Katie Bramall-Stainer gave us an interesting insight into the state of contract discussions when she revealed that the push back on including GPs in the Additional Role Reimbursement Scheme (ARRS) is because of the challenge of demonstrating that these GPs are “additional”.  The quote from the Pulse interview is this,

“The challenge that is given back [from the Government and NHSE] is: how does that prove additionality? The comeback to that is that GPs aren’t additional. Then let’s describe a number of GP roles which will absolutely be additional and which would bring [NHSE] what they want from a neighbourhood integrated team angle and what we would need, for the work that we’re already doing in practices, but that actually falls outside the contract.”

At the same time GP partner income has fallen 20% this year and the financial challenges GP partners are experiencing is leading some to the position where they are even having to lay off GPs.   So now we are in the position where there are insufficient GPs (6,000 short by the government’s own reckoning), but practices cannot afford to employ the ones they have.

I am not sure there is any need to rehearse here the reason for the current financial situation, but suffice to say the last two annual contracts have been imposed on general practice with an inflationary uplift agreed in 2019 of less than 3% when actual inflation was running at over 10%.  Less money has been invested into general practice than any other part of the NHS in the last three years, to the extent that now the general practice percentage of NHS expenditure is lower than it has been since 2015 (ie the disinvestment has undone any of the 2016 GP Forward View and 2019 contract investment and we are now back at a worse position than when the crisis in general practice was first acknowledged 8 years’ ago).

The idea of demonstrating ‘additionality’ can only be relevant in the context of overall investment.  It comes from the (unfounded yet persistent) fear government/NHS England have that any investment into general practice will end up as additional profits for practice partners rather than in benefits for patients.  But in the context of disinvestment the notion of additionality becomes redundant, as the most that practices can do is try and maintain service provision within the reduced resource envelope.

70% of GP practice costs are staff costs.  Inevitably, then, when practices need to reduce costs they need to review staffing and skill mix (like any organisation).  A significant amount of funding for staffing is now contained within the ARRS, which cannot currently be used for GPs and instead can only be used for a determined list of additional roles.  No surprise then that practices are starting to have to replace GPs with the cheaper, funded roles.

Allowing practices to use ARRS funding for GPs would put a stop to this crazy situation.  Demonstrating we have additional numbers of pharmacists and physiotherapists to the numbers we had before is not additionality if at the same time we are having to sacrifice GPs and other members of the core practice team.

Without investing additional funds the concept of additionality is null and void.  Money is required not for GPs identified as being additional to practice work, but just for GPs full stop.  What is really needed is sufficient investment into the core contract to the point where it really is additional (as opposed to replacing recent cuts).  Enabling the ARRS funding to be used for GPs is just common sense given how unlikely such a rise is, and should come without any additionality caveats.