Employment and deployment of additional roles staff in general practice: a realist evaluation of what works for whom, how, and why.

Background: The Additional Roles Reimbursement Scheme (ARRS) was introduced in England in 2019 to alleviate workforce pressures in general practice by funding additional staff such as clinical pharmacists, paramedics, first-contact physiotherapists, and from 1 October 2024 the scheme funds recently qualified GPs. However, the employment and deployment models of ARRS staff present ongoing complexities and challenges that require further exploration.

Aim: To explore the decision-making processes behind primary care networks (PCNs) and general practice staffing choices, and how these choices influence the operationalisation of ARRS.

Design and setting: This was a qualitative case study across four PCNs in England using a realist evaluation framework.

Method: Data collection took place between September 2022 and November 2023. Semi-structured interviews were conducted with PCN clinical directors, GPs, practice managers, and ARRS staff (n = 42). Transcripts were analysed using a realist evaluation framework to identify the context-mechanism-outcome configurations.

Results: Direct employment models fostered staff development and retention, contingent on established trust among practices. Subcontracting was favoured to mitigate employment risks but could lead to unintended consequences such as conflicting accountabilities and less integration with existing GP practice staff. The optimal deployment model involved rotations across a limited number of GP practices, ideally two, with one serving as a base, ensuring consistency in training and management.

Conclusion: This study provides novel insights into the complexities of different employment and deployment models of ARRS staff. These findings will be invaluable for creating a sustainable GP practice workforce and informing future workforce strategies as the scheme expands to include recently qualified GPs.