GPs and the additional roles reimbursement scheme

In October, funding was made available for newly qualified GPs to be hired via the ARRS. Pulse PCN editor Victoria Vaughan talks to clinical directors to gauge their views on the policy. 

Dr Abhi Mantgani, clinical director Arno Primary Care Alliance, Merseyside

Dr Shanika Sharma, clinical director of West One PCN, East London

Dr Matt Greenwood, clinical director of Horsham collaborative PCN, West Sussex

Dr Sajid Nazir, clinical director Viaduct PCN, West Yorkshire

Dr Dan Bunstone, clinical director, Warrington Innovation Network PCN, Cheshire

Dr Sian Stanley, clinical director, Stort Valley and Villages PCN, Hertfordshire

OVERVIEW

Victoria Vaughan: Is adding GPs to the ARRS a good idea? 

Dr Shanika Sharma: The positives are that any money is good money at the moment, so it’s good that it’s ring-fenced and it’s for GPs. To be honest, that’s where the positives pretty much end.

It’s not very well thought out. As a GP trainer, GPs transitioning from before Completion of Training (CCT) to post-CCT, find it difficult enough to move into one practice, even if that is their training practice. If you’re then asking a newly qualified, or a GP within two years of qualification, to work across seven practices, which is the sort of demographics of our PCN, logistically, I don’t think that’s going to be possible.

And I don’t think anybody will want to do that because every practice works differently.

The timing is very rushed. It doesn’t align with CCT training, which for most GP trainees finishes at the end of August, so most from this year would have taken up a salaried role, decided to locum or take a few months off. Trying to recruit, backdated to October 1, is going to be very difficult. Getting someone in place, the logistics of the contract and pensions – none of that has been factored in.

Dr Sajid Nazir: I’m a trainer. Three of my ST3s have just finished. In some ways they’re unemployed, applying everywhere for jobs, and suddenly I might have something for them. One of them was out of sync and is finishing in a few weeks, so potentially, it’s something she’s looking forward to.

However, there are lots of issues with this as well. In the feedback we’ve given over the past years, we did ask for GPs in ARRS, so they’ve listened in some ways, but there are some fundamental issues.

When you look at the funding, it undercuts the going rate by probably 20-25% across the country. People are desperate for jobs, but in my opinion, they’re undervaluing this cohort of new GPs. Why only new GPs? What about people who are three years out of training and still looking for work? It doesn’t really solve that recruitment crisis.

I think it’s been poorly thought out locally. In West Yorkshire, they haven’t worked out the funding even for this year, so we’re unable to recruit. We have people waiting, and then we can only give a six-month contract. But they want it to be like the model contract, without all the funding that’s necessary to implement that, so it full of difficulties. I’m afraid that it’s a sticky plaster – a headline solution, which is a good sound bite, but actually is going to be difficult. We’re scratching our heads as to how best to implement the role across the PCN.

People are desperate for jobs, but in my opinion, they’re undervaluing this cohort of new GPs.

Dr Sajid Nazir

Dr Abhi Mantgani: I think there was an assumption in general practice circles that the whole of the ARRS budget would be given to PCNs to do what they want and appoint as many GPs as they want. But there was no way the Government was going to simply give all those resources without conditions.

I never felt that including GPs in the ARRS was a good idea. If there is going to be more for GPs, that money should be funded through GP contracts.

As Sajid said, this is all about headline-grabbing; they have announced this but even now we don’t know what our allocation is and we don’t know the rules for the scheme. How this is going to work, what happens when somebody goes off on a maternity or sick, what kind of a reimbursement is available? And in the bigger scheme of things, this has done a great disservice to the younger doctors, because it has now set the yardstick of about £8,300 pounds per session as what the Government recommends for a newly commencing GP. When the demand was there, GPs demanded whatever they wanted, and they got very, very high salaries. But now that the government has set a figure, I think this is going to work against new doctors coming into the general practice pool. As usual, we are going to make this thing work as fast as possible, but I don’t think this has been a great idea, and it needs to be rethought.

Dr Sian Stanley: I agree with everything that’s been said. I do think it’s a bit of an own goal for GPs. Yes, we might be improving employment numbers, but at what cost?

There might be a way of making it work, but we need some guidance from the College or the training deaneries to say this could be regarded as a senior registrar post, which is something that I did when I first came out of training and found very useful. If this was a senior registrar post, and you could combine it with a special interest, then it suddenly becomes a very good retention tool for newly qualified GPs, who could be supported in the early stages of their training.

What we’ve decided to do is link the ARRS job with care home beds. That’s not to say that they’re going to be looking after the care homes – the practices themselves are – but the burden of care homes is so great on the practices we’ve decided that the salaried GP will just work across two practices that have the majority of those care home beds. They’ll have that backfill, and their senior GPs can go and carry on doing that.

What we’d quite like to develop locally is maybe utilising this ARRS GP to do some teaching or having their own special interests that we might be able to cultivate within public health.

But it’s a fudge, and it is a fudge that we’re always having to do in primary care – to be given the nub of an okay idea and then having to mould it. That’s quite time-consuming and it’s quite risky for us because those parameters aren’t set properly for us, and it’s not really our funding to do with what we want.

Dr Dan Bunstone: I echo what’s been said, but I will move on to some of the positives. We’ve taken the opportunity to retain our really good trained salaried GPs; they anticipated they may stay in the training practice and, to Sian’s point, complete a senior registrar type of a role. When I qualified, I took a locum job and just chucked myself out there. Actually, we can do that in a more controlled way, which is great.

We’ve got a hub that the GPs are going to work on. And the plan is to create a pretty diverse job plan that doesn’t just leave them with all the crap that nobody else wants to do. And you know, we’ve been really cautious to create that, to be really innovative, make it look exciting, and also recognise that, not to be patronising, it is their first job out of training. So actually, to put some stretch targets in there, but not maybe give them our most complex patients to deal with.

JOB ROLE

Victoria: You’ve mentioned the issues with this role but also that you’ve got trainees who are interested. So, who wants this short-term, lower-paid job?

Sajid: Pretty much everyone, certainly in major cities and towns, because it’s the dire job market. My registrars have been applying for months. None of them have secured a permanent job. One of them has got a part-time, long-term locum. But in terms of fixed positions, it’s very difficult. Some of them who finished a few months ago are always in contact and looking for work. I’m talking about 10-20 people applying for salaried positions. For them, it’s a possible solution – it’s some form of security, though it might not be what they would have envisaged, traditionally. That’s really where the excitement ends.

I do worry a little bit about other areas where there’s a potential of abusing that new GP who’s come in, who’s paid for, in some ways, and doesn’t necessarily belong in a practice that will take responsibility, so it falls on the PCN.

We’re looking at it, but it’s just the fact that there isn’t any more room in the practices to actually take a role on

Dr Matt Greenwood

Abhi: We have somebody who trained about three months ago in one of our practices. He is doing locums – or trying to do locums but he’s got very little work – and he wants to come on board. We will create a job role, which means that it is going from practice to practice, working two/three weeks, depending upon the size of practice, so that everybody gets an equitable access. We want to mix it with at least one session of enhanced access and perhaps something to do with the development of a project within primary care. He’s enthusiastic about it. Basically, he had no job, and he wants to come on board. He’s a very bright young man but this is not an ideal situation.

Victoria: Despite the difficulties, everyone here is going to hire a GP through the ARRS system apart from Matt is that right?

Dr Matt Greenwood: We’re looking at it, but it’s just the fact that there isn’t any more room in the practices to actually take a role on. We’ve taken people on the idea that we could utilise this named funding pool, but we’re now not being given any clarity as to whether people who were employed after the announcement, but before the rules [can be part of this].

SALARY

Victoria: I am interested in your views on the salary difference for GPs in ARRS. Is it a concern?

Sian: This might not be a particularly popular viewpoint, but I don’t have a particular problem with the monetary side of things, in the sense that a lot of people in my generation would often do those jobs at the beginning of our career, to get experience under our belts, to get the mentorship that we wanted, to be able to have a special interest. It was used very much as a retention scheme at that point. Sounds awful, doesn’t it? Pulling up the drawbridge behind you, but that’s what I did and what a lot of us did. This is a stepping-stone role. It’s incumbent on us as a profession, as clinical directors (CDs), to make it work. We need to understand who our junior colleagues are, look after them and mentor them – and not use this role as a ‘let’s make them work across seven practices and flog them to death’ sort of thing.

This is a stepping-stone role. It’s incumbent on us as a profession, as clinical directors, to make it work

Dr Sian Stanley

Dan: I don’t necessarily think it’s an unpopular view because we probably remember a time when we had locums who, frankly, were very junior, commanding a very high day rate, and wanted terms and conditions that were entirely preferable to that of the partners. You were in a bizarre situation. We took all the risk of being a partner and had to pay locums significantly more.

We’ve long talked about needing an additional 8,000 GPs; if you do some very quick maths and work out that each of those GPs’ average wage might be £100,000 a year, that’s £800 million pounds, nearly a billion. I don’t see a billion pounds sat sloshing around the primary care budgets with nothing attached to it. That’s why we’ve got this really weird disconnect where we need the GPs, but to have the GPs, the funding needs to come with that, too. I think we’re seeing that, it’s a fudge and it’ll take time to achieve. And on exploitation, I would argue that that is definitely our role as a CD – to absolutely make sure that you don’t do it with your salaried GPs and you call it out if you see it. We’re working as a team across the community. We have to level up. We have to raise that standard of what we can achieve from our colleagues.

Sajid: I was just going to disagree a little bit about the monetary issues because I think we have to compare it to consultants when they start. The issue here is that the funding is inclusive of all the costs. We did a quick look for our registrar and it’s hardly any increase from where she is at the moment. I do think it’s undervalued and I think it’s a slippery slope. I don’t think the government has selected that pay grade because of the slightly junior status of those GPs. I think that’s their yardstick. This is what you are worth. We’ve got to be very careful if we accept it and say, ‘Well, if you’re new you can accept this pay’ because it doesn’t work like that in hospital. There is a rate scale they worked up towards. But if you look at their starting scale and remember their employer’s pension, national insurance, etc., is paid on top of that, it’s significantly higher than what we’re being offered. And actually, it’s nowhere near those sorts of rates. I’ve not seen £8,000 a session in the last 10 years.

In my PCN, we actually had a discussion about whether we should do this at all – are we accepting this because, really, we’re undervaluing the profession? I understand people need to be grown into the role, and there is junior and senior, but NHS England took away seniority payments a few years ago. That was their own thoughts on someone being paid differently, so there’s a concern that if they expand the scheme, it will be open to other GPs, not only new GPs. And I can’t see them opening different pay scales depending on how much experience you’ve got.

It’s not really exploitation, but I do think it’s undervaluing those colleagues because even though some of them may have charged high rates as locums, a lot of them were employed as salaried, you know, at £10,000 to £12,000 a session. And they’ve been asked to take a significant cut and accept it. It’s woefully underfunded. We’ll make it work because we have to make it work – if we don’t take the funding, we’re probably going to lose it.

Shanika: I completely agree with what Sajid is saying, and it actually doesn’t match the previous fellowship pay scales. If we look at the Salaried Portfolio Innovation (SPIN) scheme we had in London for those new to general practice, the starting salary for that was in the range of £9,500 to £10,000 or £11,000 per session. I think there is a risk here that we’re undervaluing the profession. We are in a recruitment and retention mess, and that’s really because the GMS contract is not being funded proportionately to demand and rising populations.

ARRS roles have been brought in, which have been fantastic, but that’s meant that a lot of practices have not been able to afford newly qualified GPs. As a partner, we have to think twice before taking on a locum for a session because of how it will impact the practice financially. It’s not that we don’t want GPs; it’s just that we can’t afford to have locum GPs for sessions.

Abhi: I’m a bit concerned about what is being said. Until recently, GPs were completing their training programme and quite often opting to have a portfolio career – they wanted to work in different practices and were doing locums on the days that suited them. I didn’t see anybody saying these people should not be working as independent contractors or working as locums, and they should be handled with kid gloves as a senior registrar. Now we have a national programme through ARRS and I am fully supportive of the fact that this is totally unfair to some of the younger doctors, but they will have to work under some sort of guidelines, supervision and protocols set by the PCNs. Otherwise, how else will we integrate them and support them as they mature? We need to be realistic about the market situation, and that’s what this is.

Victoria: You’ve mentioned exploitation –  what do PCNs need to think about to make sure they’re not being exploitative and what should newly qualified GP applicants stir clear of?  

Dan: You want to be careful that the job looks okay. Working across seven surgeries, five days a week, covering frail, elderly, mental health and children will be a pretty challenging job to do. Maybe speak to your trainer and say to them, ‘Would you apply for this job?’

Sajid: This sort of mirrors the model contract, and that’s there for a reason – to protect salaried GPs and so there’s a standard to work towards. The concern is where people are being employed and not really working to that standard. That means not getting the protected time they should, for example. And because people are quite desperate for work at the moment, they might decide to put up with it. It’s incumbent on us as CDs to make sure that’s not what we’re pushing.

FUTURE

Victoria: Health secretary Wes Streeting has, in the past, liked the idea of a salaried GP service. And although this is a temporary emergency measure, are there concerns around having a tranche of salaried GPs coming in via a different route?

Sajid: There’s been a move towards this for a few years in various forms. We have neighbourhood teams that will be coming along, and I see this role being employed by them. I do think this is perhaps a pilot towards that sort of model. But the people at the top don’t understand what it is to be a GP – these people will need mentoring and it takes a lot of time and effort to build into their job plan the full, holistic support that is required in this sort of role.

That sort of model would be extremely expensive compared to what we do as partners. And I don’t think they understand. When they find out, it will have been a very expensive mistake.

Matt: The Darzi report swung quite heavily in favour of the partnership model as it actually offers huge value. I’ve crossed my fingers that it’s why Wes Streeting has decided that he won’t try to make a salaried model.

Sian: Wes can’t afford to make a salaried service. There is no way. It’d be hilarious if we all went on to the model contract from the BMA and I just down tools every day at 25 patients and then refuse to do anything else. Could you imagine the chaos? They know that the partnership model is a very cost-effective way of running primary care. The problem is that it’s not particularly trusted and that goes back to why this funding has come to us in this way. There is a fundamental lack of trust between the partnership model and the Department of Health [and Social Care] and how we’re funded.

By giving us GPs through the ARRS scheme – or by drip-feeding funding through ARRS in general – they think they can control it and make sure that we are spending in a particular way. But maybe it’s not what we need or what’s wanted in primary care. And certainly, there is that law of unintended consequences with regards to the ARRS roles, where a lot of us spend our whole time supervising them and topping them up and making sure we don’t make any blunders. There are certain cohorts of ARRS staff that are amazing, but this is a very prescriptive way of us having to employ and it’s very alien to us as partners.

They know that the partnership model is a very cost-effective way of running primary care. The problem is that it’s not particularly trusted and that goes back to why this funding has come to us in this way.

Dr Sian Stanley

Victoria: Is anyone else considering topping up an ARRS GP in the way that some PCNs top up other ARRS roles?  

Sian: We can’t afford it.

Abhi: We do want to top up, but we don’t know whether the rules allow you to do that or not.

Victoria: What should this policy have looked like, and how should it look in the future if it is extended beyond March?

Sajid: It should be within the overall ARRS budget so, locally, you can set the wages to make it fair. We need more. If you look at the number of practices, there should be several more GPs. Then, you can make it more exciting – looking at health inequalities and spending one session with the CD to help them and learn about PCNs.

Abhi: This money should be made more flexible. And it should be reinvested through general practice contracts because sustainable jobs can only be done through the practice and partnership, and not through fancy schemes like this. This attracts the headlines, but it doesn’t address the younger doctors’ needs or the access issues. This is just wasted money, in my view.

Sian: What we needed was a long-term, sustainable solution to general practice. We needed the workforce. The workforce is out there. This was an odd thing to do. For those of us who had worked with the ARRS scheme, those of us who’ve been a part of that and have been partners, this is not the way we would have brought more GPs into primary care. We would have done that through core funding and distributing it across particularly deprived areas to make sure that they could recruit.

Shanika: I think it should be in the core contract as well because that’s what would support me as a partner at a training practice. I can then do all the training, supervision, and mentorship at a practice level. And it builds sustainability at practices. It is succession planning for the future, for partners near retiring or moving forward in life.

They also need to factor in the mid-career GPs – there’s nothing in place at the moment to retain these experienced GPs. I’ve got so many colleagues who are now leaving general practice and either are not practising medicine at all or are changing to a specialty and retraining.

The other thing is that deprivation and the composition of PCNs should be factored into any funding allocations.

Dan: As often happens with NHS England, we get the perception of flexibility, but the bumper bars and safety nets are actually a trapping net that don’t allow you to do anything. We need more flexibility. I’m ambivalent about whether that goes to practices or PCNs, but I just want them to trust primary care to do what it was set up to do.