The NHS 10 Year Plan outlines a strategic vision for the NHS workforce, which aims to create a more motivated and skilled workforce by 2035, achieved through personalised career development plans and a shift from ‘train to role’ towards ‘train to task’. Here, Dr Imelda McDermott and Dr Sharon Spooner provide lessons learned from their studies assessing the contributions of Additional Roles Reimbursement Staff (ARRS) and what needs to be considered when implementing the Plan.

• The ARRS provides reimbursement to GP practices for employing additional roles staff, including newly qualified GPs.
• New research shows that, as ARRS has developed, the choice of employment and deployment models was driven by the desire of GP practices to have greater influence over staff development and retention.
• Working patterns that deployed ARRS staff across fewer practices, and linked with a base practice, could offer the best way to create a sustainable workforce.

The Additional Roles Reimbursement Scheme (ARRS) was introduced in England with the aim of alleviating workforce pressures in general practice by funding a diverse range of additional health professionals, such as clinical pharmacists, paramedics, and physiotherapists. Since 2024, the funding can be used to employ recently qualified GPs. The funding will be made more flexible in 2025/26, with continuation of funding for the cohort of ARRS GPs already recruited, and combining the GP ARRS funding with the main ARRS pot. However, the operationalisation of ARRS, particularly the employment and deployment of these additional roles, presents ongoing complexities that policymakers must address to ensure the scheme’s long-term sustainability and the delivery of effective primary care.

Our recent study addresses these complexities by exploring the decision-making processes behind Primary Care Network (PCN) and general practice staffing choices, to shed light on what employment and deployment models work for whom, how, and why. By understanding these nuances and taking them into account when implementing the 10 Year Plan, a more tailored approach to employing and deploying additional roles staff can be developed.

Direct employment vs subcontracting

Our research highlights two main models adopted by PCNs for employing ARRS staff: direct employment by a lead GP practice or a GP Federation, and subcontracting from third-party organisations such as hospital trusts or voluntary sector organisations. Of the two, direct employment was found to be more likely to enhance staff development and retention as individuals felt more integrated and embedded within the practice team.

Subcontracting, however, was seen to mitigate employment risks for individual practices, particularly when dealing with newer ARRS roles where a practice’s experience of working with them was limited. For instance, it was a common choice for employing first-contact physiotherapists, paramedics, and social prescribers. However, subcontracting can lead to limited integration of ARRS staff within existing practice teams and potentially give rise to conflicting accountabilities. Both models can result in variations in employment terms and conditions as a result of inconsistency in locally-managed, novel roles.

A rotating ARRS workforce

Patterns of deployment of ARRS staff across PCNs significantly impact their effectiveness and integration. ARRS staff working across a limited number of practices – ideally two, with one serving as a base – appears to be the widely preferred model. This allows consistency in training and management, builds familiarity between ARRS staff and practice teams, and facilitates continuity of care for patients. The base practice can provide a stable human resources and administrative foundation.

Conversely, deploying ARRS staff across a large number of (often disparate) practices can lead to staff feeling overwhelmed and thinly spread, potentially compromising care quality and hindering integration. It can also create challenges in standardising job responsibilities when working across practices with diverse patient populations. Our study also highlighted that co-locating ARRS staff in a central hub could reduce feelings of isolation, although a balance is needed with time spent within individual practices.

The inclusion of recently qualified GPs in the ARRS adds another layer of complexity. PCNs and practices will need to consider how best to support and integrate these individuals, ensuring adequate mentoring and career progression opportunities within general practice. Newly qualified GPs will be experiencing some of the multi-practice related challenges identified in our study, but because they are by definition fully qualified GPs, they may experience greater pressure to work independently at a high level while provided with limited supervision and support.

What does this mean for the 10 Year Plan?

The Plan identified the need to shift towards ‘train to task’. The premise that “many tasks can be carried out with good supervision” requires careful scrutiny, particularly given the exceptionally broad and evolving landscape of general practice.

A ‘train to task’ approach risks distraction from addressing the crucial need for staff integration and embeddedness. Direct employment models, where ARRS staff feel “part of the team”, significantly enhance staff development and retention. If ‘train to task’ leads to a fragmented workforce, with individuals trained for narrowly-defined duties and deployed across numerous sites without a stable base, this could compromise their sense of belonging, limit professional growth, and ultimately hinder retention. Moreover, ‘train to task’ risks undermining professionalism and accountability.

Concerningly, we found a declining number of experienced GPs and other healthcare professionals means that the system lacks sufficient and dedicated supervisory capacity. Simply training staff for specific tasks without adequate oversight could compromise patient safety and staff confidence. Effective implementation demands that we explicitly address how sufficient protected time, funding, and training will be provided for supervisors to meet this escalating demand. The forthcoming Workforce Plan should prioritise sustainable work schedules, with adequate time for supervisors to provide support for colleagues. This will ensure that ‘good supervision’ becomes a tangible reality, not just an aspiration.

Finally, while in some situations ‘train to task’ can enhance efficiency, it must not inadvertently devalue the professional development and clinical judgment that underpin comprehensive patient care. A narrow focus on tasks might limit opportunities for broader career progression and the development of the complex problem-solving skills that are essential to deal with undifferentiated conditions in general practice.

Our work underscores that there is no single blueprint for successfully employing and deploying the expanding additional roles staff in primary care. Decisions are driven by a complex interplay of factors, including prior experience, trust between practices, and the desire to balance integration with risk mitigation. However, the Workforce Plan and future strategies should reflect that rotating staff across a lower number of practices provides continuity for patients and staff, enables learning and sharing of best practice, and helps build contingency plans. Supporting the integration and embeddedness of these staff, especially for recently qualified GPs, is crucial for retention.

Lessons can be learned from Scotland, where they have been increasing the diversity of the multidisciplinary teams in general practice. Our newly funded study will compare how England and Scotland have integrated and embedded the expanding multidisciplinary team and the impact it has on staff and practice experiences, patient care and experiences and GP workload and job satisfaction.

Integration of GPs with other primary care roles is the core pillar of the Neighbourhood health service outlined in the 10 Year Plan, and the broader shift from hospital to community. Learning the lessons from ARRS – particularly for newly qualified GPs – is crucial in ensuring this major policy shift is sustainable.