ARRS: Successes, impacts, and the future
The Additional Roles Reimbursement Scheme (ARRS) was launched in 2019 with some big promises to improve primary care. More appointments, less pressure on GPs... it was ambitious. But has it lived up to its lofty ambitions?
Well, ARRS certainly surpassed its key targets, delivering 50 million appointments and adding over 34,000 new staff to the frontlines.
With ARRS extended through 2025, the NHS Confederation has published a report assessing the full impact of ARRS, its challenges and how it can move forward. The recently published 2024/25 GP contract has moved some way to addressing these concerns by offering greater flexibility to PCNs and further expanding the scope of ARRS funding.
We’ve picked out some of the key themes from the report and the GP Contract to assess how successful ARRS has been in its first iteration and what the future may hold.
ARRS Successes – Impact on the workforce
The headline numbers (50 million appointments, 34,000 new staff) are impressive, - but do they tell the whole story? On its inception ARRS was supposed to address inequalities inherent in the primary care system, such as housing, poverty and isolation while improving patient care and reducing GP workload.
So, how has the scheme fared in this regard? Well, ARRS has enabled Primary Care Networks (PCNs) to start laying the groundwork needed for such a large-scale change towards a more flexible, locally-driven model, including:
Multidisciplinary teams (MDTs)
MDTs bring together diverse expertise to address complex needs. With the removal of caps on ARRS roles and the inclusion of enhanced nurses, PCNs now have even more tools to tailor their teams and truly address population health needs with personalised care solutions.
Local flexibility
The increased flexibility aligns with the NHS's focus on local care and neighbourhood teams. PCNs can now prioritise specific roles – such as enhanced nurses in areas with ageing populations – to provide the best possible care to their patients.
“Integrated neighbourhood working requires partners across a community to come together – with local citizens at the centre – to find solutions to local health and care needs, looking beyond the medical model of care to wider determinates of health”
- NHS Confederation Report
“Integrated neighbourhood working requires partners across a community to come together – with local citizens at the centre – to find solutions to local health and care needs, looking beyond the medical model of care to wider determinates of health”
- NHS Confederation Report
Expanding ARRS - The GP Contract 2024/25
The 2024/25 GP contract recognises the shift in working practices and introduces some key changes to ARRS, aimed at further increasing flexibility for PCNs. These include:
- Including enhanced nurses in the scheme. This will allow practices to claim reimbursement for employing nurses working at an enhanced level. Initially capped at one per PCN, with two allowed for lists exceeding 100,000 patients.
- Removing all caps on other direct patient care roles, both nurses and non-nurses. This will allow PCNs more flexibility in staffing decisions beyond the newly added enhanced nurses.
- Allowing PCNs to recruit other direct patient care staff (outside of nursing and doctors) if agreed with their local Integrated Care Board (ICB).
- More flexible funding arrangements for mental health practitioners (MHPs). PCNs will be able to negotiate funding for subsequent MHPs with the mental health provider, up to 100% funded through ARRS, with ICB approval. All MHPs will still be employed by the mental health provider.
- Permitting PCNs to claim reimbursement for time spent by staff undertaking training or apprenticeships to achieve a level three occupational standard.
- Unspent ARRS funding will no longer be re-allocated within primary care. NHS England have advised PCNs that if they do not use their full funding allocation they will lose it at the end of the year - this year's unspent funds are estimated to total £65 million.
The Challenges - building on the foundations
The report highlights how enabling a shared workforce has been a positive consequence of ARRS to this point.
It’s allowed PCNs to start building the capacity needed to create a sustainable, patient-centred workforce that can lower GP workload and deliver better outputs for local services.
While the new GP Contract demonstrates further willingness to embrace flexibility, there are still some challenges highlighted by the NHS Confederation report that policy makers need to address to maximise the impact of future funding
These challenges include:
Whole-system workforce planning
ARRS staff compete for the same workforce pool as other vital sectors. The addition of enhanced nurses (as announced in the new GP contract) could help mitigate shortages, and with greater flexibility, PCNs can explore solutions like cross-sector recruitment and local contracting strategies.
Collaboration with the mental health sector, as seen in the new funding arrangements for MHPs, highlights the importance of a coordinated approach.
Pay and benefits
The new contract enables a 2% pay increase for ARRS roles. The NHS Conferation report, however, underlines a number of ongoing challenges for making ARRS roles competitive and that PCNs must continue to advocate for funding models that address this.
Improving patient awareness
Change management shouldn’t only focus on internal stakeholders. Public-facing campaigns are vital, as multidisciplinary care will be a new concept for many and improving patient understanding will be crucial to maximise the benefits of MDTs and local care.
Access to data
There's limited data on what influences successful ARRS recruitment across different regions and roles. Addressing recruitment challenges locally is difficult without identifying why shortages happen in some areas and not others. Enhanced flexibility will hopefully provide valuable insights, allowing PCNs to tailor recruitment drives based on local workforce availability and training opportunities.
Scaling estates and infrastructure
Increasing headcount and the decentralisation of care throws up a host of challenges to the effectiveness of multidisciplinary teams.
Practices struggle to house additional staff, present significant barriers to fully integrating new ARRS-funded MDTs. While practices are increasingly offering hybrid working and access to digital tools to collaborate, significant, dedicated funding is still needed for primary care estates to meet the demands.
Clinical supervision and training
It’s not just space and technology that’s struggling to keep up with an expanding local workforce - in its current form, ARRS offers insufficient resources for high-quality, consistent supervision and development opportunities for new staff.
With a stated aim of reducing GP workloads, suddenly having a whole host of new, multi-skilled team members to oversee is not a sustainable solution. This lack of supervision risks compromising patient safety, and impacts staff morale and retention. It also limits the potential benefits of MDT learning.
The report recommends that including supervision time in funding could help retain GPs considering retirement move into mentorship roles, reducing the loss of their clinical expertise to the workforce. The new GP contract doesn’t address this directly but does enable PCNs to claim reimbursement for the time personalised care roles spend out of practice undertaking training or apprenticeships to obtain a level three occupational standard.
The future of ARRS
The Additional Roles Reimbursement Scheme has proven successful in expanding the primary care workforce and driving changes for better patient access. While policy-makers need to address some of the key challenges raised in this report, the 2024/25 GP contract continues to empower PCNs with far greater flexibility.
The inclusion of enhanced nurses and removal of caps opens the door for a broader range of personalised care. Now, more than ever, PCNs will be able to build teams that truly address their community needs, leading to better outcomes for patients, reduced GP workload, and improved staff satisfaction.
The emphasis on flexibility allows PCNs to focus on their community's specific healthcare priorities. This local adaptability is essential in tailoring services that make a real difference in diverse populations.
“Staff such as clinical pharmacists, mental health practitioners and paramedics present opportunities for building integrated teams with system partners, while non-clinical roles like social prescribing link workers are already forging relationships beyond the health service and with citizens to bring new expertise and valuable community level insight into the design and delivery of better care. These connections represent a vital step towards integrated teams at different scales by building the relationships necessary to forge new ways of working.”
- NHS Confederation Report
As the healthcare landscape continuously evolves, the new ARRS model encourages PCNs to adapt alongside it. While there are still challenges to be addressed in the implementation of ARRS, the most significant challenge to continued success beyond March, may come from the reaction to the GP Contract.
Reception to the GP contract
Initial reaction to the GP contract has not been positive amongst GPs, with 99% voting to reject the imposition of the 2024/2025 GP contract in a special referendum held by the BMA. And, while not a formal union vote, the BMA have since set out initial plans for a route towards possible industrial action later this year.
The dissatisfaction with the GP contract seems to stem from:
- The fact the contract has been imposed for another year running without the consultation, without the agreement of the BMA GP Committee (GPC) and no commitment to negotiation from NHS England. While it is unlikely the 99% who voted to reject the contract would vote for industrial action - a recent poll of GPs suggested that three quarters of GPs would support some form of industrial action.
- The contract allows for a rise in funding of 2.23%, however many GPs would argue with actual inflation hovering around 4% (and not the 1.65% used), the result will be a real-terms funding cut. This cut is estimated to be 7% in real terms since 2019. The BMA GPC argues that if pay levels for GPs and practice staff increases by 2% without a similar real-term rise in funding, it will result in further cuts to both services and staff.
We hope you enjoyed these insights, please watch out for future updates. In the meantime, please contact us on 0131 553 6644 or email us on the contact form below if you have any questions.