said, these are very new members of staff, it will take time for them to develop to be effective as clinicians.
The pharmacists have improved care because previously GPs used to squeeze in audits and medication reviews and the effect was variable. With pharmacists, these are much more structured, so they look after high-risk medications and things like that a lot better. So I think that has improved.
Sajid Freeing up time for GPs to focus on specific stuff may improve care but it’s too early to measure the outcomes of some of the new roles.
Victoria: Will the ARRS reduce health inequalities?
Monica Yes, I think it will improve health inequalities. Maybe I’m saying that because we’ve been involved in the population [health] programme, which has worked well for us, particularly with our social prescribers. And taking the population health approach, I have seen the possibilities with the ARRS staff and being able to use them for patients who really need support.
Sarit The inequalities element is very complex. The ARRS in itself won’t, because I don’t think [additional roles are] really the solution.
[The solution is] much more layered. [ARRS] frees up time for us to focus on other things, but inequalities are about an opportunity engagement and many other things, so we need further discussion.
Sajid [I have a] slight concern that, if not all PCNs are recruiting, this [could] exacerbate health inequalities. Nicer places might recruit more staff and you may [find] people not wanting work in inner-city, deprived areas. Some parts of the ARRS have helped address health inequalities.
We have been doing local projects targeting various things such as diabetes where there have been various levels of quality. Some of our ARRS staff pharmacists are doing that work. Clearly, they will help but it’s quite complex.
Partha I believe in primary care that every little helps. If we are getting [people] working in our team, whether they are pharmacists, paramedics or PAs, this will free up time and improve access for patients. [That] reduces the inequality.
We are doing a population health management project at the moment where we are looking at a group of patients who have not been able to use the digital modes – those who are mildly to moderately frail, according to the Rockwood scoring. That has [brought us] resources that are available from the council to improve [their access to digital tools], and our social prescriber has played a pivotal role. This shows how we can eliminate an inequality.
If we can gear projects, [we can] use ARRS in the right way to address [inequalities].
Victoria: What would you like to see in the ARRS, to make it better?
Sarit I’d like to see more investment in infrastructure. And not just ARRS, this is for PCNs as a whole.
We need to invest as a system in management time, leadership time and clinical leadership time. All of that is really important as we’re going to be one of the building blocks of the integrated care partnership (ICP) and system.
Look at the vaccination programme. We achieved what many would say were miracles in getting so many people vaccinated, 75 million people vaccinated.
We can do a lot more but we need the tools to do it. With the ARRS we need a bit more flexibility, a bit more pragmatism, about how [it is] used.
I understand why NHS England has decided that if PCNs want to recruit paramedics and they are band 6 with no primary care experience, like the vast majority, they would have to train up to band 7 [via a mandatory rotational scheme with the local ambulance service] to attract the ARRS funding. But rotational schemes can be very difficult to co-ordinate, making those staff less attractive to recruit without a better support infrastructure. I can understand that the system doesn’t want a huge exodus of paramedics from ambulance services but a more pragmatic approach seems sensible.
We need a bit more voice at the higher levels, in terms of ICSs, which is happening but it’s taking a lot of work. For me, it means a lot of meetings and a lot of raising the profile of primary care to get heard at the big tables with the acute trusts. That’s going to be a challenge moving forward, for PCNs as a whole.
Sachin I’d like to see more flexibility on on the stipulated requirements on contracts for ARRS staff and the use of funds for training and supervision.
Sajid It would be good to have a greater level of independence at local levels. A lot of the rules are nationally guided but we could have local solutions. People have mentioned difficulties in recruiting certain staff and CCGs are very reluctant to go against national guidance. [It would be good to have] flexibility with recruitment roles, and funding if you needed more in a certain area, even outside London. Also, the PCN is given £1.50 core funding per registered patient to help with the support and running of the PCN but it’s not enough if you look after 20 staff. You need human resources, you need management, you need someone to look at a rota. That’s not really been thought about. I’m sure everyone’s doing more than the allocated time. We need more support. Once CCGs are disbanded, perhaps some of that [resource] can come into PCNs and we can use it.
Partha We need to realise that in the change scenario, when CCGs are being dismantled, there will be lots of extra responsibility coming to PCNs. Proper infrastructure and accountability are important and if, in five years’ time, when we are looking at using so many staff, [and] under one roof, [with] all the HR and everything else going around, there is a lot of management cost that is not taken into account.
The [PCN allocation] of £1.50 per registered patient is not going to change with time as the patient numbers are not going to increase that much. I think we are looking at more staff, to be managed in the same amount of management and CD time, which [will] not [be] possible. We are looking at lots of goodwill and lots of input, which are unpaid and might not happen.
That might be one of the pitfalls, so I think we need to put more resources there and be flexible. We need to innovate and use the recruitment funding to maximise our potential for benefit according to the local need.
Monica True innovation is what we need. We have to allow PCNs to be entrepreneurial and to be able to
We understand that the NHS cannot fund everything [on] our wish list. For instance, if we wanted to provide services in our area that are paid for, such as an allergy service (as we have the expertise). Innovation has not been as encouraged in my area as I would like it to be.
Generating income will be very important as we go forward, otherwise we will implode.
We need an estate strategy. I’m employing people over and over and over again and I’m making them work flexibly from home. We’re hot-desking. [We need funded] management time, like everybody said. [We need to] really encourage innovation and not stifle it. [We need] headspace to be truly part of the ICS partnership board and I worry that primary care will just be a tick-box in the ICS partnership minutes rather than genuinely involved.