Pulse takes on September’s talking points – what is going on with the ARRS expansion, and what precedent does the RCGP’s vote on physician associates set for primary care?
Is the Government’s decision to include GPs as part of the ARRS just a publicity stunt?
If a Pulse reader from six months ago saw we were talking about the expansion of ARRS to include GPs, as an actuality rather than a pipedream, they would barely believe it. It was something that we had all argued for and believed would be a substantial step in trying to heal the predicament the profession is in.
Fast-forward to now. It is the day before GPs can be hired as part of the ARRS and any initial enthusiasm towards the expansion has seemingly dissipated. From the moment it was announced, to the delay in details and logistics, it seems as if the announcement was an empty PR gesture, rather than a move to genuinely help general practice.
Health secretary Wes Streeting announced the inclusion of GPs to the ARRS the day before GPs were meant to start taking collective action. It is unlikely he thought doing that would result in action being called off, but the timing could certainly be perceived as being done to overshadow or undermine the movement. But regardless, the £82m added to the pot specifically for GPs was seen as a step in the right direction of his hope to ‘reset the relationship’ between GPs and the Government.
But beyond the glossy headlines, the closer we have got to the start of the scheme and the more details that have been released, the less practical and helpful the scheme seems to be.
Firstly, funding for the scheme is only available at PCN level. The BMA urged Streeting to allow funding to go directly to practices. It argued that this would provide stability required to address the unemployment crisis, and address GP shortages in the places most severely affected.
GP inclusion to the ARRS was labelled as an ‘emergency measure’ for 2024/25 from the start. This means that any GPs employed through the scheme would only be guaranteed employment for six months. This is not an appealing prospect at the best of times, but especially not to GPs out of work in an employment crisis.
These were issues apparent from the outset. Those who were concerned about the final details were promised clarity about the ‘exact criteria for employing GPs’ in the revised Network DES. But this updated PCN DES only came out last week – a mere five days before the funding came into use. This gave no time for advertising or recruitment. In short – it is incredibly unlikely that there will be any GPs working under the ARRS by day one tomorrow.
The updated DES also gave the eligibility criteria for GPs that could be hired through the scheme. Initially, we were told the ARRS expansion was to cover ‘newly–qualified’ GPs which was ambiguous. This has now been clarified. GPs can only be hired through the ARRS if: they CCT’d less than two years ago; they have not been ‘substantively employed as General Medical Practitioner’ in general practice previously; and they are not being employed on a locum basis. These guidelines are incredibly restrictive and leave a lot of unemployed GPs ineligible.
There is no indication from NHSE or DHSC whether this expansion will be extended beyond 2024/25 which would provide both employers and employees with more security and opportunity. Furthermore, because of the delay in releasing the updated PCN DES and the knock-on effect that may have on hiring, there may be money left unspent by PCNs come April. Ordinarily, ARRS funding cannot be carried over to the next financial year, but given the ‘emergency’ status of this measure and the lack of notice, it would be useful to be able to carry over any unspent budget.
The more cynical may believe that the lack of consideration and forethought was intentional by the Government. Who’s to say? At the very least though, this seems a token gesture to appease GPs without any understanding of the individuals involved and the stability needed to start tackling the unemployment crisis.
What does the RCGP’s vote on PAs mean for general practice?
The RCGP’s vote to oppose the role of physician associates (PAs) in general practice last week was welcome news to many. Although the PA debate has not been as prevalent in the past months, as pointed out by Pulse deputy editor Sofia Lind, the college’s decision to completely oppose the role has brought it right back to our headlines. But what does it actually mean going forward – not just for the deployment of PAs in general practice, but for the wider landscape of primary care?
This vote follows a consultation carried out by the college in June which found that over 80% of surveyed GPs believed that the use of PAs in general practices has a negative impact on patient safety. Consequently, the RCGP urged practices to pause the recruitment of PAs until the profession is regulated by the GMC later this year.
As always with RCGP decisions and stances, it is difficult to know straight away what the actual impact might be. Although many will consider the college to be out of touch, it is still the professional membership body for GPs. Even if the stance is purely symbolic, it may well influence some GPs – e.g. they might decide to stop employing PAs as they are following the RCGP’s position. However, the college has no official power to ‘ban’ PAs or sway the GMC’s regulation.
Something that may make its position stronger however is publishing a scope of practice, which could become enforceable if either NHSE or the GMC choose to adopt it. The college recognised that there are already 2,000 PAs working in a general practice setting and that these individuals cannot be cast out. So, the RCGP voted on a new set of guidance to limit the scope of practice for these existing PAs. Members voted down a clause that would have allowed individual GP practices the discretion to permit these PAs to work beyond the recommended scope of practice. The college has promised that it will set out clear guidance on the scope of practice (as well as on induction and preceptorship) but that this will require ‘further work’ before fully published.
This begs an interesting question into what introducing a scope means, and the impact it may have on the broader landscape of general practice. It is understandable why people want a scope – a lack of one gives way to poorly defined boundaries of capabilities and responsibilities.
But PAs are merely one of the many non-doctor roles in general practice: think of your nurse practitioners, paramedics, pharmacists etc. It is debatable whether all these roles have a ‘clear scope of practice’ or not, and if there is an agreement as to what that actually means.
Regardless, what most people would agree with is that at times, all these different roles are working beyond their capabilities whenever they encounter undifferentiated illness. Because they aren’t trained/expected to deal with these cases, and don’t want to run the risk of missing something serious, they over-investigate. Some GPs will (quietly) agree with this, and secondary care doctors certainly will.
The focus on a scope of practice for PAs could be the tip of the iceberg of non-doctors working beyond their scope. If the RCGP decides to be consistent in its response – limiting and opposing all non-GP roles – then primary care would fall apart. Don’t get us wrong – this isn’t to advocate for letting the 2,000 existing PAs run rampant. But it theoretically sets a risky precedent, and hints of throwing the baby out with the bathwater…
