Evaluating the use of Additional Roles in primary care as a sustainable approach to expanding workforce capacity and improving the quality of service delivery

Problem

The Additional Roles Reimbursement Scheme (ARRS) began in 2020 to expand the non-medical practitioner workforce in primary care. The ARRS is expected to improve primary care delivery across networks, expedite patient access, help mitigate rising demand, and provide an advanced career pathway for non-GP practitioners. At present there are 15 direct patient care ARRS roles eligible to be commissioned through the scheme. It is not known how the rapid expansion of the primary care skill mix will affect the delivery and outcomes of primary care services.The aims of our study were to:1. Describe the trend in consultations with roles eligible to be funded through ARRS compared with GPs and nurses 2. Explore the outcomes of consultations (prescriptions, referrals, re-consultations)

Approach

We used a longitudinal cohort study design.We used data from the Clinical Practice Research Datalink (CPRD) 2015 to 2021 to describe the overall consultation rate and rate by mode (in-person and remote) with ARRS eligible roles, nurses and GPs. We described the types of patients seen by each role (age, gender, IMD quintile). We also compared the outcomes (prescriptions, any onwards referrals, re-consultations within 1-14 days) of consultations with ARRS eligible roles and with nurses compared with GPs.Analyses included descriptive statistics, age and sex standardised rates, and adjusted regression models.

Findings

We included all consultations between 1st April 2015 to 31st December 2021 from a random sample of 600,000 patients from 400 Practices in CPRD, resulting in 12,122,373 consultations. We identified nine ARRS eligible roles from CPRD: Chiropodist/Podiatrist, Dietician, Occupational Therapist (OT), Paramedic, Pharmacist, Physician Assistant, Physiotherapist, Nursing Associate (NA), Advanced Nurse Practitioner (ANP). Consultations with these roles comprised 9% of the study sample (n=1,102,810) and were predominantly with ANPs (54.9%), Pharmacists (22.5%), NAs (9.7%), and Paramedics (6.6%). Consultations with Paramedics, Pharmacists and Physician Assistants were more likely to be remote compared with GPs, all other roles were more likely to be in-person. The re-consultation rate was 29.1% for GPs and varied minimally between other roles, but was notably higher for Physiotherapists (33.3%) and Physician Assistants (34.1%). The prescribing rate for GPs was 14.3%. It was slightly higher for ANPs (14.9%), around 10% for Paramedics and NAs (9.3%), and considerably lower (<5%) for other roles. The referral rate for GPs was 2.5%, was slightly lower for Physiotherapists (1.7%) and Physician Assistants (1.4%), and much lower for all other roles (<1%).

Consequences

The job roles captured in CPRD do not cover all ARRS eligible roles, notably not social prescribing link workers and physician associates. Rates of prescribing and onward referrals are comparable between the main ARRS roles and much lower than for GPs, but re-consultation rates may be slightly higher for ARRS roles.