Has ARRS created a two-tier pay system?

In the almost seven years since the additional roles reimbursement scheme (ARRS) was introduced there has been a dramatic shift in staffing in primary care with 37,000 people now employed through this route.

But along with that has come a growing concern about a two-tier pay system between those staff hired by practices and those taken on through PCNs and ARRS reimbursement.

While ARRS staff do not fall under the Agenda for Change (AfC) banner, their pay scales are based on it, while general practice pay scales are not. It can be a bitter pill to swallow for long-standing practice staff who see new roles introduced, doing very similar work, but with better pay deals than those they signed up to.

‘The difference in terms and conditions can be substantial and can be a real point of friction between PCN and GP-employed staff,’ says Dr Nicholas Jackson, clinical director of Selby Town PCN. ‘It is a live issue which PCNs do struggle with.’

‘The broad consequences are an unhappy workforce, a distorted job market with difficulties in both recruitment and retention, and an unhealthy competition between employers in primary care, hospital trusts and the private sector, for example, community pharmacy’, he notes.

ARRS rates are based on a weighted average of the AfC scale. Essentially it provides a guide to the minimum that should be paid. Yet it does remain up to PCNs to set actual salaries for staff they hire through ARRS. As roles have been added over time, the ARRS has become more complicated. Initially the reimbursable budget did match more easily what PCNs were able to claim and was adjusted to account for Agenda for Change uplifts. But for this year it was up to PCNs to find the 5.5% AfC uplifts from within their existing 2024/25 budgets.

Dr Jackson adds: ‘To complicate matters further there is the misalignment of ARRS and AfC, which means that maximum reimbursable rates for some PCN staff groups fall below AfC spine points – certainly at the top of bandings – meaning that PCNs either have to fund the difference, or risk losing staff to roles in secondary care, where AfC rates are honoured in full.’

It has been a particular issue for nursing staff. With the influx of nursing associates, advanced nurse practitioners and more recently enhanced level practice nurses, the Royal College of Nursing (RCN) has long warned about role substitution with less experienced staff used in place of general practice nurses and devaluing the role.

When you add in the fact that many general practice nurses report feeling poorly recompensed for their skills, can see colleagues doing a similar job getting a pay rise when they have been refused one because of the state of practice finances, it is easy to see how tensions can arise.

A survey of practice nurses in September by Nursing in Practice had found half had received no pay rise in 2024 leading to a joint statement from the RCN and BMA urging practices to rectify this. Respondents reported feeling poorly recompensed and – while this is not wholly linked to the ARRS – comparisons with the new staff (especially those whose pay is linked to AfC) is exacerbating the situation.

The ARRS funding for new and experienced general practice nurses (GPNs) hired from April has been released by the British Medical Association (BMA) ahead of publication of the contract.

It states for GPNs working on a Band 5 Agenda for Change (AfC) the salary will be £43,352 as a maximum reimbursable amount per role. Experienced GPNs employed through ARRS, at a Band 6, will qualify practices for a maximum of £53,319. These figures include some on costs.

The National Careers Service puts the average salary of a practice nurse as starting at £37,000 up to £53,000 for an experienced nurse.

Practices have not seen big increases in their overall core sum to enable those staff pay rises but those tensions also arise because where people have been traditionally employed by practices and have been there for many years, they may have negotiated their own terms which unlike the ARRS roles has no clear national guidance or specification and may rely more on the relationship they have with their practice.

In addition, when ARRS roles were first introduced they were largely doing a different job, lots of population health, preventive or proactive care to tackle health inequalities. But since the pivot towards a focus on access there has been more blurring of the lines.

Dr Helen Anderson, a research fellow at the University of York who has just done a large piece of work on general practice nurse retention explains that there have been issues around roles like physician associates, pharmacists and paramedics ‘being employed in practices to do work that would be under the jurisdiction and professional remit of general practice nurses’.

‘Nurses in general practice were having to supervise them, often without recompense or time or how to do to do that, just in amongst the other work,’ she notes. They end up feeling undervalued and in a precarious career.

‘[In our research] there were also tensions around the pay, because for ARRS it’s more likely to be matched to agenda for change terms and conditions so it’s also about things like annual leave, maternity leave, and sick pay.’

Dr Anderson is ‘cautiously optimistic’ about the news that general practice nurses – with some caveats including that they have not held a post within the PCN, or its member practices, within the last 12 months – will be added to ARRS, because that may lead to a better deal for nurses, she notes.

They also found a lot of positive reasons why nurses chose general practice but with an ageing workforce and well publicised shortages, the ‘inequity and lack of parity’ reported in their research will need addressing, she adds.

Pulse PCN spoke to a range of primary care leaders and policy experts who did not wish to be named but all noted this was a real problem and not a simple issue or quick to fix. Some PCNs seem to have built in more equity across roles from the start.

Some PCNs may find these issues easier to tackle including where GP Federations have worked to more effectively and equally manage pay across a bigger footprint. It may also be a more simple process for single practice PCNs.

As neighbourhood teams develop bringing together people from different organisations and structures, it will also create a number of challenges culture, organisational, governance, leadership style, and differences in pay structures.

‘In an ideal world a fair funding settlement for general practice and PCNs would fully align primary care pay scales with AfC, which would create a much more level playing field in the recruitment market,’ adds Dr Jackson.

One potential solution would be for PCNs to be given more flexibility within the ARRS scheme around the type and volume of roles they employ. In recent contract updates, it was announced that funding for recruiting GPs via ARRS will no longer be ringfenced. It followed much criticism on the current pay range for ARRS GPs.

Ruth Rankine, director of the NHS Confederation’s primary care network, said: ‘The relaxation of rules around use of funding for the Additional Roles Scheme is particularly welcome and something we have been advocating for on behalf of our members for a number of years.’

Dr Sajid Nazir, clinical director of Viaduct PCN in West Yorkshire, said in recent years they had not had many problems with pay disparity between PCN and practice staff because many – such as pharmacists and first contact physios – were relatively new roles.

But that all changed when the ARRS GP was introduced. ‘In many PCNs like my own we have had to top up GP ARRS to make it attractive and fair,’ he explains. ‘I am pleased that this has been recognised somewhat in the new maximum claimable amounts for GP ARRS.

‘We do not want to create a two-tier work force and destabilise practices or PCNs, and therefore we must ensure and lobby for pay parity.’