Supervision of clinicians in the Additional Roles Reimbursement Scheme: what more is needed to assure safety and quality?

Introduction

The Additional Roles Reimbursement Scheme (ARRS) launched in 2019, aiming to increase capacity and bring new skills to general practice. Arriving in the context of an unsustainable workload and a shortage of GPs nationwide, the scheme enabled the government to exceed its manifesto pledge to recruit 26,000 extra primary care professionals. By September 2024, the ARRS was funding almost 40,000 full-time-equivalent staff to provide direct patient care in general practice.

The scheme has led to significant changes in the skill mix of the general practice workforce, with a rapid increase in multi-professional team working. Some roles were mostly new to general practice, such as first-contact physiotherapists, while others, like advanced practitioners, were already established in many practices. 

There have been mixed evaluations of the impact this has had on care. Positive findings include higher overall patient satisfaction associated with ARRS staff employment, and improved patient perception of appointment access. However, an early implementation study highlighted the challenges of integrating new roles into practices and PCNs: there were variable arrangements for support and supervision and a lack of clarity about the purpose of ARRS roles.

Ensuring appropriate supervision is in place is a regulatory requirement, and underpins safe and quality care. The ongoing debate about the physician associate role in the NHS, one of the approved ARRS roles for general practice, has emphasised the need for rigorous supervision arrangements and clear scopes of practice for all clinicians. 

In this long read, we explore ways to develop supervision for ARRS clinical roles in ways that help to assure safety and quality. We suggest a fluid ARRS supervision model for different career stages and make policy recommendations, based on evidence and a roundtable of experts ¹ .

Current guidance on supervision of ARRS clinicians

Five roles were included at the outset of the ARRS. This number grew over time to include a mix of clinical, non-clinical and allied health skills – and newly qualified GPs as of 2024. The updated 2025/26 GP contract has opened the funding up to include all staff groups. ARRS-funded clinicians are recruited into primary care networks (PCNs) with varying levels of prior experience, and they may work in a single practice, a PCN clinical hub, or rotate between multiple practices in a PCN. The PCN contract includes obligations for supervising ARRS staff, which are reinforced through the CQC’s emphasis on employer responsibility to ensure staff receive supervision. At its best, supervision can promote safe, high-quality care; support skills development; improve wellbeing; and foster a positive work environment.

NHS England has published guidance on supervising ARRS roles. It describes supervision as “a process of professional learning and development that enables individuals to reflect on and develop their knowledge, skills and competence, through regular support from another professional”.

NHS England outlines three distinct elements of supervision: day-to-day supervision of clinical practice by a named or duty-experienced clinician for issues arising during clinical consultations; professional supervision through regular support from a named experienced clinician or practitioner to promote high clinical standards and develop professional expertise; and educational supervision to support ongoing learning and develop proficiency.

While all three aspects are important, our work focusses on day-to-day practice - how best to deliver the first two elements and on their contribution to clinical safety and quality. The guidance also sets out a minimum amount of supervision for different ARRS roles and describes two main models of day-to-day clinical supervision: a senior clinician who is available for advice for a whole clinic, or supervising clinicians having ring-fenced slots in their clinical diary plus additional professional supervision for a minimum of an hour a month.

Some roles have received more attention than others: the Royal College of General Practitioners (RCGP) has released guidance around the supervision of physician associates, and Health Education England (HEE) has published a “Roadmap to Practice” for those moving into First Contact Practitioner and Advanced Practice roles in primary care. Figure 1 summarises and compares guidance from NHSE, CQC and a range of professional bodies to inform the design and delivery of ARRS roles supervision. We have focussed on five clinical ARRS roles, including those with a narrow clinical focus and those with broad clinical responsibilities.

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Figure 1: Summary of general practice supervision guidance by clinical role

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The evidence on effective supervision of ARRS roles

We identified four themes on supervisory effectiveness from the growing body of research on the implementation of ARRS roles in general practice.

Effective induction and integration are crucial for implementing ARRS roles successfully. A high-quality induction ensures clear communication of the role to the new clinician and team members, and allows supervision arrangements to be agreed. Role clarity and clear communication between practices within PCNs which share ARRS clinicians is also important. Comprehensive inductions lead to better supervision and more efficient use of staff.

Role clarity for supervisors, supervisees, and the practice team is important to avoid mismatched expectations. Clinicians in qualitative studies note that unclear roles reduce productivity, risk ARRS staff leaving and may lead to them being asked to work beyond their competency, posing clinical risks that supervisors must manage.

Supervisor training and motivation is a key factor for supervisory quality: when supervisors are motivated, supervisees are more likely to receive better-quality supervision and to build a relationship based on mutual trust. This is related to capacity, but also understanding of the scheme.

Tailoring intensity of supervision to the level of experience and role/scope of practice of each ARRS clinician is vital. Practitioners report needing to make large adjustments when entering general practice for the first time, and studies describe how the support required varies based on past experience, age and the job role. Supervision needs can be assessed through methods such as more intensive initial supervision, direct observation or competency assessments.  Supervision needs also change when roles transition within teams. 

What is actually happening in practice?

This section reflects findings from our roundtable ² , supported by our literature review. Experts drew attention to three broad factors which influence current delivery of ARRS supervision: variability between the clinical experience of ARRS staff and the roles they fulfil; characteristics of supervising clinicians; and the processes and governance arrangements to support supervision.

Variability in experience level of ARRS clinicians

We heard that the prior experience of clinicians in their core profession and in general practice shapes the roles they can fulfil, and some ARRS staff may lack the skills and competencies needed of them. For example, guidance advises that paramedics require five years of experience to join the GP workforce as advanced practitioners. However, a recent survey  of paramedics found 7.6% of respondents had been paramedics for less than two years, and 27% for less than five years, before entering general practice under a range of different role titles.

Experts suggested that this necessitates careful assessment of whether new ARRS clinicians’ skills and competencies match their role and planned scope of practice. A period of more intense supervision when taking up a new post is needed to make this judgement, to ensure clinical safety, and support integration into ways of working in general practice. Employers must be willing to adjust the scope of practice and support skills development where needed in order to match each clinician’s abilities to the work required of them.

Variability in supervisors

Many people we spoke to explained that supervision quality can be influenced by an individual’s underlying motivation to take on supervision work, as well as by wider work pressures and their views of the ARRS scheme. There is also evidence that effective supervision requires a level of trust between supervisor and supervisee which builds up over time – this relationship is unlikely to develop if the supervisor is not engaged.  The British Medical Association notes that medico-legal responsibility for supervision lies with the employer (e.g. GP partners or primary care federations), and that salaried GPs should only undertake supervision by mutual agreement. The RCGP makes a similar point in its guidance on physician associates, advising that supervision should be done by choice. This could create a challenge if multidisciplinary general practice teams do not have a doctor on duty with them who is willing to provide supervision.

We heard how the related issue of limited capacity to provide supervision also affects its quality.  NHS England guidance calls for ring-fenced time for supervision, which needs to be ‘hard wired’ into the clinical rotas and job plans of supervising clinicians. If supervising GPs who are already overloaded are asked to oversee ARRS clinicians, they may not be able to allocate sufficient time for safe supervision. 

Supervisors also have variable knowledge about the ARRS scheme; the previous supervision, training and experience of the clinicians they supervise; and the role and scope of practice for the ARRS practitioners they are working with.

Variability in process and governance

Experts shared how PCNs across the country are implementing the roles differently. In some practices, doctors work full sessions as supervisors with no scheduled appointments, while others provide supervision alongside seeing patients.  There is no national guidance on the number of appointments to be ‘blocked’ for supervision,

Where there is guidance, due to the range of roles and the different settings and circumstances of each PCN, it is often minimally prescriptive. While flexibility is a feature of effective supervision, we also heard that this leads to variability in the quality, format and amount of supervision provided. Although there are a number of frameworks and other resources to guide the delivery of supervision, in most cases, the guidance does not include specific recommendations for supervision of different experience levels.

An important concern raised during the roundtable was the lack of a formal governance framework for supervision. PCNs may specify how supervision should be delivered, but there is no formal mechanism to assess whether this is enacted. A qualitative study across seven PCNs found that implementation of ARRS roles varied across PCNs, and identified a need for  support and oversight for employed staff.  In one roundtable participant’s practice, all advanced practitioners joining the PCN through ARRS funding participate in a one-year programme covering the core skills required for the role, using a standardised approach to then assess those skills.

Learning from good practice

Our research suggests that supervision for each ARRS clinician needs to be tailored to the PCN and practice context, the stage of professional journey the clinician is at, and the role definition and scope of practice for each individual. Figure 2 presents our model illustrating the building blocks for ARRS staff supervision at different points in their careers, presenting supervision as a flexible process, intertwined with induction.

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Figure 2: Proposed model of ARRS supervision for safety and quality assurance, at different career stages

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The model includes assessment of how each ARRS clinician’s experience, skills and competencies ‘fit’ with their proposed role and scope of practice, and identification of their supervision needs. It also recognises that roles change, and that clinical and life events mean ARRS clinicians may need periods of intensive supervision and skills development.  Returning to more intensive supervision should not be seen as a failure, but instead a natural part of any career. Supervision arrangements should be agreed and revised between supervisor and supervisee, so that both parties feel comfortable. Normalising a culture of open-door access to supervisors strengthens the likelihood of safe, high-quality clinical care, and increases staff wellbeing.

When experienced practitioners reach a ‘steady state’ in their knowledge and clinical practice,  supervision is still needed, both for ongoing personal development, challenging personal and professional periods, and unusual clinical presentations.

The cost of supervision

The wide variation in ARRS implementation, roles and the need for individualisation makes costing supervision challenging, and there has been no published cost analysis to date. However, it is important to recognise that if safe supervision is to be provided, it must be adequately funded.

ARRS roles are funded by the scheme, yet supervisor time is not. The GP contract amendments for 2025/26 include removing the restrictions on which roles can be employed through the ARRS scheme, and raising a salary cap for GPs. This means it is easier for practices to employ senior staff, including GPs and general practice nurses, who can play a supervisory role. While this represents progress, GPs must have qualified within two years to be employed under the ARRS scheme, so it remains focussed on employing less experienced medical staff.

The lack of adequate funding for safe ARRS supervision has also been highlighted by the NHS Confederation and The King’s Fund. Without full funding for supervision, the opportunity cost is lost appointments for patients – or, in the absence of effective governance arrangements, supervision may not be provided adequately, or at all.

What policy changes are needed to ensure safe supervision of ARRS roles?

So how can general practices consistently provide supervision of ARRS roles in a way that ensures safety and quality for patients? Our recommendations to policy makers to help PCNs deliver supervision to ARRS roles for safety and quality assurance are as follows.

To address variation in experience and roles of ARRS clinicians:

• PCNs should be formally accountable to ICBs for delivering minimum induction requirements.
• ARRS-funded roles should have time for supervision enshrined in their job descriptions.

To address variation in the capacity, training and motivation of supervisors for ARRS roles:

• The rules on the use of ARRS funding should be changed to allow payment of senior clinicians to supervise ARRS clinicians. An analysis of supervision costs would be helpful to guide the allocation of a proportion of ARRS funding to PCNs to deliver supervision.
• All clinical staff supervising ARRS clinicians should receive specific training for their supervisory role. An example might be taken from the RCGP guidance for supervision of physician associates, which states that supervisors should have received training from UK Department of Health-recommended courses on education and supervision, including knowledge and skills expected for the relevant role.
• Where clinical capacity allows, clinicians should have the opportunity to opt out of the supervision of ARRS-funded clinicians.

To address the variation in the design and governance of ARRS supervision:

• ICBs should be formally accountable for assuring that minimum supervision is taking place in each PCN.
• Further developments in PCNs and integrated neighbourhood teams should include a process to deliver consistent and high-quality ARRS supervision.