Practice nurses – the ARRS’s collateral damage?

There is no doubt that general practice workforce problems have left practice teams and patients demoralised. Patients still struggle to get appointments and nurses, and the rest of their teams, are working flat out and getting burnt out in the process.

Previous governments’ solutions over the past decade have been focused away from the traditional roles of nurses and GPs, and have been focused on the wider team – specifically through the ARRS.

The ARRS was launched in 2019 to be used to help reimburse the salaries of some staff to work in GP practices, including nursing associates, advanced nurse practitioners, pharmacists and more recently enhanced level practice nurses.

Until December 2024, there had been no plans to include the general practice nurse (GPN) role in the scheme. But just before Christmas, health secretary Wes Streeting announced that a proposal to include practice nurses in ARRS had been put to consultation with the British Medical Association (BMA) as part of the incoming GP contract.

In its current form, the scheme has caused some problems for nurses. A major new report from Cogora, the publishers of Nursing in Practice, has revealed that many GPNs have felt sidelined by the ARRS while at the same time feeling overworked.

Using the findings from the report, a new series from Nursing in Practice will look at all the workforce issues affecting nurses in practice, including the recruitment crisis, how they will get trained, how factors such as deprivation, practice income and geography affect nursing numbers, retention and future plans for the nursing workforce.

But first, we will focus on how the ARRS has affected practice nursing.

The ARRS has completely changed the make-up of the general practice team. Long gone are the days of a clinical team comprising solely nurses and GPs.

It is useful to look at how we ended up here. Pre-2015, the typical practice comprised GPs and nurses providing almost all of the clinical work, with the practice administration run by a manager and reception staff.

But in the early 2010s, the idea of other health care staff taking on the clinical workload became more prominent. In 2014, NHS England launched its ‘Five Year Forward View’, which recommended GP practices becoming ‘multispecialty community providers’, who would employ ‘senior nurses, consultant physicians, geriatricians, paediatricians and psychiatrists to work alongside community nurses, therapists, pharmacists, psychologists, social workers, and other staff’. In 2015, the first concrete policy change came in with a £15m scheme for GP practices to employ pharmacists.

This became turbocharged in 2019, with the new GP contract. Through the ARRS, practices were incentivised to join ‘primary care networks’, groups of practices that would mainly cover populations of 30,000-50,000 patients. It committed £938m extra funding per year by 2023/24, with £1.79bn directed towards these new PCNs, and predominantly through the ARRS.

This scheme funded the recruitment of non-GPs to general practice, with the 2019 contract providing pharmacists and social prescribers in the first year, followed by physiotherapists, physician associates and paramedics in the following years. Since the announcement of the 2019 contract, the ARRS has been expanded to include occupational therapists, dieticians, podiatrists, mental health practitioners and enhanced level practice nurses among others. Most recently, newly qualified GPs were added in 2024 by the new government.

This has drastically changed the configuration of the general practice team.

Data from NHS Digital reveals that the number of nurses in general practice is increasing (chart 1). But at the same time, they make up a much smaller percentage of the general practice workforce – 18% in 2024, compared with 26% in 2019 (chart 2). And they are carrying out a decreasing percentage of the appointments (chart 3).

There are caveats to this, of course. During this time, we have gone through Covid. But it is unlikely that the situation would have been different regardless – multidisciplinary teams have been a focus for years.

There is also the increasing role of advanced nurse practitioners to consider – a workforce that has risen from 343 full-time equivalent staff in December 2023 to 501 in December 2024, according to data from NHS Digital for England. However, this data for December 2024 is understood to include the new enhanced level practice nurse role – an experienced GPN with postgraduate qualifications – which was added to the ARRS in April 2024.

The move to multidisciplinary working has had a major effect on the role of the practice nurses, in two major ways: first, they find themselves working more solitary; and second, they find themselves taking on more responsibilities – and not always welcome ones.

More than half of respondents to Nursing in Practice’s September survey say they are working more solitary than two years ago (chart 22), and this is on the whole due to new staff taking on their work and nursing teams being shrunk.

The Royal College of Nursing’s (RCN) new professional lead for primary care, Kim Ball, told Nursing in Practice last year that ‘it can be a very isolating role in general practice’. She added: ‘I think there’s been a lot of change in general practice in terms of having more of a multidisciplinary team and nurses feel that they’re being excluded from discussions about service provision.’

One nurse, who has been practising for four decades, agrees that the job is more solitary now. ‘There used to be time for nurses to meet up in peer groups. Now, often, there may only be one nurse in a practice along with ARRS staff. The nurse might be doing mostly cytology and baby immunisations. Long-term conditions will be delegated to the physician associate or nursing associate, who will not have the clinical knowledge like I would do.

‘Without practice nurses, general practice will lose its heart – whenever I read that GPs will have to do all these new immunisations, or checks, I know the truth – it will be the nurses who do them.’

At the same time, there are also concerns about workload. One nurse in London points to covering two practices with populations of 10,000 and 5,000: ‘All the liability of all things nursing relies on you, eg immunisations, infection control, smears, diabetic physical checks, wound dressings, stock, fridge responsibility.’

Nadine Laidlaw, a lead practice nurse in Newcastle, says she is ‘single handedly managing chronic diseases with some of the most complex patients in our practice’, including patients who ‘speak no English and have no health literacy, let alone any idea how to navigate the healthcare system’. This involves ‘following national guidelines, address holistic issues with social care or domestic issues’, alongside ‘”routine jobs” like cervical screening, immunisations and health promotion’.

The GP industrial action taken last year has exacerbated this. An ANP in Somerset says this has meant providing more ‘routine appointments’, seeing patients attending for management for ongoing conditions. ‘In these circumstances, I find that patients are more likely to become frustrated at not seeing a GP. As an ANP in an acute care role, I feel I experienced this patient frustration far less.’

The pressures in secondary care are also leading to greater complexity, a practice nurse in South Yorkshire says: ‘We do have fewer breaks. This is for various reasons, partly because chronic disease reviews are now more complex due to multi morbidity, socio-economic and mental health problems impacting increasingly on health, and more option in terms of medical and lifestyle management to discuss. We also have had an increase in workload that used to be absorbed by secondary care. For example, wound care.’

There is an overall feeling that the ARRS has compounded low morale too (chart 4), in two particular ways. First, the influx of ARRS staff has shone a light on pay (although we will look at this in more detail in our next article).

But the second reason is more fundamental – that the practice nurse’s role is being replaced.

A nurse team lead in Herts and West Essex’ puts it bluntly: ‘GP nurses will soon be replaced with nursing associates, physician associates and advanced nurse practitioners.’ She adds that practice nurse roles will be ‘reviewing long term conditions, which can be repetitive and sometimes boring. We have years of experience and knowledge that will be lost. There should be a way to encompass this. Not everyone wants to do further training.’

This will have an effect on patient care, nurses say. A practice nurse in Manchester says: ‘Many peers have expressed concerns about the erosion of the GP nurse role with a move to less holistic care and a desire to “get through the numbers” by using shorter appointments with staff who give brief advice rather than personalised care. They are often inexperienced in primary care and have a broad overview of conditions but lack additional training in chronic disease areas.’

A November 2024 study by researchers from London South Bank University supported these findings. It concluded: ‘There was positive impact on workloads from ARRS roles working in original scope, for example pharmacists medicine reviews. However, any benefit was offset by the increased workloads created by those new to general practice and/or working outside of traditional scope.

‘This ranged from a lack of resources to provide the support those new to primary care require to practice safely, the expectations of others that GPN will fill the gap in support and teaching to GPN directly safety netting the work of others. There was a lack of consultation regarding a major workforce change, leading to feelings of devaluation. There are some significant equity issues highlighted particularly around pay and opportunity.’

Then there is the influx of nursing associates. According to latest figures from NHS Digital, the nursing associate workforce in general practice has increased by a quarter from December 2023 to December 2024 (from 410 to 511 full-time equivalent staff). Being an ARRS role and a Band 4 position, we have reported several concerns in recent years that GPNs are being substituted or replaced by this cheaper alternative role.

The RCN has previously warned that the ARRS has sparked ‘a lot of role substitution’ of GPNs since its introduction, while the Queen’s Nursing Institute (QNI) has been calling for clearer guidance on the ‘scope and limits’ of nursing associates amid some reports of those in post working above their clinical responsibilities in general practice.

Asha Parmar is an ANP in north central London, she says:

‘By not including all nursing staff in the ARRS role we have diminished the nurse title in general practice. It is fantastic that nursing associates can work under ARRS and be funded for their role, but it is a shame that practices feel that this is a nurse substitute and do not appreciate the need for a registered nurse to support the nursing associate. There are some practices who only have a nurse associate with no nurse.

In terms of CPD, while ARRS roles get funded support, we have to fight for this every year. There are clinical leads and supervision for the ARRS roles but nurses only receive this depending on the practice that they are at/ PCN that they work for.

I have been trying to get a GP nurse trainee for two years across two practices and have been getting push back on the renumeration of the nurse and lack of room space with little room for flexibility on working patterns.

This has led to poor QOF performance on immunisation and smears, and having to apply quick fixes using locum nurses to improve scores. But this puts immense pressure on myself as a nurse.

Being the only nurse in two practice sizes of 10,000 and 5,000 is difficult as all the liability of all things nursing relies on you – immunisations, infection control, smears, diabetic physical checks, wound dressings, stock, fridge responsibility. It is difficult as a practice to provide continuity of care for things like complex wound dressings, high risk blood pressure reviews and immunisations as there are limited appointments, which is made even more difficult when one is sick or on annual leave.

As an ANP, I am regularly asked to do practice nursing tasks and other ANP tasks in a single appointment. My skills could be better used if there were ANP sole appointments, more nursing staff to take on practice nurse responsibility allowing the ANP to take on advanced care needs.’

It’s clear from Cogora’s report and the experience of GPNs that there is much concern about the introduction of the ARRS and the impact this is having on the nursing workforce. Practice nurses feel they are working more solitary while taking on increasing workloads, and trying to support ARRS colleagues.

There is a fear that GPNs are being pushed out in place of ARRS staff. But as one nurse puts it ‘without practice nurses, general practice will lose its heart’.

It is currently too soon to tell what effect that adding practice nurses to the scheme will have, and of course this is also still undergoing union consultation. As a core role in general practice, putting them under the label of ‘additional’ sparks some concern. And the potential move begs the question of: will it work to protect the role of nurses in general practice, or will it cause instability among the sector as nurses move to find a practice offering an ARRS position?

The full Cogora General Practice Workforce White Paper can be downloaded here