PCN co-director Dr David Coleman outlines the key updates to the Additional Roles Reimbursement Scheme for this year and offers tips on how to start planning your workforce needs to make the most of the funding available.
One of the great secondary challenges of the Covid-19 pandemic has been keeping up to date with changes outside of the Covid-19 sphere; as a PCN director, vaccination has been the order of the day since December.
Importantly, the planned increase in full-year funding for the Additional Roles Reimbursement Scheme (ARRS), from a maximum of £430m in 2020/21 to a maximum of £746m in 2021/22, has been confirmed – despite the postponement of four new PCN services (CVD diagnosis/prevention, health inequalities, personalised care and anticipatory care).
Three new roles have now come online, too. These are:
There is increased flexibility around employment, a new weighting system for London based PCNs (based on current NHS arrangements for inner and outer London), and removal of some limitations, such as those regarding the number of reimbursable pharmacy technicians and first contact physiotherapists.
NHS England have made it quite clear that they expect PCNs to maximise recruitment via ARRS.
In their January letter, NHSE stated: ‘We encourage all PCNs to make full use of their ARRS entitlements as soon as possible. PCNs are a platform for general practice investment.’
Indeed, CCGs ‘will only be able to draw down on ARRS funding on the basis of PCN recruitment under the scheme’. In other words, PCNs will have to use it (via ARRS recruitment) or lose it.
As a first step it is worth considering what the newly introduced roles can offer your Network, with an eye on your longer term workforce needs.
1. Paramedics
NHSE states that ‘paramedics in primary care are generally expected to work at Level 7 capability, but suitably experienced paramedics on a training pathway to that level may also be reimbursed if working as part of a rotational model with an Ambulance Trust’. Direct employment, or use of a rotational system are both therefore options. Reimbursement will cover 100% of salary (band 7) and costs.
Ambulance services have been operating under great strain during the pandemic and I imagine some paramedics may be looking for new challenges, but obviously there may be concerns about weakening existing services. PCNs should aim to work with your local ambulance services to ensure sustainability is maintained.
I have overwhelmingly positive experiences of working with paramedics in primary care. Obviously the role is a great fit for home visiting and minor illness or musculoskeletal consultations; but with experience and the support of an MDT, paramedics can contribute to anticipatory care, care home ward rounds/MDT meetings, and even become involved in learning disability care as part of a small team of clinicians.
A rotational system removes the benefits of role, skill and relationship (with other ARRS staff and MDT) development over a period of months to years, which makes direct employment more attractive from my point of view.
There are advantages to tapping into a rotation though: the support of an ambulance service (for supervision and host employment) may make it an attractive option for some PCNs.
2. Advanced practitioners
Advanced practitioners is a catch-all term for six defined roles that PCNs can now employ at Band 8a salary and costs, subject to the requirements outlined in Annex B here. PCNs with fewer than 100k patients can employ one WTE Advanced Practitioner; PCNs larger than 100k patients can employ two WTEs. The roles are as follows:
The advantage here is that more senior/experience/skilled clinicians within these roles can be employed at a higher rate of reimbursement. If a paramedic has a masters degree (or is working at a masters level) for example, they may not be interested in a band 7 post. This post would allow the PCN to employ a senior paramedic at band 8a as an advanced practitioner, who could then –for example – supervise and support a band 7 paramedic on a rotational scheme.
My advice to PCNs would be to look at your current ARRS workforce and look at the requirements of the DES. Where are your weaknesses? Where are you gaps? Talk to other PCNs. Which roles have been hard to recruit to? Your advanced practitioner slot gives you the flexibility to employ one of these vital roles at a slightly higher rate of reimbursement. This might give you a recruiting advantage over other local PCNs. Remember, we’re all looking to recruit from the same pool of limited staff. A band 8a salary is a good inducement – but you only have one slot, so use it wisely.
3. Mental health practitioners
The mental health practitioner (MHP) role is slightly different from other ARRS roles, as it is designed as a partnership. NHSE is clear that ‘mental health practitioners must be employed by the secondary care provider of community mental health services that covers the PCN geography’; they will be fully deployable by PCNs, who will contribute 50% of the salary and costs, which is reimbursable via ARRS. The role can be a registered mental health clinician at band 5-8a, as locally agreed.
PCNs may also choose to embed a children and young people MHP (on the same basis, with the agreement of the local provider) in addition to the adult MHP role. Staff funded in this way will be additional to any MHPs and co-located IAPT practitioners already embedded within general practice.
The MHP can act as a bridge between primary and secondary care services, as well as liaising with social prescribing workers and health and wellbeing coaches (if these are available locally). Our PCN has a significant learning disability population, so we are in the process of exploring the recruitment of an MHP with experience in this field, to help us address the requirements of the DES for this patient cohort.
Maximise your funding
The CCG has to agree with the PCN by 30 September 2021 an estimate of how much ARRS funding the PCN is unlikely to claim by 31 March 2022. The PCN will not be able to access the unclaimed funding from then on, and other PCNs will be able to bid for it. It is therefore vital to make sure your workforce plan taps into the maximum funding available. NHS England has produced a ready reckoner to help PCNs calculate their maximum ARRS sum based on weighted population (for 2021/22, this is £12.314 per weighted patient as at 1 Jan 2021).
Areas of focus
There are now fifteen roles reimbursable under ARRS. While it is tempting to think ‘we’ll see how recruitment goes and take a pragmatic approach’, the requirements are a little more rigid than that.
The Network Contract DES Specification requests that PCNs complete and return their workforce plans including recruitment updates for 2021/22 to the CCG by 31 August 2021. The commissioner will confirm the plan with each PCN’s Clinical Director and, once each 2021/22 plan is agreed, will share with NHS England and NHS Improvement Regional Teams by 30 September 2021.
So the timeline is tight and all PCNs will be looking at the same roles, while also grappling with the remainder of the vaccination programme.
Structured Medication Reviews are a significant focal point of the Network Contract DES, with a widening of the scope this year to include potentially addictive drugs now defined as opioids, gabapentinoids, benzodiazepines and z-drugs. Previously this was just ‘pain medication’, which was open to interpretation. This will be a huge piece of work and PCNs should make sure they have sufficient clinical pharmacist and pharmacy technician support. Speak to the existing team and see how they feel about the proposed workload; they will almost certainly have ideas about what is required to tackle it.
It is also important to think beyond the current Network DES specification and consider the four postponed areas that will come online from October onwards.
CVD diagnosis and prevention feels like it could be addressed by a nurse associate working alongside a prescribing pharmacist.
Health inequalities is a wide remit and is something the whole MDT could contribute to, with specific challenges varying from one PCN to another. For our PCN, I envisage the health and wellbeing coaches and the social prescribers playing a key role.
Personalised and anticipatory care would equally benefit from an MDT approach with different roles contributing, such as occupational therapists, dieticians, pharmacists, and paramedics. Care co-ordinators can play a vital role in overseeing this portfolio of work and linking the professionals together.
Another factor to consider is your practice workforce across the PCN. What can practices do and what will they struggle with? Practices may prefer a home visiting service (advanced practitioners, paramedics) to support their workload, and may be happy to handle more of the anticipatory care themselves. There is no one size fits all, but a scattergun approach without consideration of the DES and the local challenges is unlikely to satisfy anyone.
Dr David Coleman is a GP partner and PCN co-Clinical Director in South Yorkshire
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