Recognising health inequalities within the Additional Roles Reimbursement Scheme in primary care

Problem

The Additional Roles Reimbursement Scheme (ARRS) introduces non-medical healthcare professionals (e.g., clinical pharmacists, first contact physiotherapists, personalised care workers) into primary care to: expand and enhance the workforce; reduce pressure on GPs; and facilitate a more multidisciplinary approach to enhance patient outcomes. This research explored the barriers and enablers to implementation of ARRS staff within primary care. Specifically, we explored whether the ARRS has been used to increase workforce capacity in areas of greatest need, and whether the type of professionals employed is aligned to the population requirements. The findings of this project will accelerate the evaluation of a significant area of primary care workforce innovation for which there is currently a limited evidence base.

Approach

This qualitative study involved individual or paired interviews with a range of stakeholders related to the scheme. Thirty-seven participants were recruited within the ARC West footprint across three Integrated Care Boards, whose populations included pockets of significant deprivation. Participants included workforce leads, Primary Care Network (PCN) managers, representatives from primary care training hubs, and a range of ARRS staff. Data were analysed using Framework Analysis with the initial framework derived from ARRS literature and the Advanced Practice Framework.

Findings

The framework analysis identified nine categories present in the data that were related to ARRS implementation. One category in particular that identified health inequalities within the scheme was ‘Scheme Inflexibility’. This category describes several inflexibilities that prevented less wealthy PCNs and practices, or those in more deprived areas, in making effective use of the scheme. These inflexibilities included unanticipated additional costs for recruiting and retaining staff (i.e., cost of living pay uplifts, supervision cover costs, estates costs, engagement of third parties) and rigid salary scales that can limit success with recruiting for posts. Participants reported that if the full funding could not be used by a PCN, it was often reallocated to be bid for by PCNs with the means to use the funding. Additionally, PCNs sometimes needed to recruit pragmatically based on who they were able to recruit rather than hiring the roles they needed to meet their populations’ needs. In general, PCNs in areas of higher deprivation struggled more to recruit staff. The inflexibility of the scheme’s funding can exacerbate health inequalities in areas of deprivation. Patients in these areas are potentially prevented from accessing the broad skill mix that can be provided by ARRS staff.

Consequences

These findings suggest that the ARRS is not currently being used effectively to increase workforce capacity in areas of greatest need. Practical recommendations concerning greater flexibility around funding, banding and capped payments to staff recruitment companies within the scheme are suggested to inform operational and strategic decision making to address these inequities within primary care.