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February 2022

 
Integrating additional roles into primary care networks

 

YOO® ©

 

About this report

This independent report was commissioned by the Department of Health and
Social Care. The views in the report are those of the authors and all conclusions are
the authors' own.

This report was funded by the National Institute for Health Research (NIHR) Policy
Research Programme (grant number NIHR200702) as part of the partnership for
responsive policy analysis and research (PREPARE) programme, 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.

The King's Fund is an independent charity working to improve health and care in
England. Our vision is that the best possible health and care is available to all.

 

About this report
Integrating additional roles into primary care networks

 

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Contents

About this report
Key messages

@ Introduction

@ Methodology

© Findings

0 Conclusions and recommendations
Appendix: Methodology
References

About the authors

35

39

43

46

 

Contents
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Key messages

e  InJanuary 2019 the Additional Roles Reimbursement Scheme (ARRS) was
introduced in England, which would eventually support the recruitment of
26,000 additional staff working in general practice by 2023/24. This scheme
formed a critical plank of the government's manifesto commitment to increase
the number of annual appointments in general practice by 50 million.

e The ARRS 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.

e 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.

e 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.

e - 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.

e We found ambiguity among some 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.

 

Key messages
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e 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 of this
has been compounded by the impact of the Covid-19 pandemic on
general practice.

e 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.

e  Avariety of support - including clinical supervision and managerial, human
resources (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.

e Centralised or subcontracted employment models have the potential to
provide some of this support more easily but have the downside of ARRS staff
feeling even more distanced from the teams they are working alongside.

e  Alack 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.

e The uncertainty around the future of 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 role in this.

e We found examples of good practice and positive stories of implementation,
but to ensure successful implementation of the roles we make
recommendations including:

° -_aclearer, shared vision for a multidisciplinary model of care

© acomprehensive package of support for implementation of the scheme

° a focus on future sustainability, including funding, estates strategy and
career progression

e _ leadership and management skills development embedded in GP
specialist training.

 

Key messages
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© Introduction

Multidisciplinary teams are fundamental to the future of general practice. Evidence
from the United Kingdom (UK) and internationally suggests that team-based care
offers advantages in delivering the core attributes of general practice that we have
identified previously (Baird et al 2018), including improved access, more efficient co-
ordination and improved continuity (Wagner 2000). Fundamental to this approach is
the belief that when practices draw on the expertise of a variety of team members,
patients are more likely to get the care they need (Schottenfeld et al 2016).

In January 2019, a new five-year contract framework for general practitioners (GPs)
was agreed, a central feature of which was the Additional Roles Reimbursement
Scheme (ARRS), which would support the recruitment of, initially, 20,000 additional
staff working in general practice by 2023/24. These additional roles form a critical
plank of the government's manifesto commitment to increase the number of annual
appointments in general practice by 50 million (Conservative Party 2019). The roles
are also key to delivering the enhanced range of services expected of primary care
networks (PCNs), also introduced in 2019 to bring GP practices and others together
to work at scale.

Under the initial 2019 contract agreement, NHS England and NHS Improvement
would contribute to the cost of the specific new clinical roles within PCNs, with

the different roles coming in over the period of the contract. Initially the funding
covered 70 per cent of the ongoing salary costs plus on-costs for three roles -
clinical pharmacists, physician associates and first-contact physiotherapists (with
community paramedics able to be recruited from 2021/22) - along with full funding
for social prescribing link worker roles during the contract period.

Updated contracts for 2020/21 and 2021/22 set out increases in the scale and
ambition of the new roles. NHS England and NHS Improvement now reimburse 100
per cent of the salary costs and on-costs for the range of additional roles and the
number of staff funded under the scheme will increase to 26,000 by 2023/24. This
means that, on average, each PCN will have approximately 20 full-time equivalent
staff funded through the ARRS by 2023/24. Eligibility for reimbursement extends
to a wide range of roles:

 

Introduction
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e care co-ordinators

e Clinical pharmacists

e - social prescribing link workers

e - pharmacy technicians

e dieticians

e _ first-contact physiotherapists

e health and wellbeing coaches

e - mental health practitioners

e nursing associates and trainee nursing associates

e occupational therapists

e paramedics

e _ physician associates

e __ podiatrists.

PCNs have swiftly recruited to these roles and the ARRS has undoubtedly
accelerated the development of multidisciplinary teams within and across
general practices. However, anecdotal data suggests that the roles are not being
implemented and integrated into primary care teams effectively and there is a risk
that the scheme will fail to have the intended impact. Given the importance of
these roles in helping to tackle the increasing pressures in general practice and

the long-term sustainability of services, successful implementation of the roles
is crucial.

Integrating the ARRS roles and making multidisciplinary teams function effectively
is a complex task. 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 the
ARRS roles within general practice.

 

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@ Methodology

For this study we focused on four ARRS-funded roles: pharmacists,
physiotherapists, link workers and paramedics. 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 focused on those employed under the ARRS and therefore
have a PCN role, rather than those who may have been previously recruited and
funded directly by practices.

We reviewed the available literature that provided guidance on implementing the
ARRS roles, including from national bodies and professional organisations. We also
searched workforce data to explore what data sources are currently available to
measure and assess the effective implementation of these roles.

We carried out focus groups and semi-structured interviews with professionals
from each of the four ARRS staff groups. We also interviewed stakeholders from
relevant national bodies and PCN clinical directors and managers.

In total we recruited 48 participants from across England for the study, including
15 pharmacists, 10 physiotherapists, five link workers and three paramedics.
Participants also included eight stakeholders from national bodies (the Chartered
Society of Physiotherapy, the College of Paramedics, Health Education England,
the National Association of Link Workers, the NHS Confederation, NHS England
and NHS Improvement, the Royal College of General Practitioners and the Royal
Pharmaceutical Society) and seven PCN clinical directors and managers.

A full methodology can be found in the Appendix.

 

Methodology
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© Findings

Literature

As the ARRS is new, there is limited evaluative literature to examine. There

are evaluations of pilot schemes implementing pharmacists and first-contact
physiotherapists within general practice (eg, NHS South, Central and West
Commissioning Support Unit 2020; Mann et al 2018) but these pre-date the ARRS.

Extensive guidance on the implementation of ARRS roles is available from
NHS England, Health Education England and the various professional bodies.
Examples include:

e models of recruitment and employment (NHS Confederation 2021b; NHS
England and NHS Improvement 2021)

e detailed roadmaps for training (Health Education England 2021a, 2021b)

e guidance for implementing roles (NHS England 2021; NHS England and NHS
Improvement 2020b).

We also found multiple case studies outlining best practice in implementing the
roles (eg, NHS England and Portsdown Group Practice 2021; NHS England and NHS
Improvement 2020a; Chartered Society of Physiotherapy undated). In addition to
guidance on the websites of professional and national bodies, the FutureNHS
collaboration platform contains a wide range of guidance, sample job descriptions
and other forums.

Workforce data

There is limited quantitative data available on the roles employed under ARRS. In
September 2021 the NHS Digital PCN workforce dataset had information reported
from 78 per cent of PCNs, although there is significant geographical variation

in the coverage of data, with only 59 per cent of PCNs reporting in one region
compared to 90 per cent in another. To take account of this difference in coverage
we estimated the number of full time equivalent (FTE) staff per 100,000 patients

 

Findings
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using the number of patients registered with a GP in the PCNs returning data. We
then applied these figures to the whole population to calculate estimates for each
region, adjusting for the missing data.

Of the four ARRS roles examined with the PCN workforce data, pharmacists are the
largest group followed by social prescribing link workers, physiotherapists and then
paramedics. We found that between June and September 2021 the PCN workforce
increased across all four roles under study in this report. Some of the increases
were much larger than others. For example, there was a 52 per cent increase in the
number of FTE paramedics. We could not find data on attrition, as this was masked
by additional recruitment.

It is also important to note that this data only covers staff employed by PCNs under
the ARRS scheme, not those working in the four roles employed by individual
practices.

 

 

 

Figure 1 Selected full-time equivalent ARRS roles per 100,000 population,
June 2021
c 12
2
8
a 10
a
z 8
2
po
o 6
8
S 4
o
ea
GS 2
o
ir 9
England East of London Midlands North East North West South East South West
England and
Yorkshire

Mi Pharmacists MM Social prescribing link workers Mi Physiotherapists i Paramedics

(Source: NHS Digital 2021)

We could not find data on individual attrition, as this was masked by additional
recruitment.

 

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Findings from the interviews and focus groups

The scale of ambition that the ARRS represents is huge and requires the
implementation of significant and complex change across general practice.

While we heard positive experiences from PCN clinical directors and from ARRS
professionals themselves, and found good-practice case studies in the literature,
overall we found a less positive picture of the implementation of the ARRS roles
and areas where improvement will be required. We have divided our findings from
the interviews and focus groups into two main sections, the first looking at what
PCNs need in order to successfully implement this significant change programme,
and the second examining the extent to which the fundamental needs of staff
working in ARRS roles are being met. We also look briefly at the impact of the
Covid-19 pandemic. We close this section with a summary of profession-

specific issues.

Primary care networks' ability to successfully integrate the additional roles

It was clear from our research that the fact that many PCNs are in their early stages
of development affected their ability to fully embrace and integrate the additional
roles. Added to this was limited leadership capacity within PCNs or access to a
wider infrastructure to support cultural and organisational change within primary
care. All of this has been compounded by the impact of the Covid-19 pandemic on
general practice.

The need for a strategy and clarity of purpose

A lack of a clear, shared vision and buy-in for the ARRS roles across PCNs was
evident in our research and was linked to the fact that PCNs in many cases lack a
clear, shared overall purpose and strategy. Knowing which roles to recruit, and how
to deploy them effectively, was not always clear. A PCN clinical director phrased it
this way:

'Supermarket Sweep' with Dale Winton... was this gameshow where people

have this trolley and you could run around this fake supermarket and just throw
everything in, right. And | just use that analogy for the way we employed PCN staff,
it's like being in a sweetshop... you're putting loads in because they're free.

At the heart of this issue was a lack of agreement about the role and purpose of
PCNs and the sovereignty of individual practices. Despite the significant ambitions

 

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for PCNs (Baird and Kumpunen 2019), in reality they are often a vehicle for delivering
the specific demands of the Directed Enhanced Service (DES) contract, with
individual practices maintaining their own identity and strategy. There was clearly
disagreement within PCNs and among the ARRS professionals themselves about
whether the roles should be used only to deliver the PCN's specifications, or
whether they were to provide extra capacity to 'core' general practice. This was
further complicated when staff from the same profession had already been employed
directly by practices, for example paramedics or pharmacists. For some, this

manifested itself in differences within the PCN about how the roles should be used:

And | think one of the things that I'm really struggling with as the senior is... getting
my pharmacists, who the practices believe are theirs, to deliver PCN work, when

the practice kind of thinks: 'Well, hey, I've got this person and | want them to do x, y

and z', which is not necessarily part of the DES.

(Pharmacist)

Participants reported a lack of understanding or agreement about what the
individual roles could, or should, contribute and how they would best be deployed
across the network in pursuit of that vision. Case studies from our literature scan
recommended taking a system-wide approach, looking beyond practices and PCNs
to the wider system so that clinicians could be deployed across different parts of
the pathway and there would be a system-wide approach to the delivery of care:

So, there's a constant tension about what is the purpose... once we know the
purpose, we'll know how to use the staff, either at a population level or at practices.
But [ think at the moment it's heading in the wrong direction to provide a stable
layer of support or additional patient support.

(Stakeholder)

Conversely, where PCNs had been able to develop a clear and shared vision and
strategy, this informed their plan for recruitment:

So, we started off thinking about [the] vision and purpose [of the PCN] for quite a
long time actually, thinking about what we're really here to achieve and what value
we want out of the PCN. And we used that to dictate which ARRS roles we would
look at first.

(PCN clinical director)

 

Findings

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One PCN clinical director had set up an audit in which every GP in the network was
asked to complete a simple questionnaire each time they saved a patient record,
asking them to record the skills that would have been needed to meet that patient's
needs and replace the need for an appointment with a GP:

Now, | very deliberately didn't put the names of the roles. | didn't say physician
associate or paramedic because | knew people wouldn't know what they do.
I've broken it down into skills, because | don't think it's about the role, it's about
the skill.

(PCN clinical director)

However, the same clinical director found that the preferences of individual
practices were given precedence over the PCN's decision-making, potentially
because the PCN strategy was not felt to take precedence over individual practice
needs or wants. This tension between PCN and practice priority was a feature of
our research and affected the way in which staff were deployed.

Even when there was a willingness to address the issues, there was felt to be
limited time or capacity within PCNs to have the kinds of conversations that would
be necessary to create an overall strategy:

There are some [GPs] that don't have the time to find out how this benefits the
practice or how this benefits the patients, or don't even have the time to breathe
because | mean | do sympathise [with] my clinical colleagues that are very much
under pressure where they don't actually have time to think.

(Stakeholder)

The need for a shared understanding of the individual ARRS roles

A common theme that participants across the different ARRS roles raised was the
fact that there was no clear understanding within general practice of what those
professionals were able to offer. While some felt that was perhaps inevitable,

as these were often new roles and would be worked out over time, it was a
considerable cause of stress for both ARRS professionals and the wider team:

And there's an educational component for the GPs... What is the best way to utilise
a social prescriber? What can a care co-ordinator really do for you? Because at the
moment we've got a tool, and no one's shown us how to use it and we don't know

 

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what we're trying to build with it. So, something around clarity and something
about time and something around just recognising that this isn't going to be a
quick fix.

(Stakeholder)

Misunderstanding about what the individual ARRS roles could offer was common
across the different roles. It appeared that for first-contact physiotherapists and
for link workers this was partly because of a problem in accessing services in other
parts of the health and care system. For example, a lack of access to physiotherapy
treatment in the community meant that first-contact physiotherapists employed
under the ARRS scheme, whose role is assessment and referral but not treatment,
found it hard to get traction for what they were there to do:

It was a struggle to start with, to get all the clinicians we work with [to realise] that
we weren't a physiotherapy treatment service... So, we did an awful lot of meetings
and talking and education and, as everybody said, really getting to grips with the
admin staff. But our difficulty is there's such a constant change of staff... and admin
changes all the time, and our GPs, unfortunately. So, when we have locums coming
in, again you might pick up they've come in a couple of weeks later and they're
already thinking you're a treatment service.

(First-contact physiotherapist)

Likewise, link workers reported receiving referrals that were not appropriate for
their role but were being made because of a lack of alternative provision:

You become a last-chance saloon, because mental health services are so overrun
that you, you know, we're supposed to be dealing with low to mid or working
alongside, you know, primary mental health services to support them, but not being
that main deliverer, and that's happened quite a lot, where you've got people who
are on the edge and not appropriate for services.

(Link worker)

Several of the ARRS staff said that they wanted more guidance, for example, about
how long a structured medication review would take or the potential role of a
social prescriber. Given the extensive amount of guidance about ARRS roles that
is available from national bodies such as NHS England, Health Education England
and the various professional bodies, this was surprising. However, the breadth and

 

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extent of this guidance may be at the heart of the issue, as it was clear that PCN
leaders did not have the time or headspace to absorb that guidance, nor to socialise
it with others in their PCN.

As an example, various bodies have created 'roadmaps' for different ARRS
professionals, outlining the core competencies needed and the different stages of
career progression (Health Education England 2021a). Some are more structured
than others, but they were seen to be particularly complicated to interpret for PCNs
and practices: The NHS, essentially, produced hundreds and something pages of

a roadmap, which specified various restrictions you can and cannot employ and it
was quite vague at the time.

(PCN clinical director)

The need for increased internal and external capacity to support organisational and
cultural change

It was clear that written guidance on its own did not mitigate the need for work

to understand and embed the ARRS roles. Participants in our research suggested
that access to support for the organisational and team development that would

be needed to embed the roles was lacking. In some areas, training hubs, clinical
commissioning groups (CCGs), local medical committees or GP federations offered
support and training but there was distinct variation in the ability to access such
support. PCN development money could be used to buy in support, but often PCN
leaders or practices did not know what was available or what support might be the
most helpful to them. One interviewee contrasted this with the support available
within NHS provider trusts when they were introducing new roles:

Our CCG has played a role in trying to facilitate it, but actually these are provider
jobs in provider organisations and again it depends on the maturity of the PCN,
but a lot of them are still running on a wing and a prayer. And many practices'

HR [human resources] department is their practice manager who is already also
their finance department and their training department and their complaints
department, and you're right, when you're trying to bring in a new workforce you
wouldn't dream of opening a new department in a hospital and just employing 15
of said people and locking them in a space and saying get on with it.

(Stakeholder)

 

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Models of employment and recruitment support

We heard about a range of employment models, including direct employment by

the PCN, subcontracting from a local voluntary sector organisation or NHS trust

and rotational posts (see 'Profession-specific issues', p32). Often the models used
were pragmatic, according to local circumstances, even within one profession:

We have a really mixed pattern across the whole of the county so we've got multiple
PCNs. Some of them work very similarly, we're embedded into the practice for our
care; and others are a hub model where we provide the care from our centres. Some
of that is determined by their facilities and how much space they have, which is
becoming more and more precious.

(Physiotherapist)

One of the issues of subcontracted models was related to variation in terms and
conditions, particularly when roles were subcontracted from NHS organisations,
because general practice is not subject to Agenda for Change. This caused tensions
within individual professional groups who were employed under different models:

One of the issues that we had with our paramedics in my previous PCN was that
they were practice-employed rather than under [the rotational model]. And each of
them had different terms and conditions. So, their holidays were different, their pay
rates were different, and when they started speaking to each other, that caused all
sorts of problems.

(Paramedic)

It could also create tensions between different roles in practices as, for example,
practice nurses are not subject to Agenda for Change and so do not benefit from
the associated pay rises and benefits.

Centralised models of employment, where additional roles are employed by

GP federations or NHS trusts, did seem to mitigate issues of pay competition
between practices, particularly when the local job market was small or constrained,
and helped to allay the concerns of employers in other parts of the NHS (NHS
Confederation 2020) that they would lose staff to PCNs if they were paid at a

higher rate. Again, the issue of practices as individual businesses with the ability

to determine their own recruitment, terms and conditions, and indeed to compete
within a marketplace for staff, was raised.

 

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Subcontracting entire services, such as link workers or mental health practitioners,
from a third-party provider in particular affected integration with practices and the
PCN, as the individuals were not seen as an integral part of the primary care team
but as a bolt-on additional service.

External support for recruitment was, in the main, seen as a positive:

You're, usually, working alongside organisations who are well used to hosting these
roles and they have got job descriptions. They know exactly how to support them
from a professional perspective. They can help you with advertising, going through
the CVs, making sure that we're selecting the right person.

(PCN clinical director)

Now, | am a GP, | don't understand what level seven capability means in terms of
paramedic competencies. They were then quite vague around, well, how many years
of experience you need to have before you can work in primary care... we, actually,
ended up having to employ an independent consultant... without that support |
don't think | would have got where we were because even the CCG could not tell us
about the recruitment criteria.

(PCN clinical director)

However, expert external recruitment could also create tensions between those
who wanted to ensure the right professionals were recruited and PCNs and
practices that wanted to maximise the number of roles. Senior pharmacy and
physiotherapy staff reported PCNs wanting to end their use of expert recruitment
input because they felt it was impeding their supply of staff by discounting too
many candidates, whereas the professional support was keen to ensure that staff
met appropriate competencies.

Clarity and certainty of funding

Although the ARRS lasts for a number of years, the end of the funding period is
coming closer, which meant some practices were becoming concerned about what
would happen after that period:

| think the other barrier that's starting to filter through a little bit now is that
obviously the contract is getting shorter and shorter. So when we recruited at the
beginning, five years. Brilliant, yes, no problem. Now it's like: 'Oh, well, we're going

 

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to offer you a, you know, two-year contract and then we don't really know what's
happening.' You know, why would you want to leave your job for something that you
don't know you're going to be in for the long term?

(PCN clinical director)

This was particularly the case for employing practices, who held liabilities and risks
for the ARRS roles and did not always trust that these liabilities would be shared
between them and the PCN. There was likewise uncertainty about employing roles
that may not be fully funded under the ARRS:

The apprenticeship route for [physician associate] is not currently included in the
ARRS. The apprenticeship levy only covers the education element of it. So, PCNs
now will be in the situation of: 'I don't want to employ a trainee physician associate,
even though that might attach them to the practice because I'll have to find the 80
per cent of their salary, rather than charge it [to] the ARRS.'

(Stakeholder)

The rigidity of the rules around the roadmap and reimbursement meant PCN clinical
directors did not always feel able to take risks:

They couldn't tell me whether | could employ a paramedic who had less than five
years of primary care experience, and | ended up having to escalate it to regional
NHS level and eventually the answer was: 'Well, we can't really confirm, but if
you want to employ at risk, the chances are you might not be able to put that
through additional roles reimbursement, so the practice would have to pay for
the paramedic', and so we had to play it safe and had to turn down six very good
applicants because they didn't have five years in primary care.

(PCN clinical director)

The need for estates advice and redesign
Many participants raised a lack of space in practices as an issue - not only for
accommodating the ARRS staff but also for an increasing number of GP registrars:

It's much harder for either a clinical role like [a first-contact physiotherapist (FCP)]
where you're spread across all six practices and we have an extra complication
because unlike... well, like many other practices, we are very short of physical space,

 

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clinical space, to the extent that we couldn't actually host [an] FCP within any of
the six practices.
(PCN clinical director)

For some, availability of physical space dictated how the roles were deployed and
on what days:

We're trying to think creatively by having appointments at different times of the
day, by rotating staff around different practices, by putting some of the ARRS roles
into extended access hubs so that they work evenings and weekends... particularly
the physios.

(PCN clinical director)

Asurvey of PCN clinical directors by NHS Confederation found that more than 90
per cent of respondents felt that a lack of estates infrastructure was hindering their
progress and more than 98 per cent that more funding for primary care estates was
needed (NHS Confederation 20214).

Not only is the amount of space an issue, but also the type of space available is
problematic. Multidisciplinary teamworking requires different physical spaces than
traditional consulting rooms, particularly shared office and meeting spaces, and
most PCNs did not usually have access to support to help them redesign and make
the best use of available space:

There's micro teams collaborating together, you need physical spaces that are not
just one-to-one consulting rooms, you also need those group spaces and quite a
versatile estate, which we really don't have.

(Stakeholder)

One PCN did have support from their CCG to employ an external consultant specifically
to advise them on estates but many of our respondents raised a lack of appropriate
space as an issue, with little confidence that there were plans to address this:

But it's always going to be seen as secondary to, first of all, day-to-day service
delivery, and then to workforce; in the hierarchy it's always going to be at the
bottom, which is a real problem | think and is one that's only going to get worse.
(Stakeholder)

 

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While increased remote and flexible working may offer some solution to estate
pressures, previous research by The King's Fund on staff experiences of remote
working in general practice during the Covid-19 pandemic found associated
challenges. Remote working increased flexibility and the ability to participate in off-
site meetings, but staff reported feeling isolated from peers and found it even more
challenging to access appropriate professional support (Baird et al 2021).

Are GPs ready for a move to multidisciplinary teamworking?

A theme across our interviews and focus groups was that there is a lack of clarity
about what multidisciplinary working might mean for the way in which GPs and
practices themselves operate, and an ambiguity from some GPs about the roles.
One PCN clinical director summed it up as follows:

This has implications which fundamentally alter the nature of UK general practice.
One consequence (intended or otherwise) of creating a multi-professional workforce
is that the role of the GP is changing from personal practitioner responsible for a
caseload, to consultant/supervisor at the head of a 'junior' team. How we feel about
that as a profession might in turn determine how medical graduates would view a
career in general practice | guess.

The anxiety about multidisciplinary working manifested itself in a variety of ways.
First, there was a feeling that the ARRS roles take the 'easy' work, leaving GPs
feeling overwhelmed by complex cases with no respite:

Every time somebody takes an aspect of my work, they often take the work that is
either simplest or fun and that leaves me with ever-more complex and exhausting
things, and we've got to look at the model of GP as well.

(Stakeholder)

Second, there was a feeling that, overall, the roles are a burden rather than a help
because of the need to supervise them:

They may do additional workload, but they're not necessarily carrying any
additional clinical risk, which is going back on to the GP.
(Stakeholder)

 

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And finally, it was thought that the ARRS roles are second best and only being
funded as it is not possible to recruit more GPs.

The fundamental needs of staff in ARRS roles: the ABC Framework

Given our findings on the ability of PCNs to successfully implement and integrate
the additional roles, it was unsurprising that the staff we spoke to expressed
frustration about their role and indeed that some had resigned from ARRS roles.
To better understand what the ARRS staff would need to thrive, we have drawn
on previous work from The King's Fund (West et al 2020; West and Coia 2019),
which identified three core needs that must be met to ensure staff wellbeing and
motivation at work, and to minimise workplace stress (see Figure 2).

 

Figure 2 The ABC framework of health care staff core needs

 

@ Authority, empowerment and influence
Influence over decisions about how care is structured
and delivered, ways of working and organisational culture

@ Justice and fairness
Equity, psychological safety, positive diversity and
universal inclusion

@ Work conditions and working schedules
Resources, time and a sense of the right and necessity to
properly rest, and to work safely, flexibly and effectively

 

@ Teamworking
Effectively functioning teams with role clarity and shared
objectives, one of which is team member wellbeing

Belonging

The need to be connected .

* ®@ Culture and leadership
to, cared for by, and caring of Nurturing cultures and compassionate leadership enabling
colleagues, and to feel valued, high-quality, continually improving and compassionate
respected and supported eae ec a

@ Workload
Work demand levels that enable the sustainable
leadership and delivery of safe, compassionate care

'OM ttn

The need to oy ola) The support, professional reflection, mentorship and

@ Management and supervision

A 5 supervision to enable staff to thrive in their work
effectiveness in work and p

deliver valued outcomes @ Education, learning and development

Flexible, high-quality development opportunities that
promote continuing growth and development for all

 

(West et al 2020, p 28)

 

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We now examine each of these areas in turn, identifying key themes across the
different groups.

Autonomy
Autonomy refers to the need for volition, choice and freedom to organise our
experiences for ourselves, and for self-integrity - being able to integrate our
behaviour and experiences with our sense of self - for example, as a provider of
high-quality and compassionate care.
(West et al, 2020)

Staff working in ARRS roles need to have influence and voice within their
organisations. They also need to have the right work conditions, including the
resources and facilities they need to do their job. ARRS staff we interviewed often
reported feeling marginalised from decision-making and a lack of ability to influence
how their roles should develop:

Because !'m spread so thinly, | can't do big pieces of work. | want to. | want to

run audits, | want to work on opioids... | haven't got the capacity to do that. The
expectation from my PCN was to do [structured medication reviews (SMRs)] and
SMRs only. | basically wasn't given any control of my ledgers; they have just booked
me in SMRs. They've not listened to me.

(Pharmacist)

One PCN clinical director suggested that GPs had become used to an unhealthy
way of working and this may have been a reason for ARRS staff being asked to work
in the same way:

Working in primary care is isolating, involves managing a great deal of risk

and coupled with unreasonable workload and no protected CPD [continuing
professional development], most health care professionals would struggle. We, GPs,
have been working under these conditions because we do not have a choice and
over the years it has become the norm, but this is not what ARRS staff would (quite
rightly) put up with.

Anumber of participants gave examples of the benefits of having a 'critical mass'
of staff, partly so they felt less isolated, but also because it gave them a more

 

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significant voice and drive within the PCN as they could develop and agree a
common work plan across the PCN (or in some instances multiple PCNs):

! think you need to get enough people into role so that there's a critical mass of
people to start to do that teambuilding structure and for them to feel that they are
making a difference.

(PCN clinical director)

We've formed sort of a mini PCN team, if you like... a GP who we've acquired
through some local funding, a physician associate, two community matrons through
the community trust and two care co-ordinators who work with them to do a lot of
the administrative stuff. The team is known as the anticipatory care team.

(PCN clinical director)

Access to information for care and triage was critical for a feeling of autonomy.
Some ARRS staff were able to proactively drive their own workload; for example,
some paramedics or first-contact practitioners spoke of being able to take cases
directly from duty lists. For others, though, restrictions on how they were able to
access information hampered their ability to practise. Having permissions to both
read and write into patient records was a particular issue for link workers and their
ability to practise safely:

How can you employ somebody and not allow them... you Know, how can you
employ a social prescriber link worker and not allow them to have access to patient
records? And the complexity... and they need access to those records because they
need to actually input into those records, so we know what's happening.

(PCN clinical director)

Professional and managerial leadership and advocacy were also key, with leaders
acting as a link between ARRS staff and other practices, their PCN or professional
networks. This allowed ARRS staff to have a voice in settings or meetings where
they were not necessarily present.

Belonging
The need for belonging reflects our desire to feel and be connected to others - to
feel included, valued, respected and supported in teams and organisations and to
care and be cared for in those contexts. There is abundant evidence to show that

 

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support from colleagues enables people to thrive in their work, helps them to cope
with difficult work experiences, and buffers them from the wider organisational
factors that cause irritation and stress.

(West et al 2020, p 68)

I've found myself to be incredibly lonely. It's been really hard to feel like part of the
team but not feel like part of the team. You always feel like the outsider coming in.
You always feel like, | always feel like I'm re-introducing myself... | always feel I'm
spread so thinly that nobody really, really knows me all that well.

(Pharmacist)

One of the strongest themes that emerged from our work was one of isolation
and loneliness, which came from being spread across multiple teams. ARRS roles
are very often deployed across practices that have different cultures, systems

and processes, and this lay at the heart of many of the issues we identified in

our review. Most PCNs are made up of multiple practices, and even those that
comprise just one practice usually cover multiple sites. While individual practices
and sites may have had good teamworking models in place, very often PCNs did
not have a sense of team or identity beyond the individual practices, which meant
PCN roles did not 'belong' to a single team. PCN clinical directors had attempted to
create a PCN identity, through lanyards or badges, or joint events, but it was clear
that individual practice cultures and processes were dominant.

We have previously identified the fundamentals of effective teams within primary
care, based on the work of Professor Michael West (Baird et al 2020; West 2012):

e asmall number of meaningful objectives
e clear roles and responsibilities among team members

e _ time to reflect on how the team is working together.

It was clear from our conversations that because of a lack of cohesion and strategy
across PCNs, these fundamentals were not present and so having an effective
team approach across the whole PCN was rare. It is common for those working in
ARRS roles to have their hours split pro rata according to the number of patients
within each practice of the PCN, rather than in response to a shared strategy

and objectives across the PCN. As a result, those staff needed to become part of

 

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multiple practice teams in the absence of a single PCN team. Those who worked at
smaller PCNs or at fewer practices often had a better experience:

[S]ome of those smaller PCNs | talked about at the beginning, they are the ones
that have managed to create... that team with that common purpose, the sharing
of support and everything else.

(Stakeholder)

It was clear from our conversations that this sense of being in a team was often
lacking for ARRS staff and played a significant role in staff retention and wellbeing.

Induction

A good induction was felt to be key to help staff feel less isolated, but was often
lacking, particularly when there had not been a predecessor. We heard examples
of good practice, including written induction plans, comprehensive information
technology (IT) induction and lots of time for shadowing clinical and administrative
staff. We also heard of poor practice:

One practice's induction, it was literally like there's the fire exit, we have a cup of
tea at half past 10, and that was my induction from them.

(Pharmacist)

Working across multiple practices that did not share systems and processes meant
that ARRS staff often had to undertake separate inductions in all the different
practices but without a single overview or approach. Within practices, practice
managers, reception staff and administrative staff were key to helping roles to
embed quickly. If they understood the roles and the referral pathways, they were able
to support patients to access new services and help the staff feel part of the team.

With my first practice they were really, really keen, they had quite a few GPs who were
very sort of up for social prescribing, so | didn't have to convince anyone, which was
really, really good, and they've got a really good team ethos, and | was put in the
medical secretary room, so | managed to establish those relationships with admin and
reception, all those people, so it was so good, it became so embedded so quickly there.

(Link worker)

 

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Many staff in ARRS roles may not have worked in general practice before, and
found that particularly isolating:

! found it quite hard to start with because coming from a community background,

| used to manage a pharmacy and | had 14 members of staff that worked for me,
including pharmacists and pre-registrars. So, for me, sort of being told to go ina
room on your own and just get on with it, | did struggle with that a little bit because
I'm used to being part of a really big team.

(Pharmacist)

We heard that a lack of network management or HR processes within PCNs was
problematic. Those employed by external bodies, for example, GP federations,
reported good initial induction and HR processes, but still lacked induction within
the PCN and individual practices. At its poorest, a poor induction could leave staff
feeling disconnected:

! thought | was a resilient person because of my professional past. And it has been
extremely hard. Emotionally it's been extremely hard. And with anyone starting a
new role, you need to find your place, to find your feet, to find the dynamics of the
team. You do feel alone.

(Link worker)

Contribution
The need for contribution reflects a need to make a positive difference through our
work as well as to achieve valued outcomes, such as to deliver high-quality care
that improves patients' lives. This reflects a deep human motivation to be able to
influence our environments for the better. The need for contribution is met, first
and foremost, when workloads do not exceed the capacity of staff to deliver valued
outcomes. It is also met by ensuring that staff have enabling supervisory support,
focused on removing obstacles in the workplace, which creates cultures of learning
and accountability rather than directive, controlling cultures focused on blame. And
it requires ensuring that staff are continuously learning, developing their skills and
growing their professional knowledge.
(West et al 2020, p 29)

The ability to feel and demonstrate value was clearly affected by the way in which
the ARRS roles were deployed and how many practices they covered. Those

 

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in ARRS roles reported being able to get more feedback and interaction with
colleagues when they were on fewer sites:

Because the impact for individual practice is watered down [even though] there is
definitely a demand, [in] terms of individual practices | don't think the staff really

feel their impact, and, therefore, | suspect the FCP [first-contact practitioner], the
additional roles staff themselves, therefore, don't get that feedback.

(PCN clinical director)

The lack of shared understanding or agreement about the purpose or function of
the ARRS roles within the practices of the PCN affected the ARRS staff's sense of
being valued and appreciated:

| have practices where they would not give a clinical room for a social prescriber link
worker. They don't invite them to their clinical meetings. Staff don't know who they
are, and for them | think it feels... | think they probably feel... it's difficult for them to
feel that they're appreciated.

(PCN clinical director)

It was important that practices understood whether or not individuals would be
able to 'hit the ground running', which was often not the case when staff were
working within general practice for the first time. Managing expectations about
what staff working in the ARRS roles would be able to do immediately, as opposed
to in the longer term, was often critical:

| think you need at least 18 months, really, before you start really seeing these
people settle in and start doing what you need them to do. | think that's the reality,
and | think if you try and expect any more than that sooner..., these guys need time
to adapt, understand how general practice works, understand their capabilities and
build their confidence up and know what they're doing and for us to kind of work
out what they're good at and what we can get them doing before you start to really
reap the benefits.

(PCN clinical director)

High expectations of the roles, sometimes based on the results of pilot schemes
and best-practice case studies, were not always met in reality:

 

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The pilot schemes have had really good outcomes in terms of reduced follow-ups,
reduced referrals on to orthopaedics, reduced need for painkillers, early starting
of exercises, all the rest of it. So, | think when they can start prescribing... when
they can start doing those things and be proper autonomous practitioners as well,
brilliant sailing.

(PCN clinical director)

Those professionals who were demonstrably able to take workload away from
GPs felt better appreciated than those who were providing new services, or less
visible input:

With physio it's been very different. The physios go in, they do the first-point-of-
contact appointments. | think GPs really value it because it takes work directly
off them, and they can see it, it's tangible. Whereas with the pharmacist it's less
tangible because there's a lot of work that goes on in the background that they
don't see, it's just... that they're doing it.

(PCN clinical director)

Participants highlighted the need for a variety of support, including professional
leadership, HR and practice manager leadership, clinical and peer support and
managerial support.

The amount of support available to ARRS staff was variable, with link workers in
particular feeling they lacked access to the support they needed. Where support
was not available, workers were left feeling isolated.

Clinical supervision

Clinical supervision was identified as increasing safer clinical behaviour and
therefore patient safety; however, access to supervision was often constrained by
a lack of capacity, incentives, funding or recognition of the work involved. There is
no specific funding to cover the supervisor role, which impacted on the ability to
find supervisors:

I've got a GP who's interested to be their supervisor, but then they have to take two
full days out of their working week for free to be their supervisor. There's no gain in
it for them.

(Physiotherapist)

 

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Various ARRS staff reported feeling that clinical supervisors were 'too busy',
unavailable or inaccessible. Where clinical supervision happened at all, many
spoke of it being infrequent, brief and/or group based. Similarly, clinical directors
emphasised that clinicians did not have the 'headroom' to invest in developing and
supervising ARRS staff to a point where they could reap the benefits, because they
were overwhelmed by their day-to-day work. Clinical directors spoke of clinicians
not having the time to complete mandated training to allow them to supervise
ARRS staff. Similar issues about a lack of GP time available for supervision had also
been found in the evaluations of pilot programmes (Mann et al 2018).

In contrast, one paramedic spoke of how two of their practices had assigned
protected time for named GPs to provide supervision, increasing accessibility
compared with GPs at one practice:

| have a named GP, who they have organised, a slightly lighter workload, so they
have time to do supervision during the day... Whereas at the other practice,
everything is just booked up and yes, all the GPs are there and they're willing to
help you but you're trying to catch them in between a patient or you're sending a
message and then just waiting to see who gets back to you.

(Paramedic)

External support models were often described favourably as they removed tasks
and responsibility from overwhelmed practices and practice staff. Interviewees
talked of HR support being covered by external employing organisations, and
clinical and peer support being provided by voluntary, community and social
enterprise organisations, hub models, PCNs and GP federations. For example,
physiotherapists described using the hub model for supervision:

Actually, in terms of the formal supervision, we provide that to ourselves. We
don't ask the GPs to do it because it was never factored in when the service was
established, so we do it all.

(Physiotherapist)

Managerial support

Managerial support played a critical role in ensuring ARRS staff had a good
understanding of their roles and responsibilities and what constituted appropriate
tasks and volumes of workload. GPs and practice managers also advocated for

 

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ARRS staff to ensure they received appropriate work. Managers were important
allies for ARRS staff, given the new and evolving nature of the ARRS roles. One
physiotherapist stated how they educated GPs about the ARRS physiotherapy roles
and how they were supported by their practice manager to get appropriate work:

[T]he other useful thing was actually having real good support from my practice
manager and the partners that actually if the GPs are sending you rubbish, send it
straight back.

(Physiotherapist)

GP or managerial support was felt to be most effective where such individuals had
a vision or strategy for the ARRS roles and would be better where individuals had a
desire to lead and support, rather than perceiving that they had merely drawn the
short straw. As one national stakeholder put it:

| think they need a purpose, and they need the leadership to go with it. And what !
think maybe hasn't happened with the leadership side is the PCN [clinical director]
are often people that put up their hand at the wrong moment or didn't step back
when everyone else did.

(Stakeholder)

Managers struggled to find time to plan management activities and others cited a
lack of clarity around what a supportive role entailed.

Previous research by The King's Fund on managing staff in different locations found
that leaders needed to develop new skillsets, particularly around managing complexity
and coping with the lack of immediate oversight and control (Baird et al 2021).

Peer support

Participants frequently highlighted peer support as being important, for several
reasons including promoting teamworking and belonging and preventing isolation
and attrition. It was also recognised as key for helping to navigate changes:

When you're at the forefront of a practice change, peer support is really important.
And peer support comes from both your own profession, but obviously peer support

 

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from other professionals who are doing similar roles, so GPs, in this instance. And
so, time with your peers is critical.
(Stakeholder)

Access to training and development

Interviewees frequently cited the idea that training and development should be

an ongoing process for staff employed in the ARRS. Despite this and the fact that
ARRS roles are described as training roles, interviewees cited numerous factors that
inhibited access to training. They described how training was not necessarily seen
as part of the ARRS role or adding value to the PCN - rather it was a luxury and the
choice of the staff member:

| actually resigned. | was told that | had to make up all the [Centre for Pharmacy
Postgraduate Education training] days that I'd done on my training as unpaid
overtime, which | argued. | argued and said: 'You can't do that because | was
contracted as having to do that as part of my role. It's a paid thing. You get the
ARRS because I'm doing the course. This is my role.'

(Pharmacist)

In addition, ARRS staff employed by external organisations were not always seen
as part of practice teams and were therefore excluded from practice training.

For some roles, training requirements were better, and for some they were less
well understood. Link workers frequently cited a lack of training due to a lack of
understanding of their needs and roles. Many relied on self-learning and seeking
free online courses and networks to join unless they were employed by a charity
that provided more guidance. For ARRS staff themselves, one national stakeholder
repeatedly heard that some suffered a lack of time to attend training, which was
linked to burnout. The late arrival of some of the roadmaps, and resulting extra
work needed to provide portfolio supervision, the uncertainty of the future of ARRS
roles and the perception that training may enable staff to move on to new roles
outside of the practice also meant training was inhibited.

These roles coming out prior to the roadmap... it's almost like we're back-pedalling.
So, contracts were set up without this being factored in, and now we're doing the
supervision and it is hard, it's really hard. I've got really established clinicians that
are really busy, not helped by the pandemic at all, trying to produce roadmap

 

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documents that they've done so much work [on], they're really good at their role,
and | sit in clinic with them and they're brilliant, but they've still got to go through
this portfolio route. It is a challenge; I'm quite happy to say that.

(Physiotherapist)

A manageable workload

Evidence from previous research shows a strong link between workload and
wellbeing for health and care staff (West et al 2020). Increasing workload was
becoming problematic for some of those we interviewed, reflective of ongoing
pressures in general practice:

The fact we were full time, with only 3.5 hours a week for admin, just meant we all
felt pretty drained and the enjoyment wasn't always there as you were so tired.
(Physiotherapist)

And also, they've recently said to me: 'We want you to do all the care homes...

if you take out an hour a day every day.' There are 27 care homes. | can't do 27
care homes in an hour a day every day and then do SMRs [structured medication
reviews] for the rest of my time. It's far too much. And even though I've said this is
an issue, nobody's listening.

(Pharmacist)

Workload issues and a lack of available staff also meant it could be difficult to
change underlying practice:

Every Monday at the practice | look for an appointment with a first-contact physio
so that, for somebody with a back pain or a problem that needs assessment but
doesn't need a GP, and invariably | end up booking them with a GP because the
next appointment for a physio is 10 days down the line because there's not enough
of them. So, whenever these roles are few, it's not going to change the way we work.
(PCN clinical director)

Again, the pressures in general practice and a need to 'fire fight' rather than plan led
to increasing workloads and/or tensions between practices trying to deliver core
services and PCN staff trying to deliver the requirement of the DES contract.

 

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Career progression

Participants in the interviews and focus groups frequently raised the opportunity
for career progression within ARRS roles. ARRS staff, PCN clinical directors and
national stakeholders recognised its importance for retaining interest in the role and
therefore for staff retention.

However, the constraints of ARRS funding meant that pay progression was often
not possible within ARRS roles, although many interviewees also reported other
barriers to career progression. These included uncertainty about the future of the
ARRS roles themselves or unclear routes for progression:

[Some are thinking] there is no career progression here for me, there is no future for
me, it's just a testbed. What is sustainability, is this just for five years, what's going
to happen? So, you have people already thinking about that.

(Stakeholder)

The problem with social prescribing is you do it and you're not rewarded for
experience. There's nowhere to go with it unless you want to manage people.
(Link worker)

ARRS roles themselves potentially offered a greater level of professional autonomy
than was possible in other settings. As an example, one national stakeholder
suggested that development opportunities for paramedics via ambulance trusts
were usually 'few and far between' and therefore the ARRS roles offered more
opportunities in that respect, supporting progression.

The impact of the Covid-19 pandemic

It is important to note that the Covid-19 pandemic has had an impact on many of
the staff we interviewed. Interviewees frequently mentioned the context of the
pandemic as both a barrier and a facilitator to embedding ARRS staff into practices
and PCNs. Many spoke of joining their PCN just at the point of the first national
lockdown in the spring of 2020, resulting in a lack of, or poor, induction processes,
being unable to meet teams in person and developing feelings of isolation. Others
spoke of having non-role-specific tasks - such as checking in with care homes (link
workers) and managing the vaccine rollout (pharmacists) - thrust upon them on
arrival. This meant that while their work was valued, it was not the work that they

 

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were hired to do, and they were subsequently unable to add value in the intended
way. Some highlighted the need for better supervision models due to an increase in
the complexity of cases during the pandemic (link workers), and others shared that
they had struggled to socialise their roles with patients due to lockdown and not
seeing people face to face. Recruitment was also affected as exams were delayed
for some roles due to the pandemic.

Conversely, some staff mentioned that their roles allowed them to meet more
people and work more closely within teams to achieve Covid-related tasks. The
pandemic promoted belonging and teamworking for some. Others mentioned that
practices were learning from how things had changed during the pandemic and
were trying to retain and evolve more effective working and pathways such as
upskilling ARRS staff to take on more tasks.

Profession-specific issues

Link workers

Our research found that there was an extremely poor understanding of the role of
link workers within PCNs, linked to the fact that they were frequently introducing
a new model of care within general practice that is not widely accepted or
understood. This had a range of consequences.

e Staff were left to their own devices to design their own role and to identify
free training and external support networks. They often felt very isolated
within the practice.

e The fact that these roles are non-clinical meant that access to IT systems and
patient records was frequently inhibited, with link workers having to design
their own patient management records, with a resulting lack of integration
with the rest of the practice.

e _ A lack of access to wider services, particularly mental health and housing
services, meant that link workers were frequently being asked to work with
patients who had significant and complex needs that they were not trained to
deal with.

e While models which see link workers subcontracted from voluntary sector
organisations provided better access to profession-specific support, we found

 

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they could fail to generate a sense of belonging and teamworking within
practice teams.

First-contact physiotherapists

The key issue for first-contact physiotherapists was that practices typically
held an incorrect perception that the role was treatment based rather than
purely diagnostic. This led to duplicate referrals and frustration for patients.
A lack of access to community physiotherapy added additional pressure.

Many first-contact physiotherapists had little desire to take on their role full time
within PCNs and preferred to spend at least part of their time in other services.

Staff reported value from working across different parts of the care pathway,
which meant they could better support patients across their whole journey.

First-contact physiotherapists tended to be at ease with more autonomy than
some other roles and seemed less concerned with how they fitted into the
primary care team. The fact they were often employed in dual roles meant they
had better access to peer support.

A hub model of delivery, with first-contact physiotherapists employed
centrally, was highlighted as a good route to ensure support and supervision.

Paramedics

Rotational models, where paramedics rotated between the ambulance trust
and PCNs, seemed to work particularly well for this role, allowing paramedics
to retain and build their skills, but also to retain benefits such as shift
allowances and Agenda for Change progression.

Again, staff in these roles tended to be at ease with more autonomy than some
other roles, although they felt that autonomy was initially reduced in primary
care compared with their ambulance trust roles.

The ARRS was seen as a good opportunity for progression for paramedics
beyond what is available in ambulance trusts - there were more opportunities
for training and development and this allowed progression towards
autonomous working.

Many struggled to receive profession-specific supervision due to challenges
around identifying and finding time to train suitable candidates.

 

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Pharmacists

e Given clinical pharmacists have been employed in general practice for some
years, we were surprised that they still had many of the same issues as those in
newer roles.

e There was a strong sense that they were not being given tasks appropriate
to their competencies. Many felt that GPs underappreciated their abilities or
wanted them to focus on 'tick-box' tasks and medication reviews.

e Pharmacists often felt isolated, especially if they had moved from hospital
settings where team structures were in place. There was a strong consensus
that having a critical mass of pharmacists and technicians, with leadership
support, was important.

 

Findings

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© Conclusions and
recommendations

ARRS roles have the potential to make a significant contribution to the quality

of patient care in general practice and represent a significant investment in the
future sustainability of general practice. These roles need to be carefully embedded
and integrated into teams if they are to reach that potential for patients and to
meet the needs of staff working in the roles. Critically, this depends on successful
multidisciplinary teamworking across general practice. At present, many PCNs do
not have the necessary capacity or skills to do this.

PCNs are relatively new and many lack the shared strategy and clarity of purpose
necessary if they are going to recruit and deploy the ARRS roles in the most
effective way. The complexities of 'sovereignty' between practices and the PCN
cause issues for those employed in 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.

While skills that enable people to work in multiple teams are important for ARRS
roles, the evidence is clear that stable membership of a 'home' team is essential

for wellbeing and effectiveness. Dropping in and out of teams can undermine
connection, community and belonging, and we saw that clearly in our research.
Building a critical mass of ARRS staff within PCNs or individual practices may help
to increase peer support and establish a 'home' team, as will roles that rotate or
split between secondary care and primary care. Nevertheless, this does not address
the issues of how to integrate the ARRS roles into a wider multidisciplinary team at
either practice or PCN level.

The confusion around strategy is also linked to a lack of agreement about whether
the roles are primarily intended to deliver the PCN DES requirements or to
undertake what might be considered the 'core' work of general practice.

 

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There was a general ambiguity from some GPs about what multidisciplinary working
would actually mean for them and their working practices, both clinically and in

the way in which their practices are run. Some expressed a feeling that ARRS roles
were taking the interesting or 'easy' work away from them, leaving them with too
much complexity, or that ARRS roles were a second-best solution to a shortage of
GPs or practice nurses. 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 potential contribution of additional roles is not universally understood, and
this was the case across all of the roles we studied, even those such as pharmacists
who have been a feature of general practice teams for the longest time. The large
amounts of written guidance, job descriptions and roadmaps have not had the
intended impact and may even have added to the confusion.

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. This is in contrast
to the support that exists for change within NHS trusts. While PCNs have received
some development funding, more active support is clearly needed to make the
necessary changes in organisational culture and structure that are required to
adequately integrate the ARRS roles, including the development of a shared
strategy and purpose, an analysis of workflow and role redesign.

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. Managing and supporting staff working across
different locations requires leaders to have particular skills in managing complexity
and coping with the lack of immediate oversight and control and yet there is limited
access to this kind of leadership skills development in general practice. Centralised
or subcontracted employment models have the potential to provide some of

this support more easily but have the downside of ARRS staff feeling even more
distanced from the teams they are working alongside.

 

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In addition, 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 future of 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 role in this. The Covid-19
pandemic has obviously had an impact on the deployment of ARRS roles, and
indeed we heard both positive and negative impacts. 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.

Our recommendations as a result of our research are as follows.

Aclearer, shared vision

e _ Acclearly stated shared vision for a multidisciplinary model of care at both
individual practice and PCN level is essential. National bodies, including the
Department of Health and Social Care and NHS England, together with the
professional bodies, need to develop and communicate a clear understanding
of the multidisciplinary model of care and the potential implications for the
way in which GPs will practise in future.

Accomprehensive package of support

e Integrated care systems (ICSs) will need to ensure PCNs' greater access to
local organisational development, leadership skills development and service
redesign support if they are to develop shared strategies and competencies for
ARRS roles.

e -_ICSs should consider how they will support practices in the necessary redesign
of the primary care estate if multidisciplinary teamworking is to become a reality.

e Health Education England and the professional bodies representing the
additional roles should consider how the current roadmaps and other guidance
can be streamlined and communicated in different ways that make it more

 

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©

 

accessible and practical for PCNs, practices and professionals to understand
and implement.

PCNs and individual practices should consider how they will plan to build
the numbers of additional roles to improve peer support and increase the
possibility of team leadership roles and opportunities for management supervision.

PCNs must ensure ARRS roles have clear and easy access to a range of
support, including clinical supervision and managerial, HR and peer support.
Those providing support need access to, and the capacity to undertake,
training and development in the necessary leadership skills.

PCNs and practices need to carefully plan their strategy for embedding ARRS
roles, considering the implications for staff who work in network-wide roles or
across multiple practices that have individual systems, cultures and practices.

The future sustainability of the ARRS

The Department of Health and Social Care and NHS England should provide
as much clarity as possible on the plans for the long-term funding of the ARRS
roles after 2023/24 in order to provide certainty and stability for both ARRS
staff and PCNs.

Future national contract negotiations should address the need to adequately
fund the managerial, clinical supervision and training needs of the ARRS roles.

NHS England should consider the development of a clear estates strategy for
primary care, building on the 2019 General practice premises policy review (NHS
England 2019) to include how to give backing to the redesign of premises to
support multidisciplinary teamworking.

NHS England, Health Education England and the professional bodies should
consider how career progression for staff working in ARRS roles will be
supported, which should include appropriate flexibility in funding so that staff
can be employed at more senior levels.

The Royal College of General Practitioners and deaneries should ensure
that management and leadership skills training is fully embedded within GP
specialist training.

 

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Appendix: Methodology

Literature review

For this research we conducted a rapid review of available literature that provided
information, guidance and recommendations on the implementation or retention
of ARRS roles. We searched relevant national bodies for each of the target roles
(the Chartered Society of Physiotherapy, the College of Paramedics, the National
Association of Link Workers, the Royal College of General Practitioners and the
Royal Pharmaceutical Society), education providers (FutureLearn and Health
Education England), relevant NHS sites (the NHS Confederation and NHS England
and NHS Improvement) and relevant general practice organisations (Ockham
Healthcare and the Royal College of General Practitioners). We excluded anything
linked to patient experience and wider considerations of multidisciplinary working
in general practice.

The literature provided us with baseline information on current recommendations
and guidance for implementation, and better equipped us to set out the
background and context to the research. It also helped to inform our approach to
the focus groups and interviews, identifying key areas to focus our questioning
on: recruitment, induction, training and support, estates and technology, as well as
more broadly, retention, attrition and practice.

Data searching

Initial examination of available data identified two useful sources of data: General
Practice Workforce data and Primary Care Network Workforce data, both published
by NHS Digital.

The General Practice Workforce data includes data on the roles employed in
general practices from 2015. We used data from June 2021.

The Primary Care Network Workforce data includes data on the roles employed by
PCNs. This data is available quarterly from March 2020. The coverage of the PCN
data in March 2020 was low (15 per cent) although it had increased to 78 per cent

 

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by September 2021. This limited the analyses we were able to carry out with the
available data. However, the increasing level of coverage will make future time-
series analyses possible.

We used the two most recent quarters of PCN data where coverage was more than
70 per cent June and September 2021). We summarised the (full-time equivalent)
number of pharmacists, physiotherapists, paramedics and link workers that PCNs
employed, by region of England. Variability in the size of PCNs and in the availability
of relevant data meant we were unable to adjust for the differing coverage by
region (Morciano et al 2020).

Focus groups and interviews

Four focus groups - one with each subset of ARRS staff - and a series of interviews
with key stakeholders and PCN clinical directors were originally proposed. Due to
difficulties in recruiting, we adapted the methods to ensure adequate data capture.

We recruited participants by email using The King's Fund's existing networks
and via the Chartered Society of Physiotherapy, the National Association of Link
Workers, the NHS Confederation's PCN Network, the Pharmacists in General
Practice Network and the Royal College of General Practitioners. We also used a
social media platform (Twitter). We recruited a total of 48 participants.

We conducted four focus groups: two with pharmacists (n=11 across the two
groups) and two with physiotherapists (n=9 across the two groups). We interviewed
four additional pharmacists and one additional physiotherapist. We also
interviewed five link workers and three paramedics.

We interviewed eight stakeholders from relevant national bodies (the Chartered
Society of Physiotherapy, the College of Paramedics, Health Education England,
the National Association of Link Workers, the NHS Confederation, NHS England
and NHS Improvement, the Royal College of General Practitioners and the Royal
Pharmaceutical Society) and seven PCN clinical directors or managers, as originally
proposed.

We provided participants with information sheets, privacy statements and consent
forms ahead of their focus group/interview. We obtained written consent from

 

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focus group participants and verbal consent from interviewees. We created semi-
structured focus group and interview schedules, tailored to the participant group.
Content included questions on practice, support, recruitment, induction and
career progression.

We conducted all of the focus groups and interviews using online web conferencing
software (MS Teams) between 26 August and 11 November 2021. The focus
groups lasted approximately 90 minutes. The interviews with ARRS staff lasted
approximately 30-45 minutes while the interviews with national stakeholders and
PCN clinical directors/managers lasted approximately 60 minutes. We digitally
recorded all focus groups and interviews, except one interview, and took fieldnotes.
Fieldnotes were taken for the one interview not recorded. Participants did not
receive any remuneration for their involvement.

We sent recordings to a third party (1st Class Secretarial) for transcription and
anonymised returned transcripts before we undertook our analysis.

Two researchers descriptively analysed the interviews and focus groups using
MAXQDA 2020 Plus. Initial coding themes were devised based on findings

from the literature. The two researchers coded a single transcript and discussed
discrepancies, revised coding descriptions, added new codes and then coded

a further subset of the transcripts. The subsequent review of the framework
resulted in minimal revision of a small number of code definitions and the addition
of one new code. Subsequently, the rest of the transcripts were coded without
any further changes to the framework. Data under each code was then reviewed
for cohesiveness and summarised to aid write-up. The codes were synthesised
into an overarching framework, drawing parallels between the data and the ABC
Framework developed by colleagues at The King's Fund (West et al 2020; West and
Coia 2019). This suggests that a sense of autonomy, belonging and contribution

is required for staff to maintain their wellbeing and motivation in the workplace.
Subsequently, we created two overarching themes. The first was 'Primary care
network's ability to successfully integrate additional roles', which consisted of
subthemes encompassing the practicalities, understanding and resources required.
The second was 'The fundamental needs of staff in ARRS roles', which consisted of
subthemes containing data demonstrating the need for autonomy, belonging and
contribution of staff in these roles.

 

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Patient and public involvement and approvals

The Health Sciences Research Governance Committee at the Department of Health
Sciences, University of York approved this research project after an ethics review
process (HSRGC 2021/465/A: 'Challenges to the implementation and integration of
the ARRS staff in PCNs'; approved 30 July 2021).

We sought patient and public involvement for the project using the University
of York's Involvement@York programme. A panel of four programme volunteers
provided comments and feedback on the research protocol and associated
materials, which were incorporated into the delivery of the project. This included
changes to the language used on the consent forms and information sheets to
make them more accessible.

 

Appendix: Methodology

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About the authors

Beccy Baird works in the health policy team at The King's Fund, leading research
and analysis across a range of health care issues with a focus on general practice.
She has worked in the NHS and social care for more than 25 years, and before
joining the Fund was associate director for service improvement in a cancer
network. Beccy spent two years in San Mateo County, California, developing a
model of integrated health and social care funding and delivery for older people.
She began her career as a researcher in older people and mental health services.

Beccy has an MSc in health systems management from the London School of
Hygiene and Tropical Medicine. She is a qualified coach practitioner, accredited
with the European Mentoring and Coaching Council.

Laura Lamming works in the policy team at The King's Fund. Before joining the
Fund in 2020, she worked in various academic health research departments,
including the University of Bradford, the Bradford Institute for Health Research and
the Cambridge Institute for Public Health.

During her career, Laura has worked on projects promoting physical activity,
medication adherence and healthy eating in regional or primary care settings as well
as quality improvement projects in hospital settings. Laura has an MPhil in Public
Health from the University of Bradford, which looked at physical activity promotion
apps that provided feedback on user affect.

Ree'Thee Bhatt is a GP trainee on a placement working with the policy team at The
Kings Fund. She previously worked as a paediatric trainee for three years covering
general paediatrics, newborn intensive care and paediatric neurology in the Thames
Valley Deanery. Currently, she is a GPST1 trainee on the Imperial College and
Imperial Healthcare NHS Trust scheme in north-west London.

Her previous research background includes presentations and publications
presented nationally and internationally at conferences in subjects ranging from
Covid-19 in neonates to breastfeeding patterns in communities in South Africa.
As part of the Next Generation GP London cohort and an Imperial training

 

About the authors 46
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representative, Ree'Thee has a keen interest in developing her leadership skills for a
future portfolio career in general practice.

Jake Beech left The King's Fund in October 2021. He was a researcher in the policy
team, supporting the Fund with its responsive and monitoring work. He helped
ensure the Fund had a good overview of key developments in health and social
care, including scoping new and emerging issues.

Before joining the Fund, Jake worked at Age UK in its national policy and research
team, supporting its quantitative analysis of health and social care data and its
influencing work for the improvement of later life in England.

Jake has a BA in natural sciences and an MSci in systems biology from the
University of Cambridge.

Veronica Dale is a statistician in the Health Services and Policy Research Group

in the Department of Health Sciences at the University of York. She has an MSc in
Biometry from the University of Reading. She joined the University of York in 2002,
as a trial statistician. She has since worked in the addiction research group, working
on trials based in the field of addiction, and as statistician for the National Audit of
Cardiac Rehabilitation. She is currently working on a number of projects relating to
health policy and the NHS workforce.

 

About the authors

47
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© The King's Fund 2022

First published 2022
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Edited by Kathryn O'Neill

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www.kingsfund.org.uk yw @thekingsfund
 

Oa t=2 (a) le Peer

The Additional Roles Reimbursement Scheme (ARRS) was introduced in
England in 2019 with the aim of supporting the recruitment of 26,000
additional staff into general practice. While primary care networks (PCNs)
have swiftly recruited to these roles, how well are they being implemented
and integrated into primary care teams?

Integrating additional roles into primary care networks explores how ARRS roles
are being embedded within general practice, focusing on the experience

of staff working within these roles and the people managing them. The
authors highlight a number of factors that are having an impact on how well
the roles are being implemented and integrated, including 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. In addition, there are practical considerations regarding
adequate estate and questions over future funding for the roles.

The authors share examples of good practice and positive stories, but make a
number of recommendations to ensure successful implementation, including:

-_aclearer, 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.

ISBN 978-1-915303-01-1
The King's Fund
11-13 Cavendish Square
London W1G OAN
Tel: 020 7307 2568
Charity registration number: 1126980 9781915303011

www. kingsfund.org.uk