Dr Neil Paul and Denise Smith, from Sandbach, Middlewich, Alsager, Scholar Green, Haslington (SMASH) Primary Care Network, advise practices on how to take advantage of the Additional Roles Reimbursement Scheme
While the world has been turned upside down the past few months by the Covid-19 crisis, practices still need to plan for the future. As leaders at our Primary Care Network (PCN) we have been constantly reminding our member practices about the additional roles opportunities.
We feel there is a real opportunity here to invest in primary care staff through the Additional Roles Reimbursement Scheme (ARRS) and every day that goes by without the money being spent is an opportunity lost.
A couple of key issues seem to be getting in the way, namely concerns about the sustainability of the funding and employment liabilities issues.
There are also some understandable frustrations about the limitations placed on the roles that are covered by the scheme.
Here are our tips on getting past these concerns and focusing on your needs so your practice and PCN can make the best of the funding available.
The main concern we hear is regarding sustainability. Possibly the most common question we get from partners in local practices is ‘What if they pull the money – will I be left with a huge cost?’ Or similarly, ‘What happens at the end of the 5 years – will we suddenly have to pay all the cost?’
Our view is that practices should not be unduly concerned.
Even if, in the worst-case scenario, the funding does come to an end after this contract, you will have had these roles for free for 5 years. If the roles prove to be a massive asset, then you can build on that model and keep them on. Conversely, if they aren’t delivering on the goals for your practice, you can look at alternatives.
While it is right to be aware of potential liabilities, there is probably also too much concern about the HR rules. If the money is pulled, you can close the post. Don’t forget that GP practices are separate from the NHS so previous years served in the NHS doesn’t count if you do have to make redundancies.
The Network aims to help practices to recruit and retain staff working through the recruitment and induction process, ensuring clear job descriptions and advertising the post to attract the candidate with the right skill set and to agree suitable terms and conditions. In our area, Cheshire CCG and the Alliance Federation are supporting the PCN to ensure the PCN has a robust plan in place, articulating a clear vision.
We have heard of PCNs discussing all sorts of models of employment. Accountants and lawyers are running seminars to promote setting up new structures and new organisations, but we do not feel this is necessary. Our GP Federation holds all the local PCNs’ funding in a separate account – so it doesn’t go through their books but the accountants supply a detailed statement for each practice of where their money went which each practice needs for year-end accounts. The Federation processes all our invoices separately on a monthly basis and provides monthly finance reports for our PCN board meetings. The Federation also administers the process to claim any additional roles monies for practices and PCNs. Having a central team doing this makes it simpler and more efficient. It also gives our Federation further purpose in supporting the PCNs.
Our strategy is simple – last year we worked out what the total ‘Additional Roles’ budget was for the PCN and then held lots of conversations with our practices about what they wanted to do together. This led to us agreeing to employ a social prescriber and a first-contact MSK practitioner across all practices which used up most of the money.
This year we have decided to get appoint two more social prescribers to have three in total (our PCN is split into three distinct geographies) but then to split the remaining money among practices and let each decide what to do with their share of the money in order to deliver the DES and any other commitments. This makes employment much easier and avoids potential VAT issues. It is more work for each practice manager, but again the Federation is happy to coordinate writing job descriptions, advertising and even helping with interviewing.
Staff working across practices are recruited through outside agencies. Our social prescribers come from a large CIC called Pathways that provides this service across the North West. They also handle all the HR.
Similarly our MSK service comes from our local community provider. Again, several PCNs locally do the same and the GP Federation has helped to coordinate this. We are in discussions over appointing podiatrists and dieticians; issues to discuss are how we avoid ‘competing’ for staff, which could destabilise the provider, and the potential for offering part-time or fixed-term posts to use up unspent money.
We are determined to not lose this money but with the time it takes to recruit, and the Covid situation, we are aware this is sliding. We are yet to hear from our CCG about whether we can spend in-year underspend – either our own or others.
Our advice to practices is to see this as an opportunity and to consider investing now to save later. Significantly the total funding available to each PCN goes up dramatically in the next 2 years and it might be worth some practices taking a risk and spending some of their own money early to get someone in post in the knowledge that the full cost will be picked up, rather than wait for that to come in and then struggle to recruit. Alternatively it may be possible for one practice to use another’s unused funding in the knowledge that their funding will go up next year.
As an example: We know that paramedics are being reimbursed from April 2021. Think now about what you want. If you think a paramedic would be useful, don’t wait until April to advertise as it will be August or longer before they are in post. Advertise now and try, if you want, to make their start date April, but if they want to start in January – pick up 3 months of their cost knowing they are paid in full from April. That’s a small investment to get the right person, and thinking ahead of the game, instead of leaving it like other practices may mean you have a wider choice of quality candidates.
We would prefer the rules were easier. To try to help offer at least some flexibility, we asked whether member practices wanted a PCN-wide team or preferred to hire their own staff – they chose to mainly hire their own, partly for simplicity but partly because practices still feel they get more from directly employed staff. So far our member practices have mainly gone for clinical pharmacists.
In addition to the shared social prescribers and first-contact MSK practitioner, we are looking at the new care co-ordinator role and believe that has the possibility to help across practices. The definition of what they do is quite broad but in many ways they could be seen a GP’s admin assistant. Their role is to help patients navigate the system, chase results and do a myriad of other tasks that usually get dumped on the GP. The role seems more clerical than clinical and they could genuinely be a great help. We are talking to Pathways CIC about whether they could provide these staff. Note that accreditation and training required is not yet in place for this role.
Physician associates locally all seemed to have been trained in hospital and to be very disease specific just at a time when primary care is trying to go to non-disease specific clinics. There hasn’t been much take up of them as a result, though we hear in other areas they are amazing.
There is news that nurse associates will come under the scheme from Oct 2020 but it is not fully clear what the role is or if there any are trained. They are advanced HCAs, but not nurses. Not knowing exactly what to do with them or waiting two years for them to be trained and only be in the practice briefly makes it difficult to rely on. A common theme is the lack of established roles – practices want developed, trained staff to help them now. The confusion of roles available, and lack of information about what you will get out from these roles, delays decision making.
There is also a worry that we end up employing staff that should be paid for elsewhere in the system. Once mental health practitioners become eligible, for example, do we use up this money to pay for them and allow the IAPT service to continue being poor, or do we get something else and press for more investment in IAPT from other monies?
Lastly, there are other non-clinical roles practices may benefit from. One of our PCNs wants to be able to spend some of the ARRS funding on an IT support/trainer. We funded one through another pot of money for 6 months and he really helped practices. He not only helped do some of the burdensome reporting but also did one-to-one and group training as well as fixing problems and liaising with the CSU. Knowing the hugely positive impact on patient care that optimising the use of IT options in primary care can have, we would love to spend some of the money on IT support and indeed project management – we are seeking funding for this through other routes.
Dr Neil Paul is clinical director and Denise Smith is lead practice manager at the Sandbach, Middlewich, Alsager, Scholar Green, Haslington (SMASH) PCN
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