Unless there is some radical change of position soon by NHS England it looks almost certain that significant sums of primary care network (PCN) funds will be unclaimed by the end of this financial year. This is totally preventable, and could easily be remedied.
There will be a variety of reasons for PCNs not being able to use their share of ARRS funding, which remains the largest source of income for our fledgling PCNs. On paper the policy makes great sense - by funding new clinical staff, it should improve patient care and take a load off overstretched GPs.
So maybe it is worth thinking about why the ARRS has not been used, and some of the evolving issues - for example:
- GPs are working at least at 'BC' (before COVID) levels of activity, are already overstretched and exhausted, experiencing regular staff absences and simply might not have the time or energy to research the network DES, advertise and interview.
- Let’s not forget there was a pre-exisiting GP crisis which has been overshadowed by the pandemic.
- The time taken to on-board and train up new team members is not recognised or funded and is significant, especially where it removes a GP from other work.
- These are often novel roles. This requires lots of meetings and training sessions for existing team members to understand how to integrate. Practice staff already trying to manage the rapid changes associated with COVID need time to understand and learn how to make full use of these new colleagues.
- New ARRS staff will often be working over multiple practices - which may have slightly different processes - for different line managers. They might not be able to work on site due to lack of space. Integrating new staff, in novel roles, who you rarely see in person is challenging at the best of times.
- Lack of flexibility. Although there has recently been a small change to allow nursing associates from October 2020, the choice of roles available through the ARRS remains restrictive. Arguably a paramedic or minor illness nurse might have the greatest immediate impact on workload – but paramedics are not allowed until April 2021 and a minor illness/emergency nurse practitioner role is conspicuously absent from the list available.
NHS pandemic response
In January GPonline published an article calling for a more flexible PCN DES, and much of this stands true. While the NHS has adapted and responded remarkably this year, one could argue that the changes have been greatest in primary care, with total reorganisation of working patterns and a rapid shift to ‘digital first’ solutions. The pros and cons of digital first are known, but one of the great successes, AccuRx, may not be funded from April 2021.
Due to the sheer numbers of patients managed - as we deal with around 90% of all NHS contacts despite receiving something like 7% of the overall budget, every penny invested in primary care will have a much larger impact on patient care than like-for-like spending elsewhere in the NHS.
So what are some potential solutions? Here’s my own list of basic suggestions after following developments closely, endless emails, many hours of PCN meetings and discussions with colleagues locally and nationally.
Flexibility for the ARRS
This is key. There seems no reason to prevent each PCN or member practices to make a business case for staff they need. The world has changed since PCNs were introduced - and one might need a youth worker, one a dedicated frailty clinician, another an IT specialist. The list will vary, as practices' demography, geography and demands vary nationwide - that is the nature of general practice.
Why not allow GPs, as a one-off this year, to use any remaining funds towards additional locum cover? We are being asked to deliver a markedly enlarged influenza immunisation programme, with COVID immunisation on the horizon. The resources have been allocated as part of ARRS but staff take time to get into post and trained to do the work needed. So why not trust practices to provide value for money?
GP practices nationwide have spent their own funds on physical changes for patient and staff safety during the pandemic. This might include perspex screens and intercoms at reception, electronic doorbells, laminate flooring or plastic chairs. None of this has been supported financially despite promises from NHS chiefs.
Every GP practice will have purchased extra kit including PPE, thermometers, oxygen sats probes, webcams, headsets, sanitising wipes and gels and more. Many PCNs would relish the opportunity to acquire new kit to directly improve patient care and reduce referrals: such as ambulatory BP monitors, FeNO monitors, dermatoscopes and extra AEDs.
Remove red tape
CQC, QOF, local improvement schemes, LES, DES, prescribing work. We are still being asked to do performance-related work, despite NHS leaders' promise to 'remove routine burdens to free you up to devote maximum operational effort to COVID readiness and response' - and clear calls from our leaders, such as Professor Martin Marshall to keep red tape to a minimum.
These ideas are neither ground breaking nor contentious. In appraiser speak they are all SMART.
These are unprecedented times, we are in a global pandemic, yet unable to access available time-limited funds, and being forced to continue near-normal bureaucracy. NHS England, policy-makers and politicians should be asking themselves what the public will think if they learn £12bn has been squandered on the private sector Test and Trace system, £100bn proposed for Moonshot, £35m on the tracing app - but NHS GPs have received no extra financial support, despite unclaimed money being available.
There is window of opportunity for NHS England to simply and quickly change the ARRS, to allow a high trust, low bureaucracy one-off system until April 2020. We know that GPs understand their communities, are experts in population health, have a can-do mentality and have proven during the pandemic and long before that when given trust and freedom they will innovate and deliver for their patients.
Not liberating the ARRS, along with any other surplus PCN or primary care funds ring-fenced locally by CCGs, will disadvantage patients and worsen GP morale, with obvious negative collateral consequences for the wider NHS.
- Dr Simon Hodes (@DrSimonHodes) has worked as a GP partner in the same Watford practice since 2001 and is also a GP trainer, appraiser and LMC rep. The views expressed above are his own.