For our second PCN roundtable on 2 June, leads from across the country gathered to discuss how they use the Additional Roles Reimbursement Scheme (ARRS) and the challenges they’ve faced. Here are the key discussions from the session.
The group was made up of a mix of different sized PCNs represented by Clinical Directors and/or Managerial Leads. Each participant provided a different perspective reflecting the variety of approaches we are seeing in our work with PCNs.
Approaches to the allocation of ARRS funding
Contributors to the discussion identified that there is a spectrum of approaches that have been adopted when it comes to the new roles under the ARRS. At one end some PCNs have looked at the specifications in the Direct Enhanced Services (DES) across the PCN – worked out the activity required to deliver the specifications, identified the additional resources necessary and have employed new staff on this basis.
On the other end, and in the context that every practice and indeed PCN is different, it was recognised that some practices have agreed a 'fair share' of the available funding through which each practice is recruiting the staff that they want and need to boost their resilience. In this instance, money is delegated to individual practices to decide how to use it. Clearly, there is a myriad of approaches in between.
Most of the leads agreed that devolving money to a practice level doesn’t necessarily support the delivery of PCN services and the specifications in the DES. For this approach to deliver benefits it requires the practices to understand the roles they would benefit most from and the ability to recruit – often to several part-time roles.
The preference was to adopt a collaborative approach to determine which roles would have the greatest impact and could be assigned to work across multiple practices or from a central site serving patients from all practices. It was also acknowledged that individuals, geography and premises are key factors influencing levels of collaboration.
Participants raised concerns about the sufficiency of the ARRS funding to cover the identified roles, as ‘hidden costs’ have been identified. This pertains particularly to the team need fund team leader roles as teams expand.
Addressing any shortfall in funding has required some creative thinking with some of the leads accessing additional funds, such as the non-recurrent Investment and Impact Funding and/or the PCN development allocations to ‘top up’ the budgets.
The joint commissioning of Mental Health roles with local providers and the ability to move at pace is proving a challenge in some areas with some practices using their own funds to ensure they have optimum coverage.
There was consensus amongst participants that the lead practice employment model, while suitable for a smaller number of roles, was less attractive to the lead practices as the numbers of additional staff increases.
Some of the leads are working with local NHS providers, local authorities and third sector organisations as the employing organisation of some of the additional roles. While benefits to this model were described such as inclusive training and supervision, the key challenge articulated with this model includes the funding for the management fees charged which are not covered by the ARRScheme.
A further benefit of this model is the opportunity to strengthen relationships with these entities and create collaborative working practices and the potential to mitigate estates issues through shared use of local authority buildings to house the extended teams.
Another model being explored is the recruitment of additional roles through a Primary Care Federation (or other legal entity). This option raised the question as to whether the direction of travel would be for PCNs to become legal entities for this purpose. One consideration with the federated model was the ability to be able to offer NHS pensions and ensure the roles are attractive to the right candidates. While this is possible, the need to hold qualifying contracts can be an obstacle. which is an area SCW has experience in and would be delighted to advise on.
Several of our PCN leads highlighted the complexity of some of the roles where mixed funding and mixed job descriptions have emerged depending upon when the team members were recruited (pre or post ARRScheme).
The benefits of having standardised contracts of employment were discussed. It was agreed that there is an opportunity for PCN member practices to develop consistent contracts of employment for all new starters. This approach was preferable to undertaking significant processes to amend and align the contracts for existing staff but would, over time, enable consistency.
Onboarding and retention
We know that a sense of belonging is crucial to life satisfaction and wellbeing, this is equally true at work. Contributors to the discussion highlighted the importance of ensuring that the new team members felt a sense of belonging whether that be with an individual practice or the PCN.
Many of the new team members have been working from home over recent months which can lead to a sense of isolation. At the same time, there is a sense that home working is the solution to some of the logistical issues with primary care estates – this will be compounded when, post-COVID-19, more people return to the practice sites and space will be a premium again.
PCNs need to consider how best to ensure that the new team feels part of the practice or PCN team – failure to do so will lead to increased staff turnover.
Differing approaches to the deployment of the additional roles, often influenced by the availability of space in practices, posed different challenges in the context of belonging. Amongst the PCNs represented there is a mixed economy of approaches with many of the roles being deployed with a dedicated practice, some working across multiple practices and other roles working from a central site serving patients from all practices.
Working from multiple sites (referred to as practice-hopping) can add further complexities to organisational issues such as assigning rotas and working space. It also can compound the issue of which team the individual belongs to, and which practice will take responsibility for the provision of pastoral support and personal development.
There are additional issues for employees working across multiple practices. Most PCNs do not have aligned policies and guidelines across member practices. It was felt to be unreasonable to expect someone to read and digest different policies at each practice site. Some of the leads described the challenge of aligning processes and policies across a group of independent businesses but there was a shared acceptance of the potential benefits.
There was a shared concern that recruits may feel alienated if employment and induction programmes aren’t aligned. The success of such activities is the foundation upon which the new team members will gain a consistent sense of purpose and a sense of belonging.
The provision of both clinical supervision and personal development opportunities were also recognised as challenges.
There were many concerns shared across participants.
- The majority of the PCN leads agreed that hiring a few roles under the scheme is manageable but the challenges increase with the number of employees.
- There was a consensus that there should be more flexibility within and across the funding streams available to PCNs to enable them to invest in innovative and sustainable models of care.
- Each additional team member should have the opportunities to develop skills and progress into leadership roles. Funding needs to be readily accessible to support this.
- Costs increase when considering management and team leader roles, requiring higher salaries. These roles will become necessary as teams increase in size.
- A few of the PCN leads confirmed they have accessed other funding streams available to them to offset some of the additional costs but this can involve a leap of faith identifying non-guaranteed and non-recurrent funding such as through the IIF. This is not a solution that all PCNs would be comfortable with.
- It was suggested that the development of pan PCN groups to provide a ‘team identity’ for ARRS roles would add real value and create opportunities to create develop platforms for shared learning across PCNs.
- The PCN leads indicated that sharing learning and experiences across PCNs through case studies, spotlighting those PCNs achieving maximum benefit and impact through the scheme, would be useful to increase the spread of best practice and inspire innovation.
- Working with partner organisations provides the opportunity for shared service delivery spaces and mitigate the logistical challenges of finding capacity in already stretched primary care estates. There is a role through the emerging ICSs for the facilitation of these discussions across a place or geography.
In summary, there is no doubt that while the additional roles and funding are welcomed, developing a sustainable employment model is a challenge.
Funding flexibility and collaboration are key to the ongoing success of the scheme.
The provision of opportunities to learn and explore issues with others in different systems with different experiences and solutions is valuable.