GP mythbuster 106: Staff not directly employed by a GP practice

We describe the responsibilities when recruiting and managing staff deployed in first contact practitioner roles and the Additional Roles Reimbursement Scheme.

First Contact Practitioner (FCP): a health care professional who is able to treat patients without a referral from a GP or other healthcare professional. They are recognised by Health Education England. See First Contact Practitioners and Advanced Practitioners.

Additional Roles Reimbursement Scheme (ARRS): there is funding for primary care networks to support recruitment of additional staff. This is specifically to increase capacity and help to solve the workforce shortage in general practice. It is not to fill existing vacancies or subsidise the costs of employing people who are already working in primary care. See Additional Roles Reimbursement Scheme (ARRS)

FCP and ARRS roles in primary care can enhance patient care. They can help make sure the patient sees the right person at the right time. Roles include, for example:

• care coordinators
• clinical pharmacists and technicians
• dietitians
• first contact physiotherapists
• health and wellbeing coaches
• mental health practitioners
• occupational therapists
• orthoptists
• nursing associates
• paramedics
• physician associates
• podiatrists
• social prescribing link workers.

Deploying FCPs and staff under ARRS is a significant change for general practice providers. Some staff deployed in these roles may be working in primary care for the first time and the setting may be unfamiliar.

Providers are accountable for staff who they may not employ directly, but who deliver regulated activity on their behalf.

Regulatory requirements

The Health and Social Care Act 2008 (Regulated Activities) 2014 Regulations set out a provider’s responsibilities. Our guidance on meeting the regulations explains that providers are responsible for the staff they 'employ.'

This will include staff who work in the practice on their behalf.

The GP practice who is directing and controlling the regulated activity is responsible for compliance with regulation and legislation. This means that even if they are not responsible for someone’s direct employment a practice may be responsible for making sure they have:

• oversight
• support
• supervision
• guidance
• advice and information.

During an inspection, we will not review any regulated activity delivered by staff who are not employed or managed by a GP practice.

Practices must clearly agree the responsibilities and accountabilities of both parties. This should cover areas related to:

• employment
• supervision
• training

Employment

The meaning of 'employed' in the regulations is wider than staff employed on an employment contract. It means anyone who works for the provider, under their ongoing direction and control.

Providers need to ensure that all the staff they manage have had the appropriate recruitment checks. This is irrespective of who holds the employment contract.

A provider does not necessarily have to physically carry out or repeat all the recruitment processes. But they must reasonably assure themselves that it has been done. For example, someone provides services to a GP practice yet is directly employed by a local NHS trust, federation, Primary Care Network or Integrated Care Board (ICB). It would be essential for the practice to obtain assurances. This could be a:

• letter of confirmation
• memorandum of understanding
• service level agreement from the trust.

Supervision and oversight

Providers must make sure staff are competent and provide appropriate supervision and oversight. A senior member of the clinical primary care team should provide day-to-day supervision of all clinical staff under their direction and control.

Supervision can be:

• Clinic/practice supervision: day-to-day support for issues arising in the practice
• Clinical/professional supervision: regular support to promote high clinical standards and develop professional expertise. This does not always need to be a GP
• Educational supervision: supports learning and enables learners to achieve proficiency.

Supervision guidance for primary care network multidisciplinary teams (NHS England) sets out the minimum supervision requirements for staff recruited through ARRS. For more advice about supervision see:

• Workplace supervision for advanced clinical practice
• Health and Care Professions Council supervision guidance.

Primary care networks, as extensions of GP practices, determine how staff operate in general practice. GPs must be on the National Medical Performers List to provide general practice services. Other staff, for example nurses and allied health professionals, operate under the direct supervision of GPs on this Performers List.

Healthcare professionals should also be on their relevant professional register. For example, Nursing and Midwifery Council, Health and Care Professions Council, General Pharmaceutical Council.

Training and competency

FCPs working in primary care are non-medical diagnostic clinicians. Health Education England's (HEE) Roadmap for Practice describes the training and education for FCPs in 2 stages:

• stage 1 should be completed with a signed off portfolio of evidence before employment in primary care
• stage 2 is completed when working in primary care. This should be within 6 months for those in full-time equivalent FCP roles or longer if the employer and commissioner agree.

We will look for evidence that providers have systems in place to ensure that:

• staff are recruited appropriately
• staff are operating within the limits of their capability, scope of practice and competency
• they provide staff with appropriate information, support and supervision to enable them to carry out their role.

We expect to see:

• evidence or assurance that staff recruited into FCP roles have completed stage 1
• arrangements for completion of stage 2.

What we look for

We regulate at the level of the individual registered provider. For primary care networks, these will be the GP practices listed as core network practices in the Network Contract DES, Network Contract DES contract specification

We will look for evidence that providers have systems and processes in place to ensure that:

• staff are recruited appropriately
• staff are operating within the limits of their capability, scope of practice and competency
• they provide staff with appropriate information, support and supervision to carry out their role.

Fit and proper persons requirement

We expect to see evidence that the provider has verified and is satisfied about safe recruitment practice. For example, asking a PCN’s employer for assurance and evidence that the necessary recruitment checks have been completed. This may include:

• professional registration
• Disclosure and Barring Service checks
• references
• qualifications.

This relates to Regulation 19: Fit and proper persons employed.

Governance systems

We expect systems or processes to be in place to assess, monitor and mitigate the risks relating to the health, safety and welfare of patients. This is irrespective of who holds the employment contract.

This relates to Regulation 17: Good governance.

Suitably qualified, competent and experienced staff

We expect appropriate recruitment checks, professional registration and supervision for all staff. This is irrespective of who holds the employment contract.

This relates to Regulation 18: Staffing.

Assessing staff skills, knowledge and experience

We assess how providers ensure staff have the skills, knowledge and experience to deliver effective care.

This will include but is not limited to:

• clinical supervision
• communication of alerts and guidance
• complaints and significant event arrangements
• induction
• job plans
• policies and procedures
• quality improvement processes
• safe recruitment
• training and development programmes

We will check:

• how the provider has assured themselves that staff are capable for the role
• that the provider maintains this over time through ongoing supervision. This supervision may be carried out by any senior member of the team.

This relates to Regulation 18: Staffing.

Further information

Frequently asked questions on the FCP/AP roadmaps (HEE)
Guidance on enabling the workforce (HEE)
National Association of Link Workers website
Workforce development framework: social prescribing link workers (NHS England)
Health Education England Roadmap for Practice
NHSE Supervision for ARRS in Primary Care settings