The rapid emergence of a variety of additional roles in general practice has boosted the primary care workforce as a whole but, asks Kathy Oxtoby, does this bring disruption for nurses, whose role has been established in practice teams for decades? How are new roles in PCNs impacting nurses in general practice?
General practice nurses are under greater pressure than ever, dealing with a growing backlog of care and an ongoing shortage of staff. A government scheme that offers funding to primary care networks (PCNs) to boost the number of healthcare professionals working in general practice could therefore be seen as a welcome step towards easing this workload burden.
Introduced in 2019, NHS England’s Additional Roles Reimbursement Scheme (ARRS) has been supporting the recruitment of additional staff – including pharmacists, physiotherapists, podiatrists and paramedics.
This continues to expand at pace. To help PCNs build the teams they need, NHSE recently announced changes to the ARRS, including adding advanced clinical practitioner nurses to the reimbursable roles, raising the cap on advanced practitioners to three per PCN, and removing the cap on mental health practitioners.
According to NHSE, there were 25,262 ARRS staff as of 31 December 2022, with PCNs a year ahead of schedule to meet the 26,000 target for March 2024. The figure was a significant rise from the 14,069 reported a year earlier. However, research by the King’s Fund warned that while PCNs swiftly recruited to these roles, ‘they are not being implemented and integrated into primary care teams effectively’.
What do general practice nurses think about ARRS?
Some GPNs told Nursing in Practice that, while they broadly welcome the input of ARRS colleagues, they have concerns that the rapid influx of new roles and processes could jeopardise their own role in the longer term.
Marilyn Eveleigh, nurse and chair of Nursing in Practice’s advisory panel, believes the scheme could help take general practice ‘to another level’.
She says: ‘Since 1990, GPNs have successfully expanded their roles in general practice teams, changing the face of primary care. Now ARRS roles have the potential to take services to another level, with timely improved care closer to home and nurses coordinating holistic care.’
She welcomes the scheme’s additional nursing roles but suggests it could have involved more nurses from the outset and that new roles will mean changes for nurses.
‘It was a lost opportunity when the ARRS list did not initially include nurses. Because we have a national shortage of registered nurses, alongside increasing and complex patient needs, I’m not concerned the GPN role will be eroded – but it will inevitably change.
‘ARRS threatens to dilute the GPN role’
Others are more concerned. RCN UK professional lead for primary care Heather Randle, says she supports the scheme, but questions what the changes, mostly introduced without consultation, could ultimately mean for established nursing teams.
‘From a GPN point of view, ARRS threatens to dilute the role. Patients may be getting a diabetic check by one person, a pharmacy review with another, but this is forgetting the unique role the practice nurse does so well.
‘A GPN is like no other role in healthcare. You need general knowledge and skills in so many different areas. But ARRS is putting the role at risk,’ Ms Randle warns.
‘What has not been looked at is the value of the GPN role, and how to recruit to that role and keep those skills going. ARRS has been done to GPNs, not with them.
Sarah Hall, a steering committee member of the RCN GPN Forum, and a Queen’s Nurse, shares these concerns.
She says ‘I do feel really strongly about the way these roles have been brought into general practice – that they are undermining the role of the general practice nurse.
‘My worry is that people working in additional roles are taking on the roles of GPNs, and that general practice won’t need as many GPNs.’
ARRS may have expanded the general practice team, but it has made no difference to the shortage of GPNs. ‘General practice nurses were not included in the ARRS, so the capacity of registered nurses could not be increased through this funded scheme,’ comments Queen’s Nursing Institute chief executive Dr Crystal Oldman.
‘Instead, some general practice nurses have found they are mentoring and teaching practitioners coming in under ARRS – an additional demand on their time.’
Ms Randle says some GPNs are being asked to supervise practitioners in ARRS roles, such as pharmacists, who often have ‘better terms and conditions [which] can make GPNs feel undervalued and invisible’.
From a patient perspective, the new roles could be confusing, she suggests, and may disrupt the continuity that comes with being cared for and treated by a GPN.
‘Put yourself in the patient’s position – rather than seeing their practice nurse, they may now have three different visits to different practitioners. For the patient, care must feel disjointed and frustrating.’
The ARRS scheme’s impact on GPNs to date seems to depend largely on the PCN’s approach. Dr Oldman says the QNI’s networks of general practice nurses report ‘a mixed impact’.
Ms Hall explains. ‘One GPN I spoke to says their PCN has integrated the roles well, there is great teamworking, and they are using their specialist knowledge to support each other. However, another told me that additional roles staff were not embedded within their PCN, and these staff were finding it difficult to feel part of a team.’
On the positive side, Andrea Mann, a GPN and clinical director at Crossgates PCN and East Leeds Collaborative, says she has not heard of ‘any negative feedback or resistance to working alongside the PCN clinical team’.
Ms Mann explains that a ‘conscious decision made at board level was to make sure our PCN team was working across the four practices’. She adds: ‘They are very much embedded within practice teams, and they spend time at each practice across the working week.
‘Whether it’s nursing roles or other allied health professionals, they have worked really well in the PCN, and there’s good communication and working relationships with GPNs and GPs at the practices.’
Jenny Bostock, a clinical director for Ramsgate PCN and an advanced nurse practitioner, says the ‘unrelenting’ workload in general practice means having new roles to support GPNs is ‘a positive solution’.
‘A large proportion of GPNs are coming to retirement age and the ARRS roles are being seen as the solution to recruitment and bridging the gap,’ she says.
‘However, it is taking time to train the new roles and ensure they are competent in their clinical skills.’
Ms Bostock says clinical pharmacists at the PCN are starting to take on areas of chronic disease, which is relieving the workload of some GPNs who have historically managed all the chronic disease.
‘This is particularly useful with smaller practices. Clinical pharmacists have a good background of drugs and can manage chronic diseases well.’
Physiotherapists have also attracted praise. North London-based ANP Saira Yeadally Khan says: ‘They really help patients with musculoskeletal conditions and have definitely helped my workload.’
Shift to a medical model
While nurses welcome clinical pharmacists’ expert knowledge of medicines, there are concerns about them working to a medical model, rather than taking a holistic approach to patient care.
Bradford-based GPN Naomi Berry says her workload ‘doubled’ when clinical pharmacists first started carrying out medication reviews of her patients.
She explains: ‘Their approach was very medical – they didn’t take a holistic approach in the same way
as a practice nurse would.’ For instance, sometimes pharmacists did not identify the need for blood pressure checks or specific blood tests, creating the need for additional practice nurse appointments.’
Ms Berry says regular feedback to the pharmacists has improved the situation, ‘but it would have been good to have sat down at the start, to talk through what I do as a practice nurse, and how they could alleviate some of the workload pressures when seeing patients’.
Pharmacists may also not understand the patient’s needs beyond medication, Ms Randle adds. ‘Sometimes, for example, an inhaler might be better for the patient’s symptoms, but they might not be able to afford it. It’s those nuances of general practice we’re losing.’
Nursing associates: ‘an asset to practices’
The new nursing associate role – introduced in England to bridge the gap between healthcare assistants and registered nurses – is also having an impact on general practice nursing. Some 6,874 were registered with the NMC as of March 2022, and with the roles eligible for ARRS funding since 2020, more nursing associates and trainees are coming into general practice.
Ms Bostock says nursing associates are seen as ‘an asset to practices’. She explains: ‘They support the GPNs and take off the simple work, giving them time to deal with more complex patients.’
Trainee nursing associates are being trained by GPNs ‘and are doing a great job as they can take bloods, blood pressures, measure height and weights, and perform simple dressings’, she says. ‘However, one of the issues is the time that needs to be invested in their training.’
Jenny Aston, an ANP for Granta Medical Practices in Cambridge, says uptake of nursing associates is increasing ‘now practices understand their potential benefit’. However, ‘they do need to spend time out of the surgery to do training, and they do need supervision’.
Another ARRS role with a positive impact is the social prescriber link worker. These professionals help patients with issues such as housing and employment.
‘Social prescribers are proving invaluable,’ says Ms Aston. ‘They are really helpful in dealing with aspects of patient care that are non-medical, such as housing.’
Roles covered under ARRS
The following are covered under the scheme in primary care:
• Care coordinator
• Clinical pharmacist
• Pharmacy technician
• First contact physiotherapist
• General practice assistant
• Health and wellbeing coach
• Mental health practitioner
• Nursing associate
• Occupational therapist
• Community paramedic (currently under review)
• Social prescribing link worker
• Physician associate
• Advanced practitioner
*Source: elearning for healthcare and Health Education England: New Roles in Primary Care.
The potential of collaboration
Increasingly, some services, such as vaccinations, are being offered at a PCN level rather than at individual practice level, a development that GPNs report as having a positive impact.
Nursing in Practice heard that the Covid and flu vaccination rollouts have worked particularly well.
‘At our PCN, care coordinators, nursing associates and pharmacists all undertook training to give these vaccinations at Covid clinics and care homes, and were also doing home visits,’ says Ms Mann.
‘This allowed practice nursing teams to carry out vaccinations for those coming into practice clinics,
and gave us extra capacity to offer more vaccinations.’
For Ms Bradley, her PCN’s drive to deliver Covid and flu vaccinations ‘was a really positive experience in that it allowed practice teams to get to know and work with people within the organisation’.
The successful rollout of Covid and flu vaccinations, with general practice nurses and those in additional roles working together, demonstrates how much can be achieved by proper collaboration across primary care.
Where this is happening, nurses say they welcome more roles in the practice and different people to collaborate with as a team. ‘We’ve got good working relationships, and PCN staff have worked hard to embed themselves and be visible across practices,’ says Ms Mann.
Ms Yeadally Khan agrees, saying she is ‘very much in favour’ of additional roles. ‘For example, if I need information on medication, I can now ask a pharmacist.’
Additional roles can also benefit student nurses. ‘It’s so valuable for them to spend time with a pharmacist or paramedic,’ says Ms Bradley.
Making the most of additional roles
Care needs to be taken, therefore, to ensure the new roles are properly embedded across PCNs, with ARRS staff working closely with GPNs to the benefit of patients.
‘My vision is about embedding the PCN team, having them enhance the services we can deliver across the practices, and for everyone to really embrace these new roles and skills,’ says Ms Mann.
Training and supervision are also crucial. Ms Mann’s PCN, for example, has introduced regular joint training sessions with practice and PCN teams.
PCNs also need to communicate effectively with GPNs and their teams about how additional roles will work, and should involve them in any key meetings, says Ms Bradley. She suggests having senior nurses at PCN level can ensure GPNs have a voice in this respect.
Practice nurses need to be proactive in raising any issues or concerns they might have about how additional roles are working, and what could be improved. ‘Giving feedback is essential,’ says Ms Berry, ‘and it’s also important to take time to talk to those doing additional roles about how you work, and ask if there is anything you can do to help them. Because, if we embrace these roles they can have a really positive impact.’
Funding is always a background worry in primary care. Looking to the future of the ARRS model, Ms Bostock says: ‘While we are assured the funding model will increase slightly each year, we are aware government policies could bring cuts. This would completely destabilise general practice, which is already struggling.’
Meanwhile, there remains a fear that if coordination at PCN level slips and ARRS roles are seen to take away the responsibilities that attract people to practice nursing in the first place, the diminishing GPN workforce may reduce still further – or disappear altogether.
‘If ARRS roles take all the specialist areas, and manage long-term conditions, and nursing associates take over the day-to-day work of practice nurses, where does the GPN fit in?’ asks Ms Hall.
And with ARRS roles highlighting that practice nurses remain outside Agenda for Change pay and conditions, Ms Randle says: ‘We need to value the role of the practice nurse and make sure it isn’t diluted so that we don’t lose that skill set in general practice.’
Ms Eveleigh concludes: ‘It’s sad to hear that anxiety and threats to GPN roles are circulating in some PCNs; I’d encourage GPN leaders to step forward and advocate for better communication and transition of services, using successful models employed elsewhere.’
There are further opportunities, she says: ‘With other clinicians sharing the load, this is a fantastic opportunity for PCNs to raise the status of nurses working in residential homes. GPNs are ideally placed to integrate them more closely into the primary care family and help develop their skills.’
Nurses’ views on ARRS: concerns and solutions
A summary of points and suggestions raised by general practice nurses
• ARRS could dilute the GPN role
• Mentoring and teaching ARRS practitioners is an additional demand on GPNs’ time
• GPNs are being asked to supervise practitioners in ARRS-funded roles who are often on better pay, terms and conditions
• From a patient perspective, ARRS roles can be confusing and can disrupt continuity of care
• Practitioners in ARRS roles may focus on a medical model to deliver care, rather than a holistic approach. This can lead to additional work and patient appointments for GPNs
• ARRS roles need to be embedded across PCNs
• More training and supervision is needed, such as regular joint training sessions with practice and PCN teams
• PCNs need to communicate effectively with GPNs and their teams about how additional roles will work, and should involve them in any key meetings
• Having senior nurses at PCN level can help to ensure that GPNs have a voice
• GPNs need to be proactive in raising any issues or concerns about how additional roles are working, and what could be improved
• GPNs can share information with ARRS practitioners about how they work, and ask how they can help them. Giving feedback is essential