Community Care, News, Population Health, Workforce February 22, 2022

Is the answer to improved health hiding in plain sight?

By Dr Anne Elliott and Professor Tim Evans

The UK is suffering from a major gap in the provision for exercise as a prevention or management tool for chronic disease. Outlining this growing healthcare crisis is Dr Anne Eliott, Senior Lecturer in Physical Activity for Special Populations and Healthy Ageing, and Prof Tim Evans, Professor in Business and Political Economy at Middlesex University London.

Over and above record NHS waiting lists¹ and the adverse effects of the Covid pandemic, there is a tsunami of chronic disease on the horizon, and it is flowing towards us at a stately and predictable rate². We can see the wave growing and developing, we can gauge its potential cost, we can foresee the amount and quality of resources that will be needed, and we can estimate the number of specialist healthcare professionals that will be required to address it – and yet we seem unable to avert what increasingly appears to be an inevitable disaster.

We cannot lay the blame for the growth in long-term illness on a lack of health education, as positive health messaging from both the state and private sectors is prevalent in all popular media and easily accessible for all age groups and populations. At the bare minimum, the general public understands the importance of ‘eat less’ and ‘move more’. Over the last 20 years, successive governments have sponsored numerous initiatives that have attempted to address such issues, from Change4Life (PHE 2009) that aimed to encourage families to exercise together, to the recent adoption of an old idea, social prescribing³ (NHS 2020), that targets loneliness and depression at a local community level.

However, differing socio-economic determinants have been identified as obstacles to participation. Although authorities try to address these barriers, sedentary behaviours and lifestyles are responsible for 40 per cent of premature mortalities and continue to be the weak spot for ‘preventative medicine’⁴, a term now well established within Parliament and across the UK’s broader political discourse.

Cost is consistently found to be one of the biggest barriers to moving towards a healthier lifestyle. Through physical activity in the private sector and with levels of economic status found to be correlated to health outcomes⁵, it would be beneficial to make access to exercise easy as both a preventative tool in the public sector and as a response to the onset of many diseases further adversely impacting the medical sector.

A gap in provision

There is a clear gap in provision for exercise as a prevention or management tool for chronic disease and there isn’t availability or knowledge in the existing medical workforce to bridge it

At present, general practitioners are the most efficient and effective pathway to intervention and support for people in local communities. However, there are limited options, such as exercise referral schemes⁶, found to be too short for exercise adherence and too expensive for most practices to utilise, or referral to a scheme such as the NHS Diabetes Prevention Programme. Apart from these ‘schemes’ the next level of physical specialism is physiotherapy and associated disciplines which are geared to address more clinically acute rehabilitative issues.

It is against this backdrop that there is a clear gap in provision for exercise as a prevention or management tool for chronic disease and there isn’t availability or knowledge in the existing medical workforce to bridge it. However, with some creative change and investment, the workforce required to fill this gap could be closer at hand than most commentators realise.

Currently, there are approximately 66,300 fitness instructors in the UK, of which 22,032 are personal trainers. They are well placed to work with the general public with diagnosed or undiagnosed chronic conditions – it is common for sufferers to live with low level conditions for up to 20 years before they seek help from their doctor, when the condition interferes with their quality of life. The Chartered Institute for the Management of Sport and Physical Activity (CIMPSA), acknowledges this specialist need and has drawn up professional standards for fitness⁷. Ukactive⁸ also discussed using trainers more within a wider community based social prescribing framework. We see professional bodies turning their consideration to this in light of Covid, which has created an awakening of understanding for the need to improve the physical and mental health of an ailing population.

Upskilling the workforce

While such upskilling requires investment, the costs will not be as great as leaving health outcomes to an unnecessarily disjointed and unreformed skills base

The fitness workforce has historically been eschewed by the medical profession on the basis that too many of its practitioners lack appropriate levels of educational attainment. Personal trainers are shown to have qualifications that range from a ‘two-week online course’ to a Masters degree in a sport specialisation such as Strength and Conditioning. Industry regulation has mitigated this to a certain extent by registering most practitioners with a vocational qualification equivalent to an A level. However, these fitness qualifications are not mapped to any NHS accreditation and qualification requirements and so a divide between health provisions runs deep.

An obvious solution to this division is to bring existing fitness qualifications into parity with the medical regulatory framework. The workforce can be upskilled into the range of existing NHS levels of qualifications and pathways, such as apprenticeships, which may then provide an opportunity to create roles acknowledged by the Health and Care Professions Council.

While such upskilling requires investment, the costs will not be as great as leaving health outcomes to an unnecessarily disjointed and unreformed skills base. At a time when the NHS is facing its largest ever backlog, it would be wholly inappropriate to invent a new category of worker, train them from scratch, or alternatively do absolutely nothing.

Workforce planning

While in the past the pressures of electoral politics have often prohibited effective workforce planning, inaction with regards to the country’s fitness workforce is contributing to a multifacted healthcare crisis

To mitigate the ill effects of both the waiting list backlog and the coming tsunami of chronic disease outcomes, it is important to make key investment and workforce planning decisions now. These plans should ideally be locked into our health system for the longer term through a robust cross-party agreement.

For decades, successive British governments of all stripes have avoided workforce planning issues. Incentivised by shorter-term electoral cycles, they have instead left the healthcare system dangerously exposed to the fragilities of professional overstretch. This is why the UK has so few doctors and nurses in comparison to other comparable countries in the developed world⁹.

However, with today’s spiralling costs, waiting lists setting ever higher records and more than 21 per cent of people now opting to use private healthcare¹⁰, the NHS urgently needs creative solutions if it is going to have space to develop and implement better planning.

It is in this context that this proposal to upskill and realign existing professional skills and resources makes so much sense. As a swift and effective solution to overcome a current and costly chasm in our health system, the objective has to be not only holding back the looming wave of chronic disease but to enact comparatively inexpensive reform that will mitigate its most damaging and costly effects.

Faced with an unprecedented and systemic crisis of demand, the time for imaginative supply side reform is now more pressing than ever. If several tens of thousands of people are not empowered to fill the gap in our health economy, then the NHS – and the electoral support that it has hitherto enjoyed – could become irreparably damaged. While in the past the pressures of electoral politics have often prohibited effective workforce planning, inaction with regards to the country’s fitness workforce is contributing to a multifacted healthcare crisis.

References

1 https://www.theguardian.com/society/2022/feb/09/englands-hospital-waiting-lists-may-exceed-10-million-by-2024-ministers-told

2 https://evidence.nihr.ac.uk/alert/multi-morbidity-predicted-to-increase-in-the-uk-over-the-next-20-years/

3 https://collegeofmedicine.org.uk/social-prescribing-is-as-old-as-the-hills-dr-michael-dixon-gives-a-potted-history-of-integrative-medicine/

4 https://www.gov.uk/government/consultations/advancing-our-health-prevention-in-the-2020s/advancing-our-health-prevention-in-the-2020s-consultation-document

5 https://www.health.org.uk/publications/reports/the-marmot-review-10-years-on

6 https://www.nice.org.uk/guidance/ph54

7 https://www.cimspa.co.uk/standards-home/professional-standards-library?cid=18&d=320

8 https://www.ukactive.com/news/leading-the-change-report-calls-for-government-to-help-reduce-pressure-on-nhs-by-backing-social-prescribing-in-fitness-and-leisure-sector/

9 https://www.thetimes.co.uk/article/britain-has-fewer-doctors-than-most-of-developed-world-35r6c68xf

10 https://www.theguardian.com/society/2021/sep/18/private-hospitals-profit-from-nhs-waiting-lists-as-people-without-insurance-pay-out

All news

Mind the Cap: choices & consequences for financing social care

By Francesco Tamilia

The government has announced its plans for social care reforms – but do they go far enough to address the issues endemic to social care?

Reforming social care – particularly with regards to financing it – has been a major challenge for successive governments over the past decades. Despite widespread acknowledgment of the need to reform the system, it remains in flux. In 2019, Prime Minister Boris Johnson pledged in his maiden speech that he was going to “fix social care”. Following the Covid-19 pandemic, the government has put forward clear proposals for reform – including addressing financing issues by increasing National Insurance contributions by 1.25 per cent to establish a new ‘Health and Social Care Levy’.

To discuss the financing challenges in social care, Public Policy Projects (PPP) hosted a roundtable with senior stakeholders in the sector as part of its “The Future of Social Care” report series in January 2022.

Lack of funding a chronic issue

The new social care reforms were broadly welcomed by participants, although many also expressed concern that the reforms do not go far enough to comprehensively address the depth of the issues in the sector.

“We simply don’t spend enough money on it.”

Lack of funding was, by far, the most recurrent theme of the discussion, with one attendee citing lack of adequate funding as the root cause of current market distortions in the first place.

He argued that “we simply don’t spend enough money on it. Every year, the Budget comes around, and when the social care system continues to be completely on its knees, the Treasury simply adds an extra billion pounds. This is immature. If we have to put an extra billion pounds into social care every year, then let’s say ‘over the next five years, we are going to put an extra billion pounds every year into social care’ so that care providers can plan. And then we don’t have the ludicrous chaos that we have at the moment, there is a barrier to planning there. We have to spend more on social care – and this is not just about older people, it’s about working-age adults as well.”

Where’s the money?

Speaking on the same issue, another attendee referenced historical funding in the care sector and highlighted how insufficient funding has led to an unsustainable market. He illustrated how social care expenditure over the last decade has increased since 2015-16, peaking at record levels in 2021 – largely due to the extra money that went into the system due to Covid-19. Roughly half of spending is on working-age adults and the other half is on older people. Money is indeed coming into the sector, but the question is: where exactly has the money been spent, and is it anywhere close to what is needed?

“The money coming into the system has not been spent on improving access and bringing more people into the system/”

Addressing the first question, the same attendee said, “the money coming into the system has not been spent on improving access and bringing more people into the system.” Consequently, eligibility for care has continued to tighten and has not risen in line with inflation, thereby excluding more people from the publicly funded system.

If that money hasn’t gone on improving access for more people, where has it gone? The answer seems to be on the average fees that local authorities pay for care homes. Indeed, there has been, in real terms, a 4 per cent increase in what local authorities pay for working-age adults and a 17 per cent increase in what they pay for older people’s care. “I don’t think you could argue that the extra money has gone on improvements in quality. Quality measures have stayed static over this period and Care Quality Commission (CQC) ratings have nudged up. Satisfaction ratings of publicly funded clients have also stayed pretty much the same. It seems much more likely that [the extra money] is going to fund home care and care home fees,” the same participant added.

Risk pooling a welcome step

“The private sector will never provide pooling of this catastrophic risk.”

A move by the government that was particularly welcomed by attendees was the notion of risk pooling social insurance. Rather than facing a potentially very uncertain risk profile, everybody effectively pays the same amount and is then covered against those risks. “That is undoubtedly what we should do.” said one attendee. “Social care is the only big risk that we all face where neither the state nor the private sector provides risk pooling. The private sector will never provide pooling of this catastrophic risk, it must be done by the state.” According to him, taking away the catastrophic risks gives us a chance of getting a market that will work not just for individuals, but for providers as well.

Overall, there was widespread agreement that although the new proposed legislation is a step in the right direction, more needs to be done to properly address the chronic financing issues in the sector. Yet, it’s equally important that any money that comes into the system is allocated wisely. Achieve this, and the many other issues in the care sector such as workforce and market fragility, can then be addressed.

This write-up forms one part of the wider Public Policy Projects Social Care Policy Programme. Drawing together key stakeholders from across the private sector, PPP intends to lead the debate on social care reform, to scrutinise and discuss the Government’s plans as they are delivered. Led by the Rt Hon Damien Green, the network continues to convene regularly for high-level strategic roundtable discussions in order to gather intelligence, insight and experience to deliver its recommendations through the publication of four reports.

1. Integrating Health & Social Care: A National Care Service

2. Mind the Cap: choices & consequences for financing social care

3. The Social Care Workforce: Averting a Crisis

4. A Care System for the Future: Digital Opportunities and the Arrival of Caretech

If you are interested in learning more about this significant programme of work, get involved in our work and partner with Public Policy Projects, please reach out to carl.hogkinson@publicpolicyprojects.com

Vaccination as a Condition of Deployment: When will the Government listen to social care providers?

By Louis Holmes

vaccination as a condition for deployment

On 31 January, Sajid Javid, Health and Social Care Secretary, announced a U-turn on the Government’s Vaccination as a Condition of Deployment in health and social care settings (VCOD) policy. This move was anticipated by the press but for providers evoked despair and frustration.

VCOD 1 came into force on 11 November in the care home sector, and its impact cannot be understated. Since the passing of the regulations on 22 July 2021, it has been estimated that up to 40,000 workers have left the sector, a much larger sum than the estimated 12,000 which Mr Javid noted in his statement to Parliament. Since the statement, this figure has been withdrawn, but it demonstrates the Government’s contempt for the sector and lack of understanding of the impact VCOD has had on providers.

As England’s largest and most diverse representative body for independent providers of adult social care, Care England has been at the forefront of the VCOD discussion. The organisation has responded to the consultations for VCOD 1 and 2, along with advising the Department of Health and Social Care (DSHC) on what the Government must do to ensure the sector’s sustainability.

The VCOD timeline:

On 20 January 2022, the Department of Health and Social Care (DHSC) published the guidance for VCOD in wider social care settings.
Seven days later, on 27 January 2022, DHSC held a webinar for care providers, where the guidance was discussed, along with the Care Quality Commission’s (CQC’s) approach to inspections under the new regulations. DHSC even noted that further guidance was expected to come in the following days.
As As required by the implementation of VCOD on 1 April, the care sector was putting in the correct measures to comply with the new regulations, only to discover it was all in vain.

Equal partners

Although there are numerous contributing factors to a decrease in the workforce, it cannot be denied that VCOD was a significant reason. When the adult social care workforce was on its knees, VCOD dealt another blow. Since 11 November, there have been continued reports of care home closures, and throughout Christmas, there were serious concerns about the sector’s sustainability. But providers and their staff alike powered through the changes in guidance and adapted their services so they could provide the valuable care needed to those most vulnerable.

One of the biggest frustrations felt by care providers is the disparity between the attention on the potential consequences of VCOD for the NHS, compared to social care, despite the latter already operating in the midst of the measures. The Government often fail to remember that a correctly funded and resourced care sector could be one of the main support structures for a healthy NHS and therefore should be treated as an equal partner, not a guinea pig for testing the waters for new policy.

Listening to the care sector on vaccinations

To revoke VCOD, the Department of Health and Social Care (DHSC) announced another consultation, despite the Government’s clear intentions. Although the consultation has now ended (lasting one week from the 9th to the 16th of February), it begged the question of why care providers should play along. Knowing that their response would not affect the overall outcome of the consultation, they would have been using precious time that could have been better spent delivering care.

From the two previous consultations for VCOD, it was clear that the idea of mandatory vaccination would have crippling effects on the sector. In the first consultation, 75 per cent of the sector overwhelmingly opposed the measure, with Care England’s view being it should be down to the provider to decide whether mandatory vaccination should be enforced.

Despite continuously stating the negative impact VCOD would have on the care sector, DHSC refused to alter course, creating a huge increase in workload cost and stress for care providers and their employees. The care sector, like the NHS, is not opposed to vaccines and the time and resources used to ensure organisations were in line with VCOD could have been better spent persuading staff to get vaccinated. There is now also the possibility that we will see a higher number of employees resistant to getting their booster as a long-term consequence of VCOD. DHSC estimated that the introduction of the policy would have resulted in a one-off cost to care home providers of £100 million. It should now look to compensate providers for their individual losses resulting from VCOD, given the stress and anxiety they have been put through.

There is also no guarantee that this is the end of vaccination as a condition of deployment. Due to the nature of viruses and mutations, the policy may need to be brought back in. Although this scenario is unlikely, it cannot be ruled out given the turbulent times and the confused policymaking from the Government. We expect that going forward, the Government treats the care sector with the respect it deserves, listens to care providers on important issues and values them as equal partners in the health and social care sector.

The digital journey of adult social care

By Louis Holmes

In the face of unprecedented challenge for the sector, many adult social care providers are demonstrating their ability to deliver impressive tech systems. Louis Holmes, Senior Policy Officer for Care England writes for ICJ.

Digital transformation in social care is often overlooked, particularly by those outside the health and care sector; the perception is that care providers are not as technologically mature as their healthcare colleagues. Despite funding issues, the inability to invest in tech, and not having access to the same level of resources as their healthcare counterparts; adult social care providers have demonstrated that they have the capabilities to deliver impressive tech systems, even when facing a crisis.

Outlined below are three case studies from Care England members that demonstrate innovation in the sector. For more innovation to happen however, resolving the funding of new tech must be addressed. Each study shows the benefits of the independent care sector, but the challenges faced when trying to invest in care tech.

At Care England, England’s largest and most diverse representative body for independent adult social care providers, we have seen countless case studies from our membership where there is strong evidence of digital maturity and innovation. Through our Digital Special Interest Group (DSIG), Care England members can ask digital questions or share their experiences with other group members. This space allows organisations to learn about new software, or avoid, when browsing for what is on offer. Members have found this group incredibly useful, thus demonstrating communication and engagement as necessary when discussing digital transformation.

Blackadder

Blackadder is a family-owned and operated group of nursing and residential homes in the Midlands and can brilliantly demonstrate the power of remote monitoring.

At a recent Care England event on the subject, Finance Director Michael Butcher explained that, in 2018, Blackadder set themselves the objective of being able to monitor their care data remotely. The aim of this was to reduce time and administration work when gathering paper audits, and ensure that the right data was available to the right people at the right time.

Through Nourish’s Electronic Care Management System and Power BI, Blackadder can produce hourly, daily, weekly and monthly reports, efficiently and rapidly analysing core care data points within their homes. The next stage of their digital transformation is linking their current system further remote monitoring systems and eMARs.

Integration and interoperability are essential factors care providers need to consider as they expand their digital systems. It can be the case that a provider buys several different software solutions/pieces without realising that they are not compatible with one another, resulting in barriers being created between the different systems. However, it can also be the case where a regional CCG is rolling out a programme that is not yet compatible with the provider’s current system. Thankfully, more is being done to resolve interoperability issues, but it will remain a pertinent problem as we see more technologies become available.

Hallmark Care Homes

To help avoid such instances, Care England member Hallmark Care Homes are creating a business intelligence system through Yellow Fin that collects data from several different systems used by Hallmark. Building a data lake allows Hallmark to mine important information which can then be analysed effectively by the relevant employee.

Programme Delivery Manager Saad Baig has developed a visual traffic light system through intuitive thinking, enabling head office to monitor each care home. Using a traffic light system, Hallmark can identify which homes needs immediate support and which homes are starting to edge towards becoming a concern.

Sophisticated systems such as the one being developed by Hallmark provide further freedom when it comes to choosing the right tech and enables quicker response times and delivery of care. It buys the gift of time leaving health and care workers to focus on their core role of delivering high-quality care.

Canford Healthcare

Through Microsoft 365, Amanda Rae, Quality & Compliance Manager, has created a user-friendly system that brings together several data and compliance sources, minimising burden and time spent on administration work. Amanda can link and share important tasks and documents using SharePoint, Forms, Teams, Planner, and Power Bi. It allows Canford to create the correct compliance documents that can then be shared with the Care Quality Commission (CQC).

Although it may seem daunting for providers to build a similar system from scratch, Amanda, who led the project at Canford, does not come from an IT background, demonstrating how easy it would be for any provider to build. This sort of innovation needs to be applauded and the huge innovation in ASC recognised, learned from and built on.

Adult social care: going forward

With Integrated Care Systems (ICSs) introductions scheduled for the summer, we must continue these digital discussions and connect care providers to the right people within each new system.

NHSX, with the help of Digital Social Care, has already begun working with some systems and helping develop their digital capabilities. Tools such as the ‘Digital Social Care Records – Assured Supplier List’ helps care providers choose a supplier who has been rigorously selected, ensuring that they can meet and deliver against the national specification.

The Adult Social Care White Paper demonstrated The Department of Health and Social Care’s (DHSC) eagerness to digitise the sector and outlined some bold ambitions. £150 million shall be invested into the sector over the next three years to help drive care providers’ digital journey with the commitment to ensure that at least 80 per cent of social care providers have a digitised care record in place. This is welcoming news, and Care England looks forward to working with the DHSC in achieving these goals.

Through workspaces such as DSIG, we can actively promote and share successful digital stories that help show the digital maturity of the sector and bring care providers to the forefront of digital discussions.

Louis Holmes is Senior Policy Officer for Care England.

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Don’t waste the chance to finally reform NHS dentistry

By Martin Skipper

The concurrent challenges of Covid-19 and longstanding issues with regards to dental access provides a unique opportunity to provide desperately needed reform to NHS dentistry.

As Covid-19 continues to restrict the public’s ability to access routine health services, increased attention is being paid to the precarious state of NHS dental services in England. It is becoming increasingly clear that dentistry needs ambitious reform if it is to play its part in reducing inequalities and improving health outcomes – both throughout Covid-19 and beyond.

The pandemic is amplifying longstanding issues of access to dental care. According to official NHS statistics, the number of people in England seeing a dentist within the maximum two year recall period dropped from 49.3 to 43 per cent for adults, and from 58 to 23.3 per cent for children.

Pre-pandemic data from August 2019 shows that access in deprived wards in London was already shockingly low, however. In Stanmore Park in Harrow adult access was 36 per cent, child access 34.2 per cent. While in South London the wards of West Thornton in Croydon and Bellingham had adult access of 47.6 per cent and 52.6 per cent respectively with children’s access at 31 per cent and 37.1 per cent. The third most deprived ward in London, Lansbury in Tower Hamlets, recorded adult access at 40.3 per cent and children’s access at 31.9 per cent.

Rethinking the NHS dental contract

NHS dental services are in the small minority of NHS services that charge most patients at the point of care. The British Dental Association estimates that patient charges are making up more and more of the dental budget, increasing from accounting for about 22 per cent in 2010 to over 30 per cent now. Local healthwatch report a great deal of concern and confusion among the public about dental charges. There is frustration too among the profession. Dentists do not enjoy acting as tax collectors for the NHS, nor do they benefit from the dynamic this creates with patients. NHS charges for dentistry are an anachronism that cause more problems than they solve.

As Integrated Care Boards (ICBs) begin developing plans for local health improvement and health inequality reduction, dental contract reform continues to pose obstacles to progress.

Dental contract reform must not take place in isolation from wider NHS reforms. If, as proposed in the Bill, dental commissioning is devolved to ICB level then it is vital that ICBs are involved in discussions about dental contracts. Dentistry will only be able to play its part in ICB plans if there is a contract which supports the delivery of ICB priorities.

Major problems will arise if ICBs attempt to drive local health improvement initiatives without reforming the dental contract.

If the 64 per cent of adults in Stanmore currently without access will require more care than the 36 per cent who have been going to the dentist, then they will require lengthier and perhaps more complicated treatment. This will inevitably reduce available appointments for others, delivering nothing extra towards contracted targets and cost the practice more money. At the same time the NHS is deprived of its ability to recoup its dental spend if these people are exempt. In this scenario, and it is replicated across the country, the existing contract will not be able to support ICBs in any meaningful attempt to reduce health inequalities or improve health outcomes.

If the Care Quality Commission takes responsibility for assessing whether services are accessible then there is an added incentive to change the system to ensure adequate funding. The alternative would be to rely on a primary care dental system which encourages episodic attendance and penalises routine care based on prevention. The very opposite of what we should be aiming for if we want to improve health and reduce health inequalities.

If dentistry is to play a meaningful role in health inequality improvement, then a dramatic increase in the dental budget is required, along with a move away from an overreliance on patient charge revenue. Without reform, ICBs will struggle to boost dental access in deprived communities without depriving access to others or hemorrhaging money from their limited dental budgets.

Leaders in the NHS and across government must be brave and take this opportunity to invest properly in NHS dentistry. The costs for inaction are stark. The estimated costs of hospital admissions in 0 to 19-year-olds for all tooth extractions was £54.6 million and for extractions due to tooth decay was £33 million in the 2019/20 financial year.

An integrated future for NHS dentistry?

A joined-up primary care service with dentistry as a fully integrated component would transform NHS approaches to reducing health inequalities and improving health outcomes.

The comprehensive integration of oral health considerations into existing care pathways will bring huge health benefits. For instance, current guidance around eating disorders makes barely a passing reference to dentists despite the impact on oral health of conditions such as bulimia. Diabetes and its relationship with oral health is becoming ever better understood, but pathways remain poor and local initiatives to join up services are sporadic.

Oral health is at risk of rapid deterioration for those who have had a stroke, been diagnosed with Parkinson’s, Alzheimer’s and other dementias – yet there is no joined-up approach to ensure that oral health plans are in place to support patients with these conditions. This is not to mention the potential for improving the oral health of those over 65 by using dental practices to provide immunisations, blood sugar checks, and so on.

The above issues are just some of the approaches that ICBs may like to consider in their efforts to reduce health inequalities and improve health outcomes. But without ambition and increased budget dentistry will remain a service outside of the rest of the NHS. If dentistry is to truly be a part of the NHS and a key part of the integrated health agenda, then it needs to be like the rest of the NHS: free at the point of service and available to all.