Big questions: GP ARRS figures, and elective reform workload dump

Maya Dhillon takes on January’s talking points – what’s going on with GP ARRS figures, and why is general practice still the workload dumping ground for secondary care reform?

Why don’t we know how many GPs have been hired under ARRS?

As a ‘Hail Mary’ the night before collective action began in August, health secretary Wes Streeting announced an extra £82m to the additional roles reimbursement scheme (ARRS) to hire 1,000 more GPs. 

Of course, there were restrictions and questions on this mammoth U-turn. The expansion only applied to newly qualified GPs; the money was available for ‘this year’ suggesting that jobs might only last up until March; if the £82m wasn’t used up within those six months, would it still be available to general practice?

Though announced in August, the ARRS funding for GPs was only available two months later, because the PCN DES required an update. By the time it got to October, Mr Streeting assured that the funding to hire GPs via the ARRS would ‘continue beyond March’ of 2025. 

Why all the preamble here you ask? Well, with the faff and time (Pulse editor-in-chief Jaimie Kaffash argued for it in 2023) it took to get GPs added to the ARRS, you’d want to see some results. But, four months in and we are none the wiser as to how many GPs have been employed through the scheme. 

A Pulse survey showed that at least 13 PCNs had hired GPs through the ARRS in the first weeks of the scheme. In December, RCGP chair Professor Kamila Hawthorne shared that of the 1,000 ARRS GP jobs available, just over 300 had been filled. NHS England is yet to publish the number of GPs hired through the scheme, and said it cannot provide a timeline for when this data will be publicly available. 

There seems to be a pact of silence around these figures. Primary care minister Stephen Kinnock said that data was being ‘collated’ and verified to ‘establish its reliability.’ Mr Streeting gave a cheerfully vague response that ‘hundreds’ had been recruited and hundreds more will come in the following months. 

NHSE declined to clear up the confusion surrounding numbers. But, it did send a letter to PCNs encouraging them to use their GP ARRS funding entitlement for 2024/25. It continued by saying it was ‘monitoring’ the data and will be asking ICBs to work with PCNs who have yet to take advantage of the funding. One might infer then that the £82m and 1,000 positions have not been used up and filled. A more cynical person might go on to question whether that is why the figures have not been released yet; because they are not that impressive and it reflects badly on the Government.

Given that the BMA previously criticised the salaries made available for ARRS GP salaries – calling them ‘derisory’ and ‘uncompetitive’ – perhaps there has not been a lot of enthusiasm from newly-qualified GPs to take up this role. Posts in various doctor forums and subreddits suggest so, as well as anxiety about the security of these roles.

A recent email from the GPCE chair Dr Katie Bramall-Stainer said: ‘The secretary of state is no doubt frustrated that despite removing the barriers to enable GPs to be recruited, his announced target of 1,000 new GPs is far from being realised, yet the numbers of unemployed GPs continue to make headlines.’ She continues by coming to the conclusion – that is perhaps becoming inevitable – that ARRS is not a suitable framework for GP recruitment, at least in its current form.

With contract negotiations underway and LMCs being given the chance to vote on the offer next month, it will be interesting to see how the ARRS is handled. Will the ring-fencing be dismissed and the pot be re-assigned to the core contract? Will the ARRS be completely killed for all roles? Until that point, let’s at least hope for some transparency in the numbers.

Why does elective reform have to mean GP workload dump?

The elective reform plan came in like a trojan horse for general practice: seemingly offering with one hand, and then delivering a deft blow with the other. 

Announced in early January, the plan was aimed at tackling waiting times for routine hospital treatments in an effort to meet the 18 week referral to treatment standard by March 2029. As part of the plan, GPs across England were told that they would start to be remunerated for advice and guidance (A&G) – £20 per request from a £80m funding pot. 

The BMA had already advised practices to stop engaging with A&G pathways as part of collective action. With the announcement of the £20 remuneration for the action, GP Committee England chair Dr Katie Bramall-Stainer suggested that this may now be dropped from the collective action ‘menu’, adding that it was the ‘first example’ of the Government’s commitment to ‘shift activity and resource outside of the acutes’.

Not everyone was so taken in by the proposal. Pulse editor Sofia Lind pointed out that even though payment was a good thing on the surface, the spectre of increased workload loomed near and we should all be wary of it. And rightly so – the Government said that as part of its bid to lower waiting lists, GPs would be expected to ‘increase uptake’ of A&G to 4 million advice requests in 2025/26 – up by 1.6 million from 2023/24. But £20 for a service GPs were already doing for no funding at all is still better than nothing… right?

It was only when looking closer at the plans, below the headline announcements, that the Greeks spilled out of the wooden horse. Hidden beneath the expansion of A&G, the plans to reform elective care also revealed plans to ‘standardise pathway referral criteria’ for GPs, including for ‘pre-referral investigations’. Introducing stricter requirements for hospital referrals would see a huge workload dump pushed onto GPs – which is hardly surprising. Previously, the BMA and several LMCs pushed back on trusts rejecting GP referrals, stressing that trusts are, in fact, ‘contractually obliged’ to accept GP referrals. 

Pushing unfunded extra work onto GPs is ironic given that we are supposedly pushing back on it as part of collective action. Successive governments’ default solutions to a failing NHS seems to be plugging the gap with unresourced GP work, but this is a particularly unwelcome move from a new health secretary who promised that general practice would ‘do well’ under a Labour government and that he would ‘reverse’ GP underfunding. And bear in mind it is not the first misstep – who can forget the National Insurance hike fiasco? 

The disregard for GPs’ time and efforts is nothing new. We have seen time and time again that increased unresourced workload in general practice is seen as the ‘cure-all’ for the health system. GPs are expected to do somebody else’s job; and they often do so to ensure the patient won’t suffer. What nobody seems to understand is that this will only serve to exacerbate the existing pressures and issues within the system, leading to an all-out implosion. 

Between the proformas and pre-referral investigations that ‘standardising referral criteria’ might bring, I paraphrase the words of Copperfield: ‘When do GPs get the time to actually be GPs?’