Consultation complexity and professionals consulted: a retrospective cohort study in English primary care.

Abstract

The Additional Roles Reimbursement Scheme (ARRS) launched in England in 2019 to expand the multidisciplinary primary care workforce, but its impact on workload since implementation is unclear. To examine changes in workload complexity associated with ARRS implementation. A longitudinal cohort study was conducted, which used the Clinical Practice Research Datalink (CPRD) Aurum. In total, 3 530 628 consultations were analysed involving GPs, nurses, or direct patient care (DPC)-ARRS roles for 420 986 patients from 369 English practices in 2018 and 2021. Multilevel logistic regression assessed associations between 17 patient and consultation complexity factors and being seen by a DPC-ARRS role, adjusting for year, age, sex, region, deprivation, and consultation mode. Complex consultations with DPC-ARRS-eligible roles increased from 15.8% in 2018 to 18.8% in 2021. Diagnostically capable ARRS roles were more likely than GPs to conduct the first consultation after diabetes diagnosis (odds ratio [OR] 1.4, 95% confidence interval [CI] = 1.3 to 1.5) and consultations with ≥2 preventive tasks (OR 5.6, 95% CI = 5.5 to 5.8), but less likely to manage chronic pain (OR 0.8, 95% CI = 0.7 to 0.9), dementia (OR 0.4, 95% CI = 0.3 to 0.4), mental illness (OR 0.4, 95% CI = 0.3 to 0.5), learning disabilities (OR 0.3, 95% CI = 0.3 to 0.4), consultations with ≥3 medicines prescribed (OR 0.6, 95% CI = 0.5 to 0.6), consultations resulted in emergency admission (OR 0.7, 95% CI = 0.6 to 0.8), and consultations with ≥2 diagnoses coded (OR 0.5, 95% CI = 0.5 to 0.5). Patients with interpreter needs (OR 1.2, 95% CI = 1.1 to 1.3), experiencing recent homelessness (OR 1.4, 95% CI = 1.1 to 1.7), or ≥3 long-term conditions (OR 1.1, 95% CI = 1.1 to 1.1) were more likely to be seen by diagnostic ARRS staff. Following ARRS implementation, primary care activity was delivered by a broader workforce managing increasingly complex care. Further research should assess the safety, quality, and system impacts of ARRS roles.