Employment and deployment of additional roles: What works for whom, how and why?

Background 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 2024/25, the scheme will fund recently qualified GPs. However, the employment and deployment models of ARRS staff present ongoing complexities and challenges that require further exploration. Aim This study explores the decision-making processes behind Primary Care Networks (PCNs) and general practice staffing choices, and how these choices influence the operationalisation of ARRS.

Why are pharmacy technicians leaving? Factors contributing to turnover intention and strategies for retention.

Background: Pharmacy technicians play a crucial role in the healthcare system to enable pharmacists to focus on clinical services. However, a lack of recognition for their role and contribution leads to high turnover rates.

Objective: To identify the reasons behind pharmacy technicians leaving, or intending to leave, pharmacy practice.

Workforce development in community pharmacies in England: Opportunities and tensions for a private sector provider of NHS services.

Background: The intention to more effectively mobilise and integrate the capabilities of the community pharmacy workforce within primary care is clearly stated within National Health Service (NHS) England policy. The Pharmacy Integration Fund (PhIF) was established in 2016 to support the development of clinical pharmacy practice in a range of primary care settings, including community pharmacy.

Objective: This study sought to determine how PhIF funded learning pathways for post-registration pharmacists and accuracy checking pharmacy technicians enabled community pharmacy workforce transformation, in what circumstances, and why.

The patient experience of skill mix changes in primary care: an in-depth study of patient 'work' when accessing primary care.

Background: This paper presents insights into patient experiences of changes in workforce composition due to increasing deployment in general practice of practitioners from a number of different professional disciplines (skill mix). We explore these experiences via the concept of 'patient illness work'; how a patient's capacity for action is linked to the work arising from healthcare.

Methods: We conducted four focus group interviews with Patient Participation Group members across participating English general practitioner practices.

To be or not to be: The identity work of pharmacists as clinicians.

This study explores how pharmacists legitimise the expansion of their clinical work and considers its impact on pharmacists' professional identity work. In the context of pharmacy in the English NHS, there has been an ongoing policy shift towards pharmacists moving away from 'medicines supply' to patient-facing, clinical work since the 1950s. Pharmacists are continuously engaging in 'identity work' and 'boundary work' to reflect the expansion of their work, which has led to the argument that pharmacists lack a clear professional identity.

Using normalisation process theory to understand implementation of integrated multi-sector pre-registration trainee pharmacy technician training.

Background: The pre-registration trainee pharmacy technician (PTPT) integrated training programme is a workforce intervention designed to train PTPTs in multiple sectors. The programme recruited 35 PTPTs to 2-year training posts which involved employment in one sector, and a minimum of 12 weeks' work-based training in ≥2 further settings each year.

Aim: To identify facilitating and inhibiting factors to implementation of the PTPT integrated training programme and make recommendations on ways to embed and maintain PTPT integrated training in routine practice.

General practice managers' motivations for skill mix change in primary care: Results from a cross-sectional survey in England.

Objectives: The objectives are to determine the factors that motivated GP practice managers in England to employ non-medical roles, and to identify an ideal hypothetical GP practice workforce.

Methods: Cross-sectional survey of GP practice managers in England ( = 1205). The survey focused on six non-medical roles: advanced nurse practitioner, specialist nurse, health care assistant, physician associate, paramedic and pharmacist.

Processes supporting effective skill-mix implementation in general practice: A qualitative study.

Objectives: Health policy and funding initiatives have addressed increasing workloads in general practice through the deployment of clinicians from different disciplinary backgrounds. This study examines how general practices in England operate with increasingly diverse groups of practitioners.

Methods: Five general practices were selected for maximum variation of the duration and diversity of skill-mix in their workforce.

Contribution of supervision to the development of advanced practitioners: a qualitative study of pharmacy learners' and supervisors' views.

Objective: To apply educational theory to explore how supervision can contribute to the development of advanced practitioners using the example of several postregistration primary care training pathways for pharmacy professionals (pharmacists and pharmacy technicians).

Design: Qualitative semistructured telephone interviews applying Billet's theory of workplace pedagogy for interpretation.

Setting: England.

Challenges of maintaining accountability in networks of health and care organisations: A study of developing Sustainability and Transformation Partnerships in the English National Health Service.

The English National Health Service (NHS) constitutes a unique institutional context, which combines elements of hierarchy, markets and networks. This has always raised issues about competing forms of accountability. Recent policy has emphasised a move from quasi market competition towards collaboration in the form of new regional organisational arrangements known as Sustainability and Transformation Partnerships (STPs).

Motivating factors behind skill mix change: results from a practice managers' survey in England.

Background: The expansion of the primary care workforce by employing a varied range of practitioners ('skill mix') is a key component of the General Practice Forward View (GPFV). The extent of skill mix change and where that has occurred has been examined using publicly available practice level workforce data. However, such data does not provide information regarding specific motivating factors behind employment decisions for individual practices nor future workforce plans.

Agreeing the allocation of scarce resources in the English NHS: Ostrom, common pool resources and the role of the state.

A challenge facing health systems such as the English National Health Service (NHS), which operate in a context of diversity of provision and scarcity of financial resources, is how organisations engaged in the provision of services can be encouraged to adopt collective resource utilisation strategies to ensure limited resources are utilised in the interests of service users and, in the case of tax funded services, the general public. In this paper the authors apply Elinor Ostrom's work concerning communities' self-governance of common pool resources to the development of collective approaches to the utilisation of resources for the provision of health services. Focusing on the establishment of Sustainability and Transformation Partnerships (STPs) in the English NHS, and drawing on interviews with senior managers in English NHS purchaser and provider organisations, we use Ostrom's work as a frame to analyse STPs, as vehicles to agree and enact shared rules governing the allocation of financial resources, and the role of the state in relation to the development of this collective governance.

Regional variation in practitioner employment in general practices in England: a comparative analysis.

Background: In recent years, UK health policy makers have responded to a GP shortage by introducing measures to support increased healthcare delivery by practitioners from a wider range of backgrounds.

Aim: To ascertain the composition of the primary care workforce in England at a time when policy changes affecting deployment of different practitioner types are being introduced.

Design And Setting: This study was a comparative analysis of workforce data reported to NHS Digital by GP practices in England.

Achieving integrated care through commissioning of primary care services in the English NHS: a qualitative analysis.

Objectives: Since April 2015, Clinical Commissioning Groups (CCGs) have taken on the responsibility to commission primary care services. The aim of this paper is to analyse how CCGs have responded to this new responsibility and to identify challenges and factors that facilitated or inhibited achievement of integrated care systems.

Design: We undertook an exploratory approach, combining data from interviews and national telephone surveys, with analysis of policy documents and case studies in four CCGs.

How are clinical commissioning groups managing conflicts of interest under primary care co-commissioning in England? A qualitative analysis.

Objectives: From April 2015, NHS England (NHSE) started to devolve responsibility for commissioning primary care services to clinical commissioning groups (CCGs). The aim of this paper is to explore how CCGs are managing potential conflicts of interest associated with groups of GPs commissioning themselves or their practices to provide services.

Design: We carried out two telephone surveys using a sample of CCGs.

Engaging GPs in commissioning: realist evaluation of the early experiences of Clinical Commissioning Groups in the English NHS.

Objectives To explore the 'added value' that general practitioners (GPs) bring to commissioning in the English NHS. We describe the experience of Clinical Commissioning Groups (CCGs) in the context of previous clinically led commissioning policy initiatives. Methods Realist evaluation.

Complexity in the new NHS: longitudinal case studies of CCGs in England.

Objective: The reform in the English National Health Services (NHS) under the Health and Social Care Act 2012 is unlike previous NHS reorganisations. The establishment of clinical commissioning groups (CCGs) was intended to be 'bottom up' with no central blueprint. This paper sets out to offer evidence about how this process has played out in practice and examines the implications of the complexity and variation which emerged.

What happens when GPs engage in commissioning? Two decades of experience in the English NHS.

Objective: To review the evidence on commissioning schemes involving clinicians in the United Kingdom National Health Service, between 1991 and 2010; report on the extent and impact of clinical engagement; and distil lessons for the development of such schemes both in the UK and elsewhere.

Methods: A review of published evidence. Five hundred and fourteen abstracts were obtained from structured searches and screened.

Leadership for health commissioning in the new NHS.

Purpose: The purpose of this paper is to explore the early experiences of those involved with the development of Clinical Commissioning Groups (CCGs), examining how the aspiration towards a "clinically-led" system is being realised. The authors investigate emerging leadership approaches within CCGs in light of the criterion for authorisation that calls for "great leaders".

Design/methodology/approach: Qualitative research was carried out in eight case studies (CCGs) across England over a nine-month period (September 2011 to May 2012) when CCGs were in their early development.

The 'added value' GPs bring to commissioning: a qualitative study in primary care.

Background: The 2012 Health and Social Care Act in England replaced primary care trusts with clinical commissioning groups (CCGs) as the main purchasing organisations. These new organisations are GP-led, and it was claimed that this increased clinical input would significantly improve commissioning practice.

Aim: To explore some of the key assumptions underpinning CCGs, and to examine the claim that GPs bring 'added value' to commissioning.

Views of NHS commissioners on commissioning support provision. Evidence from a qualitative study examining the early development of clinical commissioning groups in England.

Objective: The 2010 healthcare reform in England introduced primary care-led commissioning in the National Health Service (NHS) by establishing clinical commissioning groups (CCGs). A key factor for the success of the reform is the provision of excellent commissioning support services to CCGs. The Government's aim is to create a vibrant market of competing providers of such services (from both for-profit and not-for-profit sectors).

Accountable to whom, for what? An exploration of the early development of Clinical Commissioning Groups in the English NHS.

Objective: One of the key goals of the current reforms in the English National Health Service (NHS) under the Health and Social Care Act, 2012, is to increase the accountability of those responsible for commissioning care for patients (clinical commissioning groups (CCGs)), while at the same time allowing them a greater autonomy. This study was set out to explore CCG's developing accountability relationships.

Design: We carried out detailed case studies in eight CCGs, using interviews, observation and documentary analysis to explore their multiple accountabilities.