We have a strange irony in general practice right now whereby the biggest investment into the service, the Additional Role Reimbursement Scheme (ARRS), is in many places adding to the challenges practices are facing rather than helping.

What is happening is that the burden of recruitment, line management, and clinical supervision, along with the time needed in each practice to make these roles effective, is outweighing the value the new roles are bringing.  This is then exacerbated by rapid turnover in these roles, and the need to constantly start over and over again.

I have written previously on the need for PCNs to plan for the new roles, and also on the challenges associated with introducing them.  But how can PCNs and practices turn this huge investment (£746M this year) to their advantage?

In recent weeks I have been talking to areas that have found ways of making the new roles a success.  What is becoming abundantly clear is these areas have understood that the introduction of the new roles is a change process and have treated it as such, rather than simply recruiting to the roles and expecting the benefits to automatically follow.

What does this mean in practice?

The leading thinker on change at present is Professor John Kotter.  In this Harvard Business Review Article, in addition to outlining the 8 steps of a robust change process, he states 8 reasons why change processes fail.

Read the article for yourself, but my take on the first three of these reasons, as applied to the introduction of the new roles, is as follows:

Error 1: Not Linking the Roles to the Need for Change

Practices are at breaking point right now.  The workload pressures on top of trying to operate in the environment of the ongoing pandemic are making life extremely challenging for many.  What many PCNs are doing is introducing the new roles without being explicit as to how they directly link to this challenge.  Without this link in place practices feel they are making the situation worse not better.

Error 2: Not Creating a Cross-Practice Team to Lead the Changes

The way many PCNs work is that the leadership of the introduction of the new roles is left to the PCN Clinical Director (CD).  They have a PCN meeting to gain sign up as to which roles from the list to recruit, but overseeing the recruitment process and introduction of the roles is left to the CD, who then in turn has to assign line management and clinical supervision roles out across the network.

The problem is that it is simply not possible for someone to successfully introduce a new role into a practice if they are not part of that practice.  A team is needed with a range of individuals, taken from across each of the practices, that is multi-professional (including practice managers, reception managers, nurses etc as well as GPs), to work together to lead the changes to make the new roles a success.

Error 3: Not being Clear what Difference the New Roles will Make

Kotter calls this lacking a vision.  The places where the new roles are working well have a plan in place as to how the new roles are going to make a difference.  They have created multi-professional visit teams to take the burden of visits off practices, or created multi-professional non-clinical teams that can manage the social and non-clinical work that comes into practices, or built prevention teams with a clear plan to tackle pre-diabetes (etc etc).  This is in stark contrast to PCNs who have simply identified the roles they most like the sound of and recruited to them because the money is available, but have not taken the time to create a clear plan as to how these new roles will make a difference.

These are not the only mistakes being made.  All of the errors Kotter outlines can easily be applied to the introduction of the new roles.  The key message, however, is to think of the introduction of the new roles not as a task to be completed, but as a change process that if done well can add huge value, but if done badly will probably make things worse.