Integrating additional roles into primary care networks

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Overview

  • The Additional Roles Reimbursement Scheme (ARRS) was introduced in England in 2019 as a key part of the government’s manifesto commitment to improve access to general practice. The aim of the scheme is to support the recruitment of 26,000 additional staff into general practice.  

  • This represents a huge scale of ambition and requires the implementation of significant and complex change across general practice. While primary care networks (PCNs) have swiftly recruited to these roles, they are not being implemented and integrated into primary care teams effectively. 

  • Our research focused on four roles — social prescribing link workers; first contact physiotherapists; paramedics and pharmacists — to examine the issues related to the implementation of these roles, looking at the experiences of working in these roles and of the people managing them. 

  • We found a lack of shared understanding about the purpose or potential contribution of the roles, combined with an overall ambiguity about what multidisciplinary working would mean for GPs. Successful implementation of the scheme requires extensive cultural, organisational and leadership development skills that are not easily accessible to PCNs. 

Read our report, Integrating additional roles into primary care networks

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Background

The King’s Fund has a long history of supporting and developing teams working in and across health and care systems, and more recently we have been working with general practices and PCNs as they develop team-based models of care. Drawing on this experience and expertise, we developed this project to explore the factors affecting the successful implementation and integration of ARRS roles within general practice, focusing on the experience of staff working within these roles, to explore what might be done at national and local level to address any challenges.

Our research

This work focused on four ARRS-funded roles: social prescribing link workers; first-contact physiotherapists; paramedics and pharmacists. We selected these roles for several reasons: they have been covered under the ARRS for the longest period; they represent a mix of both clinical and non-clinical roles; and they represent a mix of employment models. We carried out focus groups and semi-structured interviews with professionals from each of the four ARRS staff groups and interviewed stakeholders from relevant national bodies and PCN clinical directors and managers. 

This work was commissioned by the Department of Health and Social Care and funded by the NIHR Policy Research Programme (grant number NIHR200702) as part of the Partnership for Responsive Policy Analysis and Research (PREPARE), a collaboration between the University of York and The King’s Fund for fast-response analysis and review to inform the Department of Health and Social Care’s policy development.  

Our findings

  • We found that PCNs are in their early stages of development and in many cases lack a clear, shared overall purpose and strategy or a clear, shared vision and buy-in for the ARRS roles. Many PCNs do not share a team identity, and this makes deploying network-wide staff in a supported way very complex when there are different strategies, different cultures and different identities to be managed.  
  • The confusion around strategy is also linked to a lack of agreement about whether the roles are primarily intended to deliver the requirements of the PCN contract or to undertake what might be considered the ‘core’ work of general practice.  
  • The potential contribution of additional roles to general practice is not universally understood, despite large amounts of written guidance, job descriptions and roadmaps, all of which may even have added to the confusion.  
  • There is ambiguity among GPs about what multidisciplinary working would mean for them and their working practices, both clinically and in the way in which their practices are run. While the national direction of travel appears to be that multidisciplinary working in general practice is a key part of the future vision, there has not been enough consideration about how GP roles, or the organisation of general practice itself, might need to change as a result. 
  • The cultural change required by the introduction of additional roles, and new approaches to teamworking, requires extensive organisational development, leadership and service redesign expertise and this has not been adequately available to PCNs, nor is it present in many individual practices. All this has been compounded by the impact of the Covid-19 pandemic on general practice. 
  • This lack of effective and supported implementation means that the core needs of individuals working in ARRS roles – autonomy, belonging and contribution – are not being met in many cases. 
  • A variety of support – including clinical supervision and managerial, HR and peer support – is critical to the effective integration of ARRS roles within general practice and yet there is inadequate additional funding to provide PCNs with the capacity to provide this support well.  
  • Centralised or subcontracted employment models have the potential to provide some of this support more easily but may leave ARRS staff feeling even more distanced from the teams they are working alongside.  
  • A lack of an adequate estate is fast becoming an issue in many areas. The solutions will require expertise in the design and use of space to support multidisciplinary teamworking, and it is not clear how PCNs will access such expertise. 
  • The uncertainty around the funding for the ARRS roles after 2023/24 has started to generate concern. Expectations of the impact that these roles will have are high, but like all new roles, it will take time before they are fully understood. Creating stability and certainty will play an important part in this. 
  • The Covid-19 pandemic has had positive and negative impacts on the deployment of ARRS roles. Learning from that experience and taking proactive steps to address the issues identified need to be a clear part of recovery from the pandemic if the significant investment in ARRS roles is to have the intended impact. 
  • We found examples of good practice and positive stories of implementation, but to ensure successful implementation of the roles we make recommendations including: 
    • a clearer, shared vision for a multidisciplinary model of care 
    • a comprehensive package of support for implementation of the scheme including improved support for clinical and managerial supervision 
    • streamlining and communicating current guidance and roadmaps in different ways that make them more accessible and practical for PCNs, practices and professionals to understand and implement 
    • a focus on future sustainability, including funding, estates strategy and career progression  
    • leadership and management skills development embedded in GP specialist training. 

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Comments

Creenagh Williamson

Position
Chief Nursing Officer,
Organisation
HN
Comment date
29 March 2022

A very interesting report – thank you to the King’s Fund team for this insight.

As Chief Nursing Officer at HN, a healthcare company that delivers AI-guided case-finding and clinical coaching to improve patient outcomes, this report is of particular interest to us, and certainly resonates to some degree with our experience and what we are hearing on the ground.

At HN, we’ve been working with PCNs across the UK and have effectively utilised ARRS funding. Through our ‘Anticipatory Care’ service, we offer GPs and PCNs a team of fully managed and supported health coaches, delivering a service which is fully financed through the ARRS scheme.

Our approach has been validated through intervention studies including randomised controlled trials in the UK and Sweden, and experimental studies – case studies published by East Kent Hospitals University NHS Foundation Trust and NHSE’s Personalised care team. All the evidence – available on our website at hn-company.co.uk – shows that our approach delivers improved patient health, wellbeing and self-management. Having conducted the largest randomised controlled trial (RCT) of proactive health coaching as an intervention within the NHS, HN has vast experience in recruiting, training and supervising clinical health coaches – resulting in a positive impact on GP workload. All our coaches are qualified healthcare professionals, as we believe that for this role to deliver optimum outcomes, a comprehensive understanding of the way in which health and disease impacts the individual is essential.

We have developed a proven and effective methodology, utilising individual Patient Management Systems and identifying patients that would benefit the most from a coaching intervention. Often these patients are high-intensity users of the service and are therefore the most impactful on practice resource utilisation. Each patient is then allocated their own coach, so that a positive and therapeutic relationship is developed. The coach undertakes an initial assessment meeting, during which a coaching plan is co-created. The plan identifies the areas to be addressed during the intervention and any barriers to pro-active self-care, such as health literacy, lack of confidence and/or empowerment, health anxiety, or knowledge of appropriate pathways and actions. The intervention is carried out remotely, working around the patient’s agenda and reducing the need for space within the practice, where the lack of adequate estate is already causing issues for many practices.

The intervention lasts for approximately 3 months, with the length and frequency of the coaching calls entirely driven by patient need. Working alongside other ARRS roles such as Social Prescribers, we ensure that our Coaches are integrated into the MDT, and in many cases, we support other roles, ensuring the delivery of a holistic and patient focused service.

The benefits that patients derive from this service is the knowledge and ability to pro-actively and confidently manage many aspects of their own health. From the perspective of the practice, the service empowers patients, reducing the impact high-intensity users frequently have on a practice, freeing up valuable time and resources. The service is entirely manged by HN, availing the practice of responsibilities such as staff recruitment, training, clinical supervision, peer support, leave management and HR issues. Particularly since the Covid pandemic, when an already-stretched healthcare system has come under increasing pressure to meet patient need, we’ve found that our way of working has helped to alleviate strain and allow PCNs to focus on the subsequent vaccine rollout and extensive backlogs.

In addition to the scientific evidence confirming the positive impact of our work, we also have consistently exceptional patient satisfaction scores. While HN has had a generally positive experience of implementation, we agree with the report’s recommendations that a clearer, shared vision for a multidisciplinary model of care, and more certainty over funding for ARRS roles after 2023/24, will ensure further successful implementation in the years to come.

Michelle Johnson

Position
Pharmacist,
Organisation
Hinckley & Bosworth GP Federation
Comment date
10 March 2022

I am a clinical pharmacist with over 20 years experience working in primary care, ten as an independent prescriber. I left a position of direct employment and became a PCN pharmacist. I had little choice about the employment model as GPs are not hiring when they can get a "free" pharmacist. The practice I left have struggled to recruit a replacement and are ineligible for a PCN pharmacist because they had me at baseline. The Network DES requires that I undertake the 18 month PCPEP course provided by CPPE. There is an APEL procedure but it is so convoluted that I know of no experienced primary care clinical pharmacist who has used it. They have all "bitten the bullet" and done the course at significant cost to the taxpayer. I understand the need for standardisation of core skills and competencies, but where is the value in mandatory basic training for highly skilled individuals?

The majority of PCN pharmacists (80% in my previous geographical area) are recruited from community pharmacy. They have a wide range of transferable skills and aptitude for a clinical role or the primary care setting. Attrition rates are high in some areas and I briefly had a mentorship role in the Training Hub to address some of the issues. The report addresses issues like isolation, lack of clinical supervision, etc.

From a pharmacist's perspective, we have established our utility in GP practices for over 20 years so it's not surprising that numerically we are the biggest group of ARRS professionals. It is also unsurprising that when GPs were offered a "spare pair of hands" they were keen to incorporate pharmacists into their teams. However their expectation of getting a practice pharmacist for free was sorely misplaced. Not only does the "spare pair of hands" need training (extensively in some cases) but their hands are tied to an agenda determined by the PCN.

Performing SMRs does not ease capacity issues at practice level, which is what most GPs want from a pharmacist, and the new requirements in the IIF will increase the number of SMRs to the further detriment of any other positive contribution to the practice. I accept practices will derive income from pharmacists doing SMRs, but I'm not surprised by their lack of enthusiasm for investing considerable time and effort in training pharmacists to the level of skill necessary to churn them out. Nor am I surprised that pharmacists feel lonely and miserable if SMRs are their primary function.

Salary is also an issue. There is no uniformity. Some areas manage to recruit inexperienced pharmacists at band 7 but most do not. In some areas with recruitment difficulties there is little to no differential between pharmacists of widely differing expertise and experience. I'm aware of several large practices with incumbent practice pharmacists who are paid less than the PCN recruits they are expected to supervise!

In my opinion ARRS should have expanded on the practice based pharmacist model that so many GPs had found valuable enough to fund themselves. Instead it has created a variant of the Medicines Optimisation Teams.

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