ARRS: Game changer or game over?

The additional reimbursement roles scheme (ARRS) has been a real game changer as far as primary care is concerned.

The initial ambition of 26,000 new entrants into the workforce to ease the burden on GPs has been smashed with 37,000 employees now under the scheme.

Its seismic effects have been felt across primary care.

Community pharmacy has reeled from a shift of the workforce into PCNs with clinical pharmacists and pharmacy technicians proving to be the most popular ARRS hires.

Having been initially excluded, nurses are now in the ARRS fold. A move which began with advanced practitioner, followed by enhanced nurses and now general practice nurses. But this generated concerns around a two tier pay system between practice staff and ARRS employees. This issue is of course not limited to nurses.

And to address the issue of GPs being unable to find work they were added to the scheme in October. But despite having called for the measure its not been implement in the way it was hoped to be. Only newly qualified GPs, who haven’t worked for the PCN practices before need apply, added to that the reimbursement is considered low.

The competency and appropriateness of staff has also been called in to question. This debate has centred around physician associates with alarm bells sounding after a high profile case involving a physician associate and an incorrect diagnosis – that and with an announcement that the Government has an ambition to increase PA number to 10,000 has seen a back lash resulting in GMC regulation and RCGP scope of practice and a decline in the numbers higher and no doubt a very disheartened sector of health professionals.

And have ARRS staff saved time – have they decrease the number of interaction with a GP and saved GP time or have they resulted in more appointments and a delay in seeing a GP. The evidence on this is lacking or ‘too early to tell’.

It appears ARRS staff have increased access and patients appreciate that but detractors will say is it the right kind of access and actually does it harm those patients who are deprived and/or less able to advocate for themselves. Experts say yes.

The there is the lack of space – 37,000 people have to be somewhere to do their job to see patients and given the general practice estate was not in perfect working order before this policy it would seem now to be completely unsustainable.

This report takes a look at these issues as highlighted in a White Paper from Pulse PCN’s publisher Cogora.

Download our General Practice Workforce White Paper here.

Then roots of the ARRS can be traced back to GP shortages which began a decade or so ago. In 2011/12 reports of practices – particularly outside London – struggling to recruit started to emerge. The health secretary at the time, Andrew Lansley, announced plans in 2011 to increase GP training places by 20% to counter this.

By 2015 this had become a full-blown crisis with Lansley’s successor Jeremy Hunt announcing a 10-point plan to increase GP recruitment, which included the now infamous commitment to increase the GP workforce by 5,000 within five years, as well as a promise to increase the number of non-GP healthcare professionals.

In 2015, the first concrete policy to address a shortfall in GP numbers came in, with a £15m scheme for GP practices to employ pharmacists. This was turbocharged in 2019 by the new GP contract. Through the additional roles reimbursement scheme (ARRS), practices were incentivised to join ‘primary care networks’ (PCNs), groups of practices that would mainly cover populations of 30,000-50,000 patients.

The contract committed £938m of extra funding per year by 2023/24, with a total of £1.79bn directed towards the new PCNs, predominantly through the ARRS.

This scheme funded the recruitment of non-GPs to general practice, with the five-year 2019 contract providing pharmacists (building on the earlier scheme) and social prescribers in the first year, followed by physiotherapists, physician associates and paramedics in later years.

Since then, the ARRS has been expanded to include occupational therapists, dieticians podiatrists and mental health practitioners among others, with newly qualified GPs added in 2024 by the new Government and plans to include practice nurses the latest change to be announced.

While the number of FTE GPs has gone down, the total number of practice staff has increased, mainly due to this influx of non-GP healthcare professionals. At the same time, practice nurse numbers have been rising at a steady rate.

The addition of clinical staff who are not GPs or nurses, and a huge increase in administrative staff, has led to more people than ever before being employed in general practice.

Of course, there are caveats to this – since the introduction of the ARRS, we have gone through Covid and a major economic downturn. But this has been the key policy for all recent health secretaries and NHS England, and it is likely this would have been the direction of travel regardless of these disruptions.

There has been an obvious effect on provision of patient care. In 2024, for the first time, only half of appointments in general practice were with GPs.

This shift is likely to continue, with many ARRS staff being upskilled. For example, from 2026, all new graduate pharmacists will be qualified to prescribe.

Download our General Practice Workforce White Paper here.

There is both a shortage of GPs in the system, and a shortage of jobs for GPs, which could be seen as a ludicrous situation.

Practice managers say there are two reasons for this, and the ARRS touches on both. First, there is a lack of funding; second, practice premises are often inadequate to accommodate GPs.

In 2019, as part of the five-year contract, the BMA GP Committee and NHS England agreed to set annual increases of around 2% a year. At the time, many saw this as helpful for GPs – and there were even suggestions that other parts of the NHS were envious.

Up until 2021/22, GP practices were seeing a real-terms increase in funding. Part of this would have been the money they received for carrying out Covid vaccinations.  But 2022/23 saw a real-terms funding decrease.

Since then, we have seen huge inflation and the cost-of-living crisis, yet the funding uplift remained at around 2% a year. This means that there has been a drastic cut in practices’ real-terms funding. The Labour Government’s first Budget has exacerbated matters with the increase to employers’ National Insurance Contributions (NICs), which was intended to raise money for the NHS. GP practices were considered the big losers in this policy; they were not guaranteed public funding from the increase because they were considered ‘private sector’, yet GP practices do not benefit from tax breaks for smaller businesses because they are considered ‘public sector’ for this purpose.

Since then, Wes Streeting has announced the increase in funding of £889m a year – roughly 6%. This funding has been welcomed by the profession, although cautiously. The Cogora white paper analysis suggested the increase in National Insurance will cost practice £260m. Furthermore, the details of how the funding will be provided to practices – and, crucially, what extra work they will be expected to do – won’t become clear until 2025/26 contract negotiations with the BMA’s GP Committee England are concluded.

But practices are currently facing a funding squeeze that has the effect of making ARRS staff look more attractive, even if the available roles are not the most appropriate for patient care.

These staff are not only paid lower salaries but their costs are at least partly reimbursed by the NHS.

Dr Ian Sweetenham, a GP partner in Cambridgeshire, says: ‘We couldn’t find GPs two years ago. Now that I have them coming out of my ears, I have no money to employ them.’

The general practice funding shortfall leaves practices facing unwelcome decisions. Around 6% of practices said they have had to make redundancies, while a further 20% said they had to decide not to replace departing staff.

This is affecting care. A GP partner in Leicestershire says: ‘As a practice we are always short of appointments, patient demand is tremendous. However, purely for financial reasons and the fact that the practice is struggling to function at a profit, when our three –  session salaried GP resigned we made the decision not to replace them. Instead, we decided to try to manage as best as we could without these sessions. This was in spite of the fact that when we advertised to recruit a replacement for another departing GP in the last year, we had more than 20 applicants so would have had no difficulty finding a good-quality candidate to fill the sessions had we chosen to.

‘In addition to this, we have also chosen not to replace two reception staff members who left – again, in the hope to save money. I reiterate, not for profit, but hoping to break even.’

In this context, cheaper non-GP staff look more attractive. One GP partner in Buckinghamshire said their practice had to ‘restructure [to] keep our doors open and allow us to continue to provide a service including not replacing all the clinical sessions a retiring GP used to offer. More GP sessions are being replaced by cheaper clinicians’.

GP pay is often highlighted when practice funding is under scrutiny. In 2022, following such scrutiny, the Government amended the GP contract so that partners earning more than £150,000 would be forced to declare their earnings. But simply reducing earnings would not enable them to hire more GPs.

The GP partner from Warwickshire says: ‘I earn good money as apart-time partner, and there’s an argument that my partners and I could earn less and there would be money for another GP.

‘However, it isn’t as simple as that. We’re being offered two days of an advanced care practitioner anyway by the PCN, and it seems silly not to use this. One of our nurses has just completed her ACP training, so we’ll have her for another two-and-a-half days. I’d rather have another GP, but we’re reluctant to have both. We’re unsure what Wes Streeting plans for general practice, and we don’t want to commit to another GP unless we know our funding will continue at the same level.’

Download our General Practice Workforce White Paper here.

The state of GP premises often means there is nowhere for additional staff to practise. GP premises are in dire need of modernising – a major 2023 RCGP report found they were ‘inadequate’, concluding that the allied healthcare professional staff had ‘expanded greatly in recent years, without a parallel expansion of clinical space for them to work in’. While the Budget in November 2024 did commit £100m to modernising GP premises, it specified that this would be limited to 200 surgeries.

One GP in Northamptonshire says: ‘We do not have anymore space in our building to recruit additional clinical or administrative staff, and this has led to us running at a far higher number of patients per FTE staff that we would ideally have. In our recent round of recruitment to salaried GP roles, we had many more suitable candidates that we have the space to employ and undertook competitive interviews to select our current employees including ARRS-subsidised recently qualified GP roles.

‘We really need to find an additional or alternative site but options for funding this are limited or unattractive. We already undertake remote working where it is possible to do so safely, and most of our ARRS staff are based in other GP surgery buildings within our PCN. Some clinical rooms are even shared between clinical staff within a session, with a staff member using a room while another has left to undertake a care home round.’

This is a common problem. Dr Grant Ingrams, chief executive of Leicester, Leicestershire and Rutland LMC, says his practice ‘has GPs working from home at times but there are continued problems finding space for people to work from’.

Alex Kimber is a managing partner in Dorset says: ‘I am literally in the process of converting a toilet and cupboard into a telephone consultation room, which isn’t ideal but needs must. Anywhere non-clinical on the ground floor is turning into clinical space. We’ve had to make a waiting room smaller to create another clinical room and are being creative in the way rooms are shared. Meanwhile, my non-clinical team is being shoehorned into smaller spaces upstairs with many more per office than they were designed for.

‘The ARRS staff are great but for our PCN we have to house them in our building as the other practices are smaller and just don’t have the regular space for them.’

Another GP in West London says they ‘could certainly do with additional nurses but are already struggling with space for existing staff, who are having to cope with hot-desking’.

A GP partner in Lancashire says: ‘In 2023, we changed some storerooms into additional clinical rooms and we still don’t have enough space. We have no expansion land as the NHS sold it off years ago. We have nowhere else to go to get more rooms. This impacts who we can hire and what days they can work, as we find clinicians have to room-share or change rooms daily depending on who is in.’

Download our General Practice Workforce White Paper here.

For pharmacists who have come into general practice, morale seems good. Around 70% of practice pharmacists see themselves still being in general practice in five years’ time.

Pharmacists are popular hires for PCNs and the GPs that work with them the latest data show that there are nearly 5,500 pharmacists recorded, although not confirmed, under the ARRS.

On the whole, practice managers and GP partners responding to our sister title –  Management in Practice and Pulse – surveys have found pharmacists useful.

But there is debate around whether their introduction to general practice has had a destabilising effect on community pharmacy. One thing is certain – a significant number of pharmacists who are now in practice originally worked in the community.

The House of Commons Health and Social Care Committee’s report on pharmacy concluded there should be a review of the ARRS to explore flexibility on the funding criteria that could ‘reduce the drain of community pharmacists into primary care networks’.

Of the 137 practice pharmacists surveyed by sister title The Pharmacist, only 9% had never worked in community pharmacy, with 76% transferring to general practice completely and 17% working across both sectors.

The Pharmacist survey found that 58% of the 101 practice pharmacists who had left community pharmacy said they made the move because they preferred the work in general practice, while 42% said they wanted to develop their prescribing skills. From summer 2025, all newly qualified pharmacists will need to be able to prescribe.

Utilising skills was a major factor for those who made the move. Mayoor Kerai, a practice pharmacist in Kent says: ‘I had completed independent prescribing training in community pharmacy and I wanted to use this skill. I had also reached a glass ceiling in community pharmacy and was unable to progress any further. I chose the practice role to allow for this personal development along with better salary and work/life balance.’

Another practice pharmacist in Swindon says: ‘I worked in community pharmacy for many years and I really loved interacting with people. That’s something I knew I would miss when I left community pharmacy. But although I was learning new things from time to time, I didn’t feel I was learning enough. I wanted to have a more clinical role and I wanted to learn more in that area. Although there were new services being offered by community pharmacists, I did not feel we had enough support to deliver them.’

There are also those who say there were issues with workload in community pharmacy. One practice pharmacist in Staffordshire says they left due to ‘pressures in community, underfunded pharmacy contract resulting in fewer staff, with more stress and more services alongside a prescription factory system that didn’t make best use of clinical skills’.

Another based in southeast London says: ‘I work fewer hours and don’t have to stress for being late and finding a queue of angry patients or even angry staff on occasions. I have the flexibility of managing my own break times without feeling like being micromanaged. And of course not having to stand on my feet the whole day was the icing on the cake!’

There is also little dispute that community pharmacy is facing workforce problems. A Community Pharmacy England (CPE) survey representing 6,100 pharmacy premises in 2024 found that 58% of pharmacy owners said they were short of pharmacists, while almost two-thirds (62%) of pharmacy team members reported a reduced ability to offer services or advice to patients because of staffing shortages.

Indeed last year a net loss of 432 bricks and mortar pharmacies over the 2023/24 financial year, was revealed by the Company Chemists’ Association (CCA).

This equates to more than eight pharmacies permanently closing each week, the CCA said.

But there is some dispute over whether this is a direct result of the ARRS. CPE said the scheme had ‘led to the recruitment of over 5,000 pharmacists, primarily from community pharmacy, into GP surgeries and PCNs’, resulting in ‘shortages, temporary closures and rising costs’.

But President of the Primary Care Pharmacy Association Dr Graham Stretch says there should still be enough pharmacists to support both sectors.

He told the select committee in November 2023: ‘The actual numbers are very interesting. ARRS supports 4,689 pharmacists, of which, in July 2019 to September 2023, 3,047 have come from the community sector. That is a significant number and I am not pretending otherwise. In the same period, the General Pharmaceutical Council’s register has grown by 7,308, more than double the number of pharmacists moving from community into PCN.’

However, Dr Stretch did acknowledge that ‘that oversimplifies things, because we have portfolio roles’.

A qualitative study of the effect of ARRS found there were ‘unintended consequences at system-wide levels, including large numbers of staff moving from other services to work in the scheme, which left some services depleted of their workforce’.

Dr Zoe Anchors, a researcher at the University of the West of England and one of the authors of the study, says: ‘The three things that were coming up in terms of concerns around the destabilising of NHS services were: pharmacists being taken from hospitals and community pharmacy; paramedics moving from emergency care services; and the impact on wider mental health service providers of including them in the ARRS. All of these were impacting NHS services. Some people said we are “robbing Peter to pay Paul”.’

Download our General Practice Workforce White Paper here.

There is little doubt that morale in practice nursing is low. In September, a survey by sister title Nursing in Practice revealed half of practice nurses were considering leaving the profession in the next 12 months, and in an interview with NIP, the new professional lead for primary care at the Royal College of Nursing (RCN) Kim Ball said the profession was in a ‘precarious’ position.

There are several factors behind this and, as with GPs, some of the issues predate the ARRS. But it is apparent that the ARRS has compounded this low morale.

Previous governments’ solutions over the past decade have been focused away from the traditional roles of nurses and GPs, and have been focused on the wider team – specifically through the ARRS.

The ARRS includes nursing associates, advanced nurse practitioners and more recently enhanced level practice nurses.

Until December 2024, there had been no plans to include the general practice nurse (GPN) role in the scheme. But just before Christmas, health secretary Wes Streeting announced that a proposal to include practice nurses in ARRS had been put to consultation with the British Medical Association (BMA) as part of the incoming GP contract.

ARRS has drastically changed the configuration of the general practice team.

Data from NHS Digital reveals that the number of nurses in general practice is increasing. But at the same time, they make up a much smaller percentage of the general practice workforce – 18% in 2024, compared with 26% in 2019. And they are carrying out a decreasing percentage of the appointments.

Then there is the influx of nursing associates. According to latest figures from NHS Digital, the nursing associate workforce in general practice has increased by a quarter from December 2023 to December 2024 (from 410 to 511 full-time equivalent staff). Being an ARRS role and a Band 4 position, and there are concerns that GPNs are being substituted or replaced by this cheaper alternative role.

The RCN has previously warned that the ARRS has sparked ‘a lot of role substitution’ of GPNs since its introduction, while the Queen’s Nursing Institute (QNI) has been calling for clearer guidance on the ‘scope and limits’ of nursing associates amid some reports of those in post working above their clinical responsibilities in general practice.

There is also the increasing role of advanced nurse practitioners to consider – a workforce that has risen from 343 full-time equivalent staff in December 2023 to 501 in December 2024, according to data from NHS Digital for England. However, this data for December 2024 is understood to include the new enhanced level practice nurse role – an experienced GPN with postgraduate qualifications – which was added to the ARRS in April 2024.

This change in the make up of staff is having an impact on the work of practice nurses.

More than half of respondents to Nursing in Practice’s September survey said their work is more solitary than two years ago, and this is on the whole due to new staff taking over nurses’ work and nursing teams being shrunk. Around a third say their job has changed for the worse since the ARRS was introduced in 2019.

In her Nursing in Practice interview, Ms Ball said the practice nurse role ‘can be very isolating’. She added: ‘I think there’s been a lot of change in general practice in terms of having more of a multidisciplinary team and nurses feel that they’re being excluded from discussions about service provision.’

One nurse, who has been practising for four decades, agrees that the job is more solitary now. ‘There used to be time for nurses to meet up in peer groups. Now, often, there may only be one nurse in a practice along with ARRS staff. The nurse might be doing mostly cytology and baby immunisations. Long-term conditions will be delegated to the physician associate or nursing associate, who will not have the clinical knowledge that I do.

‘Without practice nurses, general practice will lose its heart. When I read that GPs will have to do all these new immunisations or checks, I know the truth – it will be the nurses who do them.’

Most feel they are poorly recompensed and – while this is not completely linked to the ARRS – comparisons with the new staff (especially those whose pay is linked to Agenda for Change) are exacerbating their displeasure. Furthermore, there is a growing feeling among practice nurses that they are being replaced, and that is closely linked to the ARRS.

Pay has been a huge issue for practice nurses. NIP’s September survey found that half of practice nurses received no pay rise in 2024. The RCN cited NIP’s findings in its evidence to the independent pay review body for GPs, calling for an investigation into why practice nurses are not getting pay rises. The college also issued a joint statement alongside the BMA in December 2024 urging practices to give nurses the 6% pay rise recommended by the Government.

The RCN said nurse practice pay was lagging behind that of hospital nurses. Its pay review body submission said ‘large numbers of staff now find themselves further away from the pay, terms and conditions of their peers who are directly employed in the NHS’.

One nurse team lead in Dorset says that even if hospital nurses wanted to come to general practice, they would be put off by the pay. ‘Morale in general practice is very low. There are limited numbers of nurses able to afford to come out of hospital even though they would like to, as our practice cannot afford anywhere near the level of pay in secondary care.

‘Some of the very large, multiple-site practices seem to be able to afford a higher wage, although I understand from colleagues that working in them carries its own difficulties.

‘Due to the funding not having been available for practice nurses via ARRS, there is little possibility for our career progression. Even if we are allowed time towards additional training, there is no money to then financially reward the additional qualifications and responsibilities or to pay for extra hours to offer more consultations to patients.’

Concern that practice nurses are being replaced is widespread. A nurse team lead in Herts and West Essex puts it bluntly: ‘GP nurses will soon be replaced with nursing associates, physician associates and advanced nurse practitioners.’ She says practice nurse roles will be ‘reviewing long-term conditions, which can be repetitive and sometimes boring. Our years of experience and knowledge will be lost. There should be a way to encompass this. Not everyone wants to do further training.’

This will all have an effect on patient care, nurses say. A practice nurse in Manchester says: ‘Many peers have expressed concerns about the erosion of the GP nurse role with a move to less holistic care and a desire to ‘get through the numbers’ by using shorter appointments with staff who give brief advice rather than personalised care. They are often inexperienced in primary care and have a broad overview of conditions but lack additional training in chronic disease areas.’

There is a fear that GPNs are being pushed out in place of ARRS staff.

It is currently too soon to tell what effect that adding practice nurses to the scheme will have, and of course this is also still undergoing union consultation. As a core role in general practice, putting them under the label of ‘additional’ sparks some concern. And the potential move begs the question of: will it work to protect the role of nurses in general practice, or will it cause instability among the sector as nurses move to find a practice offering an ARRS position?

Download our General Practice Workforce White Paper here.

The safety of using more, less qualified staff has caused major contention. Here, much of the debate has focused on the role of physician associates (PAs).

Recently the RCGP has said there is ‘no role’ for physician associates (PAs) in general practice, in its evidence to the independent review launched by Wes Streeting into the safety of the roles.

RCGP chair Professor Kamila Hawthorne said that this position was reached after GPs reported ‘specific’ examples of patient safety ‘being compromised by the work of PAs’.

In a letter to Professor Gillian Leng, president of the Royal Society of Medicine and former chief executive of NICE, who is leading the review, she set out the college’s position on the roles.

Professor Hawthorne said: ‘I am writing in relation to the independent review you are leading of physician associate (PA) and anaesthesia associate (AA) professions, to set out the college’s position that there is no role for PAs in general practice.

‘Our position was reached through a vote at our UK Council in September 2024, following a member survey that found 50% of all respondents reporting being aware of specific examples of patient safety being compromised by the work of PAs.

‘Common themes from responses to our survey included misdiagnosis and diagnostic errors by PAs, inappropriate prescribing and management, and lack of communication to patients and GPs.’

It comes after the college voted to oppose the role of PAs in general practice last year, and went on to set out a clear scope for the 2,000 PAs who currently work in practices, which severely limited their roles.

The NHS workforce plan commits to expanding their number to 10,000 by 2036 without saying how many will be in general practice.

Regulation by the General Medical Council officially began in December with around 5,000 PAs across the UK now set to be regulated.

There have been reports of redundancies, and the numbers of PAs hired under ARRS continues to a steady decline. The recent monthly primary care workforce figures showed that the number of full-time equivalent (FTE) PAs has decreased by 37 to 1,147, from 1,184 in July.

As sister title Pulse’s report on the issue concludes – ‘Between [an ongoing] legal case and the Leng review, spring 2025 will hopefully bring clearer directions from central bodies on how PAs should be deployed.’

Download our General Practice Workforce White Paper here.

Another issue raised is the usefulness of ARRS staff who were brought in to increase access. It is still too early for long-term studies on the effectiveness of the scheme but a research paper, accepted for publication by the BJGP, found that there was a small increase in both perception of access and patient satisfaction associated with direct to patient ARRS roles.

These increases equated to around 210-350 (0.7%) more patients who were able to make appointments for each FTE ARRS role employed in a typical PCN (30,000-50,000), and 240-400 (0.8%) more patients satisfied with their care. The average number of FTE ARRS roles per 10,000 registered patients was 2.91, it added.

But for many GPs, even established staff are often not effective in easing workload, especially as they may need GP support in consultations. One GP partner in Salford says: ‘Apart from pharmacists and perhaps physios, I feel the ARRS funding has been a massive black hole that swallows huge amounts of GP funding for roles such as social prescribers that make little difference to workload.’

Others say ARRS staff can often increase workload. A GP partner in Warwickshire says: ‘I don’t want an advanced care practitioner on a high salary seeing a patient every 15 minutes for a single issue when I’m still legally responsible for them even though I’ve not seen their patients.’ The partner says the PCN-employed ACP is very competent, but ‘can’t prescribe and asks to review five patients a day with a GP’, adding: ‘I want a GP who can deal with complex cases, triage effectively, see non-differentiated patients safely.’

Another GP in a deprived area agrees: ‘ANPs are helpful but can often add another step to the management of a patient. Although a GP appointment can be more costly, it can mean fewer appointments are needed to sort out a problem, so money can be saved in the long run.’ The capabilities of ARRS staff are not uniform.

Furthermore, it is misleading to suggest these new staff are ‘free’ for practices. The funding for the ARRS doesn’t go directly to the practice, but to the PCN. A survey by sister title Pulse PCN of 276 GPs who have a say in their PCN’s decisions, found a mix in how ARRS staff are distributed across a network’s member practices.

And in exchange for this funding, PCNs – through their member practices – have to take on more work, such as enhanced care for care home residents. A practice manager in Yorkshire says: ‘We do have access to some ARRS staff including ANPs and paramedics. But in our view the vast sums spent on the ARRS care home team vastly outweigh the need – in cost terms, the money is wasted and would be better spent on our wider patient population by practices rather than PCNs employing GPs through core funding.’

The nature of the ARRS funding also means staff may not have the same commitment to a practice and, being part of the PCN, are less likely to be truly embedded in the practice.

A nurse team lead in the north of England says: ‘ARRS staff seem to be unaware of the QOF [Quality and Outcomes Framework, a scheme that incentivises practices to achieve set clinical goals] and its impact on practice finances. This makes the nurse team feel demoralised as we have to chase information to achieve QOF and bring in money. [ARRS staff] are less likely to be impacted by a poor QOF achievement as they’re not paid by the practice.’

A November 2024 study from London South Bank University supported these findings. It concluded: ‘There was positive impact on workloads from ARRS roles working in original scope, for example pharmacists’ medicine reviews. However, any benefit was offset by the increased workloads created by those new to general practice and/or working outside of traditional scope.

‘This ranged from a lack of resources to provide the support those new to primary care require to practise safely, the expectations of others that [practice nurses] will fill the gap in support and teaching to directly safety netting the work of others. There was a lack of consultation regarding a major workforce change, leading to feelings of devaluation. There are some significant equity issues highlighted particularly around pay and opportunity.’

Another recent study, published in the BJGP in December, found that ARRS has the potential to reduce prescribing rates in primary care. It looked at the general workforce minimum dataset and NHS Digital datasets across more than 6,000 practices, analysing their activity between 2018 and 2022.

It found that the use of ARRS staff was ‘significantly associated’ with lower prescription rates and higher patient satisfaction. The lower prescribing rates were particularly seen in mental health medications.

They said: ‘The lower prescribing rate could be attributed to the strong emphasis on adherence to guidelines in the training of advanced practitioners, and to the availability of a wider range of forms of help, which may reduce the need for prescribed medication. This is particularly consistent with the employment of a high number of clinical pharmacists.

‘By providing more time with a broader care team, ARRS staff may improve satisfaction, especially for patients with ongoing health conditions requiring regular monitoring and coordination.’

This implied that investing in ARRS roles, especially those supporting mental health and long-term conditions, may help to reduce prescribing and increase satisfaction, the authors said.

There is no doubt that the ARRS has been a game changer for general practice. Success of the various roles under the scheme it is not uniform and more recent additions will need further analysis as will the scheme and its efficacy as a whole. But the size of the endeavour will not be easily unravelled so while PAs are in a precarious position its not quite game over for the scheme as a whole.

Download our General Practice Workforce White Paper here.