In total, 36 interviews were conducted with 37 participants (one interview was a paired interview) from three ICSs. Table 1 outlines the characteristics of the participants. Framework analysis identified 10 categories from the data. Table 2 presents a summary of the categories, including how each category captured implementation of the scheme at micro, meso, and macro levels, and any staff type differences. Each category discusses successes/enablers of the scheme first, and challenges of the scheme second.
Successes and enablers
Multiple and certain roles maximise impact
Variation existed in how roles were used and interpreted, and how PCNs maximised their impact. Those who recruited ARRS staff discussed how a single ARRS role was not sufficient, and to maximise the impact, more than one was required:
‘I think one mental health person on their own is just doomed to fail because you can’t possibly provide any kind of service at all to 50 000 people, it’s hopeless.’
(PCN lead)
The breadth of the job descriptions also meant that roles differed in different PCNs, depending on local interpretation:
‘One practice may use a health and wellbeing coach totally different for … weight management or something, exercise. Another one may use them to support pain, addiction to opiates ... ’
(Workforce lead)
GP assistants and digital transformation leads were additional roles introduced at the end of 2022.20 Participants described how these roles could help to maximise the impact of other ARRS roles:
‘The digital and transformation lead, which is being translated as PCN manager plus. We are going to get one in, because there’s stuff that I just don’t have time for.’
(PCN manager)
‘GP assistant is a cross between a super-admin person, and healthcare assistant … and these GP assistants would be a great addition to these teams.’
(PCN manager)
Participants discussed how expanding the scheme to cover reimbursement for administrative support could increase effectiveness:
‘Everyone really wants another admin role, and that is someone who’s very highly trained to process test results, results letters, letters to consultants, so that they can start processes off.’
(PCN manager)
Training hub support
The training hubs21 were considered crucial for demystifying training pathways or providing guidance to staff in all roles:
‘[Professional lead] has been an absolute champion for just getting in touch with those silly little questions, queries, and then knowledge and information that [they] can provide about the whole process.’
(Paramedic)
‘I don’t think you can undervalue the role that the training hub could play, and do play.’
(Training hub lead)
Staff valued but impact unclear
Most ARRS staff participants felt welcomed and valued, and believed that ARRS roles were making a difference. While participants understood that the scheme’s original aim was to reduce the burden on GPs, many acknowledged that pressures on primary care meant that this had not yet been realised. Instead, participants described the broadening of services and an increase in the quality of care:
‘There’s an improvement in the quality of the care that the patients are getting because someone with far more knowledge is on that specific case.’
(Workforce lead)
However, there were circumstances where participants did describe ARRS staff saving GPs time and resources:
‘I think the pharmacists have really taken workload off of the GPs, and also the pharmacy technicians in terms of what they’ve taken off some of the admin side of things.’
(Practice manager)
While interviewees perceived a positive impact, it was hard to demonstrate, particularly given the external factors impacting primary care. The impact of the scheme was also influenced by its uncertain future; some participants described how these concerns impacted engagement with the scheme:
‘Initially, my PCN was very reluctant because they were scared of what would happen if the funding wasn’t there. Would the five surgeries have to cover our costs?’
(Workforce lead)
Staff working in ARRS roles also expressed concerns about their job security:
‘I don’t know how long the ARRS funding will last because I know it’s like 23–24. There’s this break point and you think, “Oh, does that mean I’m not going to be employed after that?”’
(Clinical pharmacist)
Despite difficulty in evidencing impact and a mixed picture relating to the benefit to GPs, participants were strongly in favour of continuing with the scheme:
‘There would be uproar, absolute uproar if [ARRS roles] were taken away.’
(Workforce lead)
Challenges of the scheme
Scheme inflexibility
Most participants described the inflexibility of the scheme. They discussed how the ‘one size fits all’ nature limited PCNs’ abilities to fully engage with the scheme:
‘It’s a very rigid scheme and as we’ve gone through the years there’s been more and more pressure for flexibility.’
(Training hub lead)
Participants described how the scheme did not cover many costs associated with recruiting and retaining staff, for example, costs for supervision, costly and inconsistent third party recruitment tariffs, estates, and pay uplifts. The rigid salary scales also led to PCNs having to find extra funding for additional costs or to make roles attractive. Not all PCNs could afford this:
‘[Healthcare organisation] just put out 10 jobs for Band 5 and Band 6 [pharmacy] technicians at £33,000 and £40,000. We can’t get anywhere near it ... ’
(Pharmacy technician)
The inflexibility of the scheme’s funding was thought to exacerbate inequalities because PCNs that could not afford the additional costs associated with hiring an ARRS role, or that were unable to recruit, ended up not using the full funding. Unused funding was returned to a central pot, and made available to other PCNs who could use it:
‘So, it is that lack of flexibility really that stops us using all our money, which seems a shame because it’s just going back in some central pot somewhere.’
(PCN lead)
‘It’s damaging, and increasing health inequalities, because we have identified a real need for a physio, it isn’t the 15 roles available to us [financially], we are locked out of being able to provide one ... ’
(PCN manager)
Creating a sustainable workforce with career progression and retention
Participants demonstrated the need for a sustainable pipeline of professionals to work in ARRS roles, including career progression opportunities for existing staff, and employment models with other organisations to retain staff. However, the ARRS does not build in sufficient career progression:
‘One of the other challenges is that there is no kind of entry level pharmacist role in general practice.’
(Workforce lead)
Some participants discussed how ARRS staff left roles because of a lack of career progression, particularly in certain roles:
‘You don’t keep pharmacists for 2 minutes. As soon as they finish the pathway they’re gone.’
(Pharmacy technician)
Participants also used rotational models to sustain the primary care workforce in the long term:
‘We now do a rotation scheme. So, they spend so many months in the hospital, so many months in a community pharmacy, and so many months in a GP practice.’
(Workforce lead)
When discussing how PCNs specifically planned and recruited their ARRS workforce, PCNs made strategic decisions to meet their population needs and recruit staff. However, sometimes workforce design was more ‘piecemeal’:
‘We do have a vision that one day we will have a team … I think instead of it growing up piecemeal the way it has, it would have been lovely to just sit down with a blank piece of paper and draw up a plan.’
(PCN manager)
PCN staff in deprived or rural areas sometimes had to make more pragmatic recruitment decisions to use funding, recruiting based on availability rather than need:
‘The plan is to have more pharmacists but where I’m not able to recruit the pharmacists … do I then sit there and do nothing or do I use that funding and take it somewhere that actually I can recruit and make the most out of that area?’
(PCN manager)
Managing scope and expectations
Some ARRS staff reported that colleagues’ understanding of their roles varied, despite this understanding being key to the scheme’s success. Defining scope was particularly challenging for the personalised care roles:
‘How is a health and wellbeing coach different to a social prescriber? How is a social prescriber or a health wellbeing coach different to a care coordinator?’
(Workforce development lead)
This understanding is crucial because it impacted how ARRS staff were used:
‘You get your GPs, and your clinicians that get it and refer in all the time … To other ones that you never get a referral from, however, you know full well they will be seeing patients that we could be helping.’
(Social prescriber)
Poor understanding also derived from a lack of appreciation that roles may not suit traditional GP appointment structures. This was particularly relevant for social prescribers, who often required longer appointments when dealing with complex psychosocial issues:
‘One of the difficulties I face as a link worker is having to justify my existence to a lot of people … they’re like “Why can’t you see 50 people a day?”, “Why don’t you do what a GP does?”.’
(Personalised care workforce lead)
Participants described their role to aid colleagues’ understanding:
‘We had a new pharmacy manager … we actually put down the stuff that we can do, she was surprised and she forwarded it to the lead clinician and he had no idea that’s what we could do.’
(Pharmacy technician)
Similarly, ARRS staff themselves struggled if they were not adequately prepared for the challenges of primary care:
‘Very often paramedics are really undereducated on what primary care really is, and how hard it is, and how complex it is, and how intense it is.’
(Paramedic training hub lead)
The steep learning curve experienced by those working in primary care raised the importance of having a clear scope and boundaries for each role. Participants discussed their concerns around scope creep:
‘I think one thing you do have to be careful with the roles as well is to define the boundaries of the roles … With practices being under significant pressure, I think there’s obviously the risk of scope creep on some of these roles.’
(Workforce development lead)
Navigating supervision and roadmap progression
For the ARRS to succeed, staff need adequate supervision and training, which is guided by roadmaps under the scheme. However, much of this guidance arrived after the roles had been established, and roadmap documents were unclear:
‘If you read the roadmap it makes no sense, it’s really confusing, it’s like, where do you start?’
(Paramedic workforce lead)
Some viewed the roadmaps as a useful, structured approach for novices entering primary care. However, for others, there was a risk of duplicating past training or experience unnecessarily:
‘There is an exemption process, which is very arduous, and I have known a couple of pharmacists that have gone through that, but it doesn’t seem to account for those that have got a lot of experience elsewhere.’
(Pharmacy workforce lead)
Supervision of ARRS staff varied and some staff felt their day-to-day supervision was too sporadic, and wanted more regular support:
‘I also had one of the GPs who’s my mentor. We were having monthly one-to-one sessions but that has gone by the by a bit … I’m very keen to get those back up.’
(Care coordinator)
Infrastructure, integration, and practical challenges
A consistent challenge for PCNs was the lack of space to accommodate ARRS staff:
‘Space is a real challenge, we have kind of had this influx of all of these opportunities for these other roles, but nowhere to put anybody.’
(Workforce development lead)
Another consideration was working across multiple sites, and staff working in this way found it difficult to integrate into teams:
‘Because you cover so many surgeries, you are dipping in and dipping out. So, you do get to know people, but really on a very, very surface level.’
(Mental health practitioner)
Those who were employed by the PCN risked getting lost in ‘limbo’ because of their employment status, as one participant explained:
‘ARRS staff are just stuck in limbo, so they don’t belong to a practice … it’s very difficult to make them feel that they belong to the PCN.’
(Business manager)
Integration challenges were not the case for all, however:
‘Being integrated with the GPs has been really helpful for me because I think I’m learning so much working amongst them, and you don’t feel like an outsider coming in.’
(Pharmacy technician)
Some ARRS staff discussed the benefit of working in hubs, where professionals in the same role across a single PCN were working in one location:
‘Because we’re over the six practices — it would be really, really good to have a hub, a base for us three. So, because we are a PCN, we should all be working together.’
(Advanced lead social prescriber)
Impact of ARRS roles on wider systems
There were unintended consequences at system-wide levels, including large numbers of staff moving from other services to work in the scheme, which left some services depleted of their workforce:
‘I suppose there might be in terms of destabilising because if you’ve got a lot of PCNs trying to recruit paramedics, for example, and there aren’t enough paramedics to go round … I guess that’s a risk that we’re all fishing in the same pond for staff.’
(PCN manager)
Some staff chose to move into primary care for personal development or because they saw a better work–life balance and more social working hours:
‘[In hospital] you used to have to cover a late shift and they don’t do that here … there’s a lot of pluses for a tech leaving secondary care to come here.’
(Pharmacy technician)
A potential positive impact of the scheme was that patients with issues previously requiring referrals could be managed in primary care:
‘So, [staff in primary care] stops those referrals going in, which is good. And, it’s the same for the physio service. That certainly stops the referrals into the main physio service.’
(ICS lead)
However, pressures elsewhere in the system (potentially exacerbated by the movement of staff into primary care) meant that primary care staff were supporting issues that they might not otherwise. This was particularly challenging for social prescribers:
‘We are hand-holding due to the lack of resources everywhere else and availability on other agencies. We’re hand-holding some very, very serious stuff.’
(Advanced lead social prescriber)
Tensions and perspectives of existing staff
A delicate balance is needed to incorporate additional staff into primary care without demoralising or deprioritising existing staff. There were concerns that some staff in primary care, particularly registered nurses, missed out on using their specialist knowledge because that work was being covered by incoming ARRS staff:
‘[Nursing staff] saw some of these roles coming in and taking away their work. They, therefore, felt demoralised, they felt that there was no value placed on the work that they had been doing for years … and it’s all been given to a clinical pharmacist to sort out.’
(ICS lead)
The difference in terms and conditions between ARRS and non-ARRS staff were also causing tensions, as well as disparities in opportunities in primary care more broadly:
‘This is one of the problems as our team see it; the additional roles are paid much more than anyone else in primary care.’
(PCN manager)
