NHS England should ‘urgently’ review the impact of the Additional Roles Reimbursement Scheme (ARRS) which could be ‘distorting’ staffing decisions, a new report has argued.
The report, published by influential health think tank the Nuffield Trust yesterday, reviewed the expansion of ‘new’ roles such as physician associates, and called on NHSE to ‘openly’ outline governance arrangements and ‘up-to-date’ scope guidance for such roles.
In general practice, it highlighted the ‘particularly stark’ reshaping of staffing, revealing that the ratio of fully-qualified GPs to other clinicians has fallen from one to 1.1 in September 2015, to one to 2.6 now, due to the ‘expansion of non-medical roles’.
The Nuffield Trust said that three-quarters (78%) of staffing growth in GP practices over the past five years has been via the ARRS, while pointing to the ‘tension’ this has caused within professions.
According to the report, those employed via the ARRS reported ‘higher salaries’ and ‘more access to professional development’ than their counterparts employed directly by GP practices.
In its recommendations, the Nuffield Trust said: ‘Financial support can be important to support the implementation of new or emerging roles, particularly in certain settings; however, the current funding arrangements may be distorting local decisions on skill mix.
‘NHS England should – as a matter of urgency – revisit the principles, practicalities and impact of salary reimbursement initiatives.’
As well as the ARRS, the report pointed to staffing decisions in hospitals, where the management team is ‘incentivised’ to use junior doctors rather than other staff because NHSE covers half of their basic salary costs.
It also highlighted potential issues with ARRS roles seeing undifferentiated patients, arguing that ‘triaging patients’ to ensure they see the right member of staff ‘is a key feature of effective role design’.
‘Failures to do this have led at times to ARRS roles receiving inappropriate referrals, which was sometimes also driven by supervising staff lacking understanding of their colleagues’ capabilities,’ the report said.
Patients seeking a diagnosis for the first time ‘create a challenging dynamic’ and the evidence base on this issue is ‘sparse’, according to the think tank.
The report explored a number of professionals including PAs, nurse associates, advanced nurse practitioners, and clinical pharmacists – but did not ‘evaluate the merits’ of any one profession.
It warned the Government and NHS England to ‘avoid repeating past failures’ when introducing new roles, and suggested that plans to grow the workforce further may be jeopardised by over-stretched services and a lack of training capacity.
For new roles, the report said there needs to be a ‘clear outline’ of what they ‘can and cannot do’, which ‘will likely require some national intervention’.
‘NHS England and, where appropriate, professional regulators and counterparts in the other UK nations, must outline (openly) the governance arrangements for the roles and/or publish up-to-date guidance on the scope and ongoing development of these roles,’ it recommended.
On PAs specifically, the report said there ‘remains a lack of awareness and confusion around their scope of practice, professional boundaries and legal status’.
The GMC – which began regulating the profession in December – has been clear that it will not itself set out a scope of practice, but will ‘have reference’ to guidance produced by royal colleges in its fitness-to-practise proceedings.
Other recommendations
- NHS Employers along with national bodies and staff-side organisations should explore what incentives and support are needed to ensure sufficient and fair access to supervision.
- NHS England should commission work to explore the capacity implications of the projected expansion of education and training specifically for emerging roles, but including the planned expansion of more established roles.
- Employers must ensure that any job adverts and role descriptions are appropriately aligned to any updated guidelines, particularly given the lack of shared understanding of the nature and purpose of some new and emerging roles.
- National bodies should commission more independent research on the impact of different staffing mixes on patient outcomes.
- The government should regularly monitor public and patient understanding of different roles involved in delivering frontline care and, where necessary, use communications campaign programmes.
Source: Nuffield Trust
A report last year suggested that the ARRS, which was intended to grow additional capacity and solve workforce shortages, has failed to substantially reduce workload pressures for existing GP staff.
It warned that GP workload shifted to the newer roles was being ‘left incomplete’ due to a lack of knowledge and skill.
