Almost half of general practice nurses (GPNs) are being expected to provide education and supervision for staff employed under the Additional Roles Reimbursement Scheme (ARRS), despite, in many cases, being paid less and given fewer development opportunities, new research has revealed.
A report by the Queen’s Nursing Institute’s (QNI) International Community Nursing Observatory (ICNO) has laid bare a general practice nursing workforce feeling ‘pushed out’ and at risk of ‘disappearing’ altogether because of ARRS.
Introduced in England in 2019, the scheme currently funds the salaries of 17 roles – including nursing associates and advanced nurse practitioners, but not GPNs.
Recently, growing concerns have been raised around the impact of ARRS on GPNs, including that nurses have been devalued by the scheme and, in some cases, substituted by cheaper alternative staff such as nursing associates.
Led by director of the ICNO Professor Alison Leary and Dr Geoff Punshon, the project saw more than 500 GPNs surveyed in 2023 on how the ARRS scheme has affected them.
Inequitable pay a ‘recurring issue’
More than a third of GPNs (37%) reported that the introduction of ARRS roles had increased their workload, while 24% said their workload had decreased. A further two-thirds (67%) said their workload had not decreased since the introduction of the scheme.
Survey results also saw almost half of GPNs (49%) report being expected to provide education and supervision for ARRS staff, and more than half (51%) said ARRS colleagues were unable to practice independently in the practice without needing input or training from a GPN.
Concerningly, the report’s authors also found a ‘recurring issue’ among GPN respondents was ‘inequitable pay and conditions’.
‘GPNs were expected to support and supervise ARRS colleagues, for lower pay,’ the report said.
‘They also had less access to developmental opportunities and paid time for learning compared to ARRS colleagues.’
One nurse said ARRS roles were ‘allowed unlimited training time and get better terms and conditions compared to practice employed staff’, adding that this caused ‘disruptions in the team’.
Another added: ‘ARRS roles are paid more than GPNs and have less qualifications, little to no experience and require support from GPNs earning much less. It reinforces the message that nursing isn’t a valued profession.’
One nurse suggested the GPN role was ‘disappearing’ as a result of the situation. ‘We are not valued like [ARRS roles] are even though we do more of the work,’ they added. ‘The GPN role in a whole is undervalued, underpaid and underappreciated.’
Another GPN said it was ‘very demoralising’ having to provide supervision and training to ARRS colleagues while being paid less.
GPNs performing ‘rescue work’
Incomplete care and care left undone was also a ‘common issue’ and saw GPNs report how ARRS staff were ‘working outside of traditional scope of practice’.
GPNs are reportedly having to ‘perform rescue work’ when care is left undone by ARRS staff and ‘complete the episode or care or teach colleagues’, especially around the management of long-term conditions.
The report said GPNs had seen an ‘additional rise in care delivered as protocolised tasks, which they found unfulfilling compared to the person-centred care they aspired to’.
One GPN said care was becoming a ‘tick box exercise’ and that patients were ‘confused’ by the ARRS roles and what they do.
Care was also becoming ‘more fragmented’, they said. ‘My job satisfaction has plummeted. Not sure I want to do it anymore,’ they added.
Another GPN added: ‘The main impact that saddens me is how we have devolved patient care into a series of tasks delivered by different people in the practice setting.
‘Diabetes patients used to have one holistic appointment with a nurse once or twice a year dependent on their health status. Now they can have four or even five separate appointments.
‘Patients hate it and I hate the lack of continuity, debasement of my skills and knowledge and the fact that patients are so inconvenienced.’
In addition, one GPN described ARRS as a ‘sticking plaster over the issues that are currently being seen in general practice’.
‘Experienced GPNs are feeling pushed out and are underrepresented in implementation of these roles,’ they added.
They also argued there was ‘no clear directive on the ARRS roles’ and ‘especially’ that of nursing associates. The GPN suggested some ‘seem to be encouraged to work outside their sphere of competence’.
Other survey findings saw 29% of GPNs feeling that their nursing expertise had been ‘utilised more’ since ARRS, while 60% disagreed.
In addition, just 17% said they felt their nursing role was ‘more valued’ while a significant 69% disagreed.
As reported previously by Nursing in Practice when early results were shared last year, more than three-quarters of GPNs also said they had not been consulted on the introduction of ARRS roles into their practice. Meanwhile, 12% said they had and a further 12% said they had the roles introduced before they were employed.
GPNs have experienced ‘significant disadvantage’
Report author and Professor of healthcare and workforce modelling, Professor Leary, commented that the introduction of ARRS had been ‘problematic’ for the GPN workforce.
‘ARRS appears to have impacted the workforce in several ways. This ranges from a lack of resources to support those new to primary care, expectations by others of GPNs filling a gap, and a lack of consultation regarding a major workforce change, leading to feelings of devaluation,’ she added.
‘There are significant equity issues highlighted particularly around pay and opportunity.’
Meanwhile, chief executive of the QNI, Dr Crystal Oldman added: ‘The survey shows that multiple assumptions were made about the primary care workforce and no real assessment of the impact that ARRS was likely to have.
‘This has led to the GPN workforce feeling devalued. In some cases, GPNs have experienced significant disadvantage.’
The report lists several recommendations:
There should be full and meaningful workforce engagement in any major change affecting the workforce;
Inequity of opportunity for example, development opportunities and pay inequity needs to be addressed;
The introduction of ARRS roles appears not be based on demand but rather availability, including the availability of funding. The scope and design of roles appears to be largely unexamined. The roles appear to be implemented to fill a deficit in already established workforces rather than as an additional value-added role arising from workforce redesign. Demand modelling should take place if implementing new roles;
The benefits of ARRS roles used to meet specific previously unmet demand were clear, but there needs to be clarity around all roles and scope of practice, particularly for those new to primary care;
There needs to be more resourcing of teaching, supervision, and support, not only for new roles but also those transitioning to a new area of practice;
There should be scrutiny at a regional and national level of how the ARRS impacts on the overall workforce strategy in primary care and the community healthcare workforce.
The report comes as a petition calling for GPNs and GPs to be added to the ARRS scheme has reached more than 10,000 signatures – meaning the government now has to respond.
Last week it also came to light that NHS England has offered funding to provide nursing associates a place on a university programme typically designed for GPNs.