Jialan Hong

Background: The Additional Roles Reimbursement Scheme (ARRS), introduced by NHS England in 2019, aimed to expand the workforce, promote multidisciplinary team-based care, and improve patient outcomes. Aim: To examine changes in consultation rates and outcomes in relation to ARRS implementation, and compare outcomes across primary care roles. Design and setting: Longitudinal cohort study using the Clinical Practice Research Datalink (CPRD) AURUM, analysing 12 170 079 consultations (2015–2021) from 600 000 randomly sampled patients at 400 English practices. Method: Joinpoint regression modelled trends in age- and sex-standardised consultation rates, further consultations within 1–14 days, prescribing, and referrals. Multilevel regression compared outcomes between diagnostic-capable roles and GPs. Results: Most consultations remained GP- or nurse-led, but rates with direct patient care (DPC)-ARRS-eligible roles increased, particularly for pharmacists, physiotherapists, and nursing associates. For paramedics and mental health practitioners, growth preceded formal ARRS inclusion, suggesting the scheme accelerated rather than initiated expansion. Most DPC-ARRS-eligible roles were consulted more frequently in less deprived areas, except physiotherapists. Compared with GPs, most DPC-ARRS-eligible roles delivered more consultations face to face (except pharmacists), had lower prescribing (except advanced nurse practitioners) and referral rates, and higher further consultation rates with a diagnostic-capable clinician within 1–14 days (except pharmacists). However, all DPC-ARRS-eligible roles had lower odds of a further consultation specifically with a GP. Conclusion: ARRS has supported and accelerated the diversification of the primary care skill mix. Patterns of consultation activity suggest an expansion of overall primary care capacity with some redistribution of workload across the multidisciplinary team, rather than a direct reduction in GP workload.

Background: 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. Aim: To examine changes in workload complexity associated with ARRS implementation. Design and setting: 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. Method: 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. Results: 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. Conclusion: 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.

Objectives: We investigated associations between socioeconomic position (SEP) across childhood, adulthood, and older age and number of teeth among Chinese older adults. Methods: Data came from 15,136 participants aged 65 to 105 y in the Chinese Longitudinal Healthy Longevity Survey (2018 wave). The outcome was number of teeth. Pathways and sensitive period models were tested simultaneously via structural equation modeling. Ordinal logistic regression assessed the accumulation of risk and social mobility models. Differences were examined across 4 birth cohorts. Results: Adult and older age SEP had direct effects on number of teeth in older age (adulthood, direct β = 0.182, P < 0.001; older age, direct β = 0.093, P = 0.005), supporting the sensitive period model. Childhood SEP had an indirect effect on number of teeth (indirect β = 0.130, P < 0.001) through adult and older age SEP, supporting the pathway/accumulation of risk and social mobility models. Effects of SEP on number of teeth were more pronounced in younger cohorts. Graded associations in the expected directions were found between the number of periods in which participants experienced disadvantaged SEP and number of teeth, as well as social mobility trajectories and number of teeth. Conclusion: Among Chinese older adults, the number of remaining teeth is subject to marked social inequalities. Our findings document the simultaneous applicability of life course models and a widening of oral health inequalities in China across generations. Interventions earlier in child and adult life are needed to address this problem and reduce oral health inequalities. Knowledge Transfer Statement: The findings of this study suggest marked socioeconomic inequalities in oral health among Chinese older adults. These inequalities are generated throughout the life course and appear to have widened across cohorts. This study emphasizes that interventions are needed to address the social determinants of oral health at all life stages.

Background: The Additional Roles Reimbursement Scheme (ARRS) was introduced by NHS England in 2019 alongside primary care networks (PCNs), with the aims of increasing the workforce and improving patient outcomes. Aim: To describe the uptake of direct patient care (DPC)-ARRS roles and its impact on patients’ experiences. Design and setting: An ecological study using 2020–2023 PCN and practice workforce data, registered patient characteristics, the General Practice Patient Survey, and the Quality and Outcomes Framework (QOF). Method: Descriptive statistics with associations were examined using quantile and linear regression. Results: By March 2023, 17 588 full-time equivalent (FTE) DPC-ARRS roles were commissioned by 1223 PCNs. PCNs with fewer constituent practices had more DPC-ARRS roles per population ( P P = 0.005). DPC-ARRS commissioning did not vary with age, sex, or deprivation characteristics of practice populations. DPC-ARRS roles were associated with small increases in patient satisfaction (0.8 percentage points increase in patients satisfied per one DPC-ARRS FTE) and perceptions of access (0.7 percentage points increase in patients reporting ‘good’ experience of making an appointment per one DPC-ARRS FTE), but not with overall QOF achievement. Conclusion: The commissioning of DPC-ARRS roles was associated with small increases in patient satisfaction and perceptions of access, but not with QOF achievement. DPC-ARRS roles were employed in areas with more GPs rather than compensating for a shortage of doctors. Single-practice PCNs commissioned more roles per registered population, which may be advantageous to single-practice PCNs. Further evaluation of the scheme is warranted.

Background The Additional Roles Reimbursement Scheme (ARRS) was introduced by NHS England in 2020 alongside Primary Care Networks (PCNs) with aims of increasing the workforce and improving patient outcomes. Aim Describe the uptake of direct-patient care (DPC)-ARRS roles and its impact on patients’ experiences. Design and Setting Ecological study using 2020-2023 PCN and Practice workforce data, registered patient characteristics, the General Practice Patient Survey, and the Quality and Outcomes Framework (QOF). Methods Descriptive statistics with associations examined using quantile and linear regression. Results By March 2023, 17,588 FTE DPC-ARRS roles were commissioned by 1,223 PCNs. PCNs with fewer constituent practices had more DPC-ARRS roles per population (pConclusions The commissioning of DPC-ARRS roles was associated with small increases in patient satisfaction and perceptions of access, but not with QOF achievement. DPC-ARRS roles were employed in areas with more GPs rather than compensating for a shortage of doctors. Single practice PCNs commissioned more roles per registered population, which may be advantageous to single practice PCNs. Further evaluation of the scheme is warranted. How this fits in Primary Care Networks (PCNs) commissioning of non-GP direct-patient care (DPC) roles via the Additional Roles Reimbursement Scheme (ARRS) has expanded rapidly, with an allocated budget of £110m in 2019/2020 employing 279 full time equivalent (FTE) DPC-ARRS staff in March 2020, to £1,027m in 2022/2023, employing 17,588 FTE DPC-ARRS staff in March 2023. Previous research, using NHS England data prior to 2020, had reported associations between increased Healthcare Associate Professionals employment and reductions in patient satisfaction and perceptions of access, with no impact on Quality and Outcomes Framework (QOF) achievement, but it was not known if these trends remained after the implementation of ARRS. This study found a small increase in both overall patient satisfaction and perceptions of access, which equates to approximately 240-400 patients satisfied with their care and 210-350 patients able to make appointments for each FTE in ARRS roles employed in a typical PCN (30,000-50,000 patients), but no association with overall QOF achievement. Further evaluation is required to identify if the observed associations can be attributed to the ARRS roll-out and if this represents value for money.

Objectives: To examine the association between consumption frequency of foods and drinks with added sugar and dental caries experience in the permanent teeth of 12‐ and 15‐year‐old children in England, Wales and Northern Ireland, using the Children's Dental Health Survey 2013 (CDHS) data.Methods: Four thousand nine hundred and fifty children aged 12 and 15 have the following information available: daily consumption frequency of foods and drinks with added sugar, tooth‐brushing frequency, dental attendance, and water‐drinking frequency. The children's dental caries experience was available as a DMFT score (number of decayed, missing, filled permanent teeth). A zero‐inflated negative binomial model (ZINB) was used to fit the DMFT score.Results: Lower socioeconomic status (SES), nonregular dental check‐ups, and low water‐drinking frequency were associated with higher consumption frequency of added sugar (all P < 0.05). The consumption frequency of both drinks and foods with added sugar also differed by region (P < 0.001), and children who more frequently consumed foods with added sugars also consumed drinks with added sugars more often (P < 0.001). Using the Zero‐Inflated Negative Binomial model, DMFT scores were not associated with consumption frequency of added sugars for children with caries (DMFT > 0), but the chance of being free of obvious caries (DMFT = 0) was lower for children with high frequency (≥4) of sugar‐added foods than for children reported to have a sugar‐free diet (OR = 0.5, 95% CI [0.3, 0.8]).Conclusions: Consumption frequency of added sugars was associated with dental caries and a number of child demographic and lifestyle characteristics. Children who consume foods and drinks with added sugar more frequently are more likely to develop dental caries, but higher consumption frequency of drinking water in fluoridated areas might reduce dental caries. The findings add to the evidence for the association between children's dental caries and added sugar consumption.