New roles in General Practice not addressing workload issues
A major new report has highlighted the multiple challenges posed by the introduction of the ARRS (Additional Roles Reimbursement Scheme) in England.
The report, by the Queen’s Nursing Institute’s International Community Nursing Observatory (ICNO), is based on the survey responses of over 500 General Practice Nurses (GPNs) in 2023.
The ARRS was introduced into general practice by Health Education England in 2019. The scheme funds the salaries of 17 roles to expand the primary care workforce. These roles include care co-ordinators, pharmacists, paramedics and associate professionals such as Nursing Associates, Physicians Associates and their trainees. It does not include GPNs.
The report’s authors are Professor Alison Leary MBE, Director of the ICNO, and Dr Geoff Punshon. The report should be viewed as an independent retrospective workforce impact assessment. Workforce impact assessments can clarify the potential or actual impact of major changes on the workforce and act as a meaningful form of workforce engagement.
Summary Survey Findings
Work/care previously done by GPs and GPNs was shifted to ARRS colleagues that they could not complete due to lack of knowledge, skill, being out of scope, regulatory issues or unfamiliarity with primary care. This meant care was left incomplete, with GPNs having to perform rescue work, complete the episode of care or teach colleagues.
ARRS roles contributed positively to distribution of work and clinical outcomes/quality of care when used in context of professional expertise, for example mental health nurses, pharmacists undertaking medicines reviews, dietitians offering an extra service previously not available. When roles were used out of normal context and jurisdiction, they impacted on the workload of GPNs as ARRS professionals sought more advice and support and were leaving work incomplete.
The introduction of ARRS roles appears not be based on local demand, but rather on availability and funding. The scope and design of roles appears to be largely unexamined. The roles appear to be implemented to fill a deficit in already established roles (GPs and GPNs) rather than as an additional value-added role arising from workforce/work redesign.
The introduction of ARRS roles was a major workforce change, with little or no consultation with GPNs despite potentially impacting on their work.
Inequitable pay and conditions were reported. ARRS colleagues were reported to be on higher Agenda for Change banded salaries and have more access to professional development.
Role creep and the burden of supervision, particularly for Trainee/Nursing Associates, was a recurring theme.
GPNs felt that more people delivering care who could not complete episodes of care led to more ‘taskification’: task orientated, disjointed care, repetition of work (for workforce and patients) and subsequent risk as care became fractured.
Perception of disinvestment/devaluation of nursing was a recurring theme. Low morale was reported because of this.
There were high expectations and assumptions from employers that GPNs would support, educate, and supervise roles, but without consultation or the provision of extra resources.
Resources and support are required to support even experienced professionals adapting to working in primary care.
The QNI chief executive Dr Crystal Oldman CBE, said: “The QNI received accounts of the impact on the GPN workforce of the introduction of the ARRS. This included issues such as pay inequity and increased workloads.
“We decided to undertake the survey led by Professor Alison Leary to investigate this impact in a systematic way.
“The survey shows that multiple assumptions were made about the primary care workforce and no real assessment of the impact that ARRS was likely to have. This has led to the GPN workforce feeling devalued. In some cases, GPNs have experienced significant disadvantage.”
Professor Alison Leary MBE, ICNO Director, The QNI, said: “The introduction of ARRS has been problematic for the General Practice Nursing workforce.
“Change in the workplace affects the workforce and major changes should be assessed for potential impact on the workforce.
“ARRS appears to have impacted the workforce in several ways. This ranges from a lack of resources to support those new to primary care, expectations by others of GPNs filling a gap, and a lack of consultation regarding a major workforce change, leading to feelings of devaluation. There are significant equity issues highlighted particularly around pay and opportunity.”
The QNI makes the following recommendations based on the findings of the survey:
There should be full and meaningful workforce engagement in any major change affecting the workforce.
Inequity of opportunity, for example development opportunities and pay inequity, needs to be addressed.
The introduction of ARRS roles appears not be based on demand but rather availability, including the availability of funding. The scope and design of roles appears to be largely unexamined. The roles appear to be implemented to fill a deficit in already established workforces, rather than as an additional value-added role arising from workforce redesign. Demand modelling should take place if implementing new roles.
The benefits of ARRS roles used to meet specific previously unmet demand were clear, but there needs to be clarity around all roles and scope of practice, particularly for those new to primary care.
There needs to be more resourcing of teaching, supervision, and support, not only for new roles but also those transitioning to a new area of practice.
There should be scrutiny at a regional and national level of how the ARRS impacts on the overall workforce strategy in primary care and the community healthcare workforce.
To read the report, click here