Fuller Stocktake: Time for a radical overhaul of primary care

By Niamh Macdonald

The Next steps for integrating primary care: Fuller stocktake report was published yesterday, outlining a vision for transforming primary care led by integrated neighbourhood teams.

The review was carried out by Dr Claire Fuller, CEO (Designate) of Surrey Heartlands ICS, commissioned by NHS England and NHS Improvement.

With weeks to go until integrated care systems (ICS) are granted statutory footing, the report emphasises this opportunity to radically overhaul the way health and social care services are designed are delivered.

According to Dr Fuller, ‘Primary care must be at the heart of each of our new systems – all of which face different challenges and will require the freedom and support to find different solutions.’

Support, enablement and respect are three key themes of the reviews findings. The report states that these sentiments are important to set the right tone and accelerate the change that needs to be delivered in primary care.

To improve access, experience and outcomes in primary care across all communities, the report outlines three key offers:

Streamlining access to care and advice for people who get ill but only use health services infrequently: providing them with much more choice about how they access care and ensuring care is always available in their community when they need it
Providing more proactive, personalised care with support from a multidisciplinary team of professionals to people with more complex needs, including, but not limited to, those with multiple long-term conditions
Helping people to stay well for longer as part of a more ambitious and joined-up approach to prevention.

Matthew Taylor, chief executive of the NHS Confederation, said: “This review must be a watershed moment for establishing primary care as an integral part of local systems, working across boundaries to deliver population-based care, and a demonstration of the benefits of the integration agenda.

“Our members – from primary care leaders through to ICSs – agree that investing in local relationships, developing and supporting frontline workers, and maintaining stability in general practice are the key components to achieving fully integrated primary care.

If we are to get serious about ramping up prevention, improving patient outcomes including by tackling health inequalities, and providing more personalised care, primary care’s deep-rooted connection to its local communities cannot be overstated.”

Responding to Dr Fuller’s stocktake, interim chief executive of NHS Providers Saffron Cordery said: “Trust leaders will welcome the findings of the Fuller ‘stocktake’ which sets out how primary care can work with partners across health and care to best meet the needs of their local communities.

“The welcome focus in the stocktake on creating neighbourhood health teams to offer continuity of care and support those with complex, ongoing health needs is essential and will help to tackle the health inequalities which have been exacerbated by the Covid-19 pandemic.

“But with just over a month to go before integrated care systems become statutory bodies on July 1st, we now face the challenge of making this vision a reality.

“First and foremost, Dr Fuller’s stocktake underlines the need to tackle the serious challenges facing those who need to access same day, urgent care. This is no small undertaking and will require collaboration across mental health, community services, primary care and secondary care if it is to succeed.”

Over half of Brits say their health has worsened due to rising cost of living

By Gabriel Blaazer

Over half of Brits (55 per cent) feel their health has been negatively affected by the rising cost of living, according to a YouGov poll commissioned by the Royal College of Physicians (RCP).

Of those who reported their health getting worse, 84 per cent said it was due to increased heating costs, over three quarters (78 per cent) a result of the rising cost of food and almost half (46 per cent) down to transport costs rising.

One in four (25 per cent) of those who said that their health had been negatively affected by the rising cost of living, had also been told this by a doctor or other medical professional.

16 per cent of those impacted by the rising cost of living had been told by a doctor or health professional in the last year that stress caused by rising living costs had worsened their health. 12 per cent had been told by a healthcare professional that their health had been made worse by the money they were having to spend on their heating and cooking.

The experiences of RCP members who responded to the poll include a woman whose ulcers on their fingertips were made worse by her house being cold and a patient not being able to afford to travel to hospital for lung cancer investigation and treatment. Other reports include respiratory conditions such as asthma and COPD being made worse by pollution and exposure to mould due to the location and quality of council housing.

Health inequalities – unfair and avoidable differences in health and access to healthcare across the population, and between different groups within society – have long been an issue in England, but the rising cost of living has exacerbated them.

The Inequalities in Health Alliance (IHA), a group of over 200 organisations convened by the RCP, is calling for a cross-government strategy to reduce health inequalities – one that covers areas such as poor housing, food quality, communities and place, employment, racism and discrimination, transport and air pollution. The government recently announced that it will publish a white paper on health disparities and the IHA is calling for it to commit to action on the social determinants of health. These largely sit outside the responsibility of the Department of Health and Social Care and the NHS.

Responding to these findings, Dr Andrew Goddard, President of the Royal College of Physicians, said: “The cost-of-living crisis has barely begun so the fact that one in two people is already experiencing worsening health should sound alarm bells, especially at a time when our health service is under more pressure than ever before.

“The health disparities white paper due later this year must lay out plans for a concerted effort from the whole of government to reduce health inequality. We can’t continue to see health inequality as an issue for health directives to solve. A cross-government approach to tackling the underlying causes of ill health will improve lives, protect the NHS and strengthen the economy.”

Professor Sir Michael Marmot, Director of the UCL Institute of Health Equity, commented: “This survey demonstrates that the cost of living crisis is damaging the perceived health and wellbeing of poorer people. The surprise is that people in above average income groups are affected, too. More than half say that their physical and mental health is affected by the rising cost of living, in particular food, heating and transport.

“In my recommendations for how to reduce health inequalities, sufficient income for a healthy life was one among six. But it is crucial as it relates so strongly to many of the others, in particular early child development, housing and health behaviours. As these figures show, the cost of living crisis is a potent cause of stress. If we require anything of government, at a minimum, it is to enable people to have the means to pursue a healthy life.”

Also responding to the survey was NHS Providers Chief Executive, Chris Hopson, who said: “Trust leaders are acutely aware of the soaring cost of living crisis facing the nation and the impact rising financial pressures could have on people’s health.

“This is particularly concerning in the wake of the COVID-19 pandemic which exposed deeply entrenched social, racial and health inequalities. As highlighted in this survey, there is a risk that the current cost of living crisis widens those inequalities.

“Trust leaders share the view that there is an opportunity to tackle the factors which lead to health inequalities and poor health. They have committed time and resource to reducing inequalities across their local communities.”

Health Inequality, News, Population Health, Primary Care, Thought Leadership May 17, 2022

How ICSs can help uproot risk aversion and progress innovation

By David Duffy

Integrated Care Journal speaks with Kathy Scott and Aejaz Zahid of the Yorkshire & Humber Academic Health Science Network (AHSN) on how the implementation of a dedicated innovation hub within ICS frameworks has helped to streamline innovation and improve patient care.

Above: Barnsley Hospital, part of South Yorkshire and Bassetlaw ICS.

Integration and innovation are two increasingly prominent principles that are, in part, designed to address the growing problems of unmet health needs. Each is intended to supplement and support the development of the other.

Integrated care systems (ICSs) offer new frameworks through which innovation can be adopted at scale, streamlining past previous bureaucratic and individualistic barriers to change and adopting a transformation led approach. Innovation is crucial in turning the core aspirations of integrated care into tangible realties, to use technology and sophisticated approaches to data to help address the root causes of ill-health and expand health service offerings.

The above outlines the core principles of integration and innovation, which can be found reiterated from a wealth of sources, if one is to engage in the sector for even a few days. Integrated care is not a new concept and neither is innovation, so how are these two principles coming together to improve patient outcomes in reality?

“There is a vast range of unmet need across the whole health and care sector.”

“There is a vast range of unmet need across the whole health and care sector,” says Aejaz Zahid, Yorkshire & Humber AHSN’s Director for the ICS Innovation Hub at South Yorkshire & Bassetlaw Integrated Care System (SYB ICS). “Much of this is of course clinical, but a huge part of this is more operational, system level needs.

“The ICS needs intelligence on all of this, but then must ascertain how it can use innovation to leverage economies of scale in terms of investing and finding solutions to those problems and challenges. What we are trying to do within the innovation hub is create straightforward and easily accessible processes which enable busy staff working on the ground to regularly bring those challenges and problems to our attention, while enabling ICS leadership to ascertain and prioritise needs which could benefit from a systemwide innovative solution.”

The ICS Innovation Hub is a single point of contact for health and care innovators in the SYB region. The hub works, via the AHSN, to identify and validate market ready innovations and help drive improved health outcomes, clinical processes and patient experience across the SYB health economy. The idea to set up a dedicated innovation hub within an ICS was developed by the Yorkshire & Humber Academic Health Science Network (Yorkshire & Humber AHSN) and has proved a successful model to help spread and adopt innovations at pace and scale. Yorkshire & Humber AHSN also provides innovation support to three different ICSs in the region.

Fostering a culture of innovation

Explaining how the Hub, and by extension, Yorkshire & Humber AHSN are working to cultivate innovation in the region, its Chief Operating Officer and Deputy CEO, Kathy Scott says “it is as much about identifying good practice as it is implementing the ‘shiny stuff’.

“As an AHSN we also have sight of a lot of potential solutions that can address those needs often identified by the innovation hub. So, we are able to nudge the ICS leadership towards potential solutions.

“We can push out new ideas and innovations as much as we like, but if you don’t have that culture of innovation and improvement there, it’s not going to stick.”

“It’s about growing the capability and capacity for change within a locality and for improvement techniques and innovation adaptive solutions to be implemented. Not simply implementing new technology and essentially running away.

“We can push out new ideas and innovations as much as we like,” continues Kathy, “but if you don’t have that culture of innovation and improvement there, it’s not going to stick.”

The ICS’s digital focus has also enabled significant work on pre-emptive care. For example, through the Yorkshire & Humber AHSN’s digital accelerator programme Propel@YH, the AHSN has worked with innovator DigiBete to support the adoption of their “one stop shop” app to help young people living with diabetes manage their treatment.

The app was clinically approved during the height of the pandemic, with extra funding provided from NHS England, and is now being used in 600 services across England. “This is an excellent example of how we can pre-emptively assess unmet need and streamline innovation into the system,” says Kathy.

Innovation as an antidote to health inequality

“Health inequalities are part of our design thinking from the get-go in any project,” says Aejaz, who points to the recent implementation of SkinVision, a tele dermatology app, as an example.

“The app was originally developed in the Netherlands, where predominantly you would have Caucasian skin that the AI would have been trained on,” he explains, “so, from the beginning, we have been mindful to capture more data on how well the app works on other skin types and feed that back to the company to improve their AI algorithms for wider populations.”

The Innovation Hub also works to ensure that implementing digital technology does not exacerbate inequality for less digitally mature users. “If somebody, for example, doesn’t have a smartphone that is able to run that app, there is always the non-digital pathway in parallel. So, it’s never either/or.”

An appetite for risk

“There is always a level of risk aversion when it comes to adopting something new in healthcare,” says Aejaz, “even with evidence backed solutions, we find there’s sometimes a level of reluctance. Staff want to know whether it’s going to work in their local context or not and whether introducing innovation would entail a significant ‘adoption’ curve. Building enthusiasm around a new idea and overcoming hesitancy to innovation is, therefore, central to the role of organisations such as the AHSN and, by extension, ICS innovation hubs.

“Building a culture of innovation is fundamentally about building a culture of increased risk appetite, where failure is most certainly an option.”

“Building a culture of innovation is fundamentally about building a culture of increased risk appetite, where failure is most certainly an option,” Aejaz continues. “We need to create systems which provide innovators with the necessary psychological safety that allows them to experiment.”

To help shift the mindset of NHS staff in favour of innovation, the Innovation Hub established a series of ‘exemplar projects’, designed to erode the fear of failure and capture learnings in the process. For example, for Population Health Management exemplars, one of the priority themes for the ICS, the hub called for providers to submit ideas to the Hub, all framed under high priority population health challenges such as cardiovascular health. Successful applicants with promising ideas received funding in the region of £25,000 as well as co-ordination support from the Hub towards their project.

The programme has enabled frontline innovators and has led to the development of a host of new services incorporating novel technologies, such as virtual wards and remote rehabilitation. The Hub is also working to transform dermatology pathways throughout the SYB region by introducing an app that allows patients to upload images of skin conditions and be processed more efficiently through the system. Funded by an NHSx Digital Partnerships award, this pilot project with Dermatology services in the Barnsley region will test out the use of this AI-enabled app to ascertain how well it can successfully identify low risk skin lesions which can be addressed in primary care. Thereby reducing demand on secondary care and speeding up access for higher risk patients. Each of these projects demonstrate the capacity for transformation when on the ground staff are given the freedom to innovate.

Interestingly, many of the ideas that the Hub works with are non-tech solutions. For example, primary care providers working with local football teams via a 12-week health coaching programme to engage with fans who may be at risk of cardiovascular disease, or introducing Cognitive Behaviour Therapy techniques to patients with severe respiratory conditions to help reduce anxiety when experiencing an episode of breathlessness.

To nurture a mentality more open to change, the Innovation Hub has developed learning networks across South Yorkshire. Through these networks, the Innovation Hub and AHSN teams have been reaching out to key leads from each of the provider organisations who are involved in innovation, improvement or research and invited them to become innovation ambassadors. “These ambassadors have become our eyes and ears on the ground across health providers, where they can start to introduce what we do and also help capture unmet needs from colleagues in their respective organisations,” explains Kathy.

Following in the footsteps of the first innovation hub established by the Yorkshire & Humber AHSN in South Yorkshire, other AHSNs across the country are now looking at setting up innovation hubs within their ICS by bringing leadership together, getting them out of their ‘comfort zone’ and giving them the space to innovate, and hoping to chip away at risk aversion and fear of experimentation. Introducing solutions outside of traditional domains will enable a culture of innovation and improvement. To streamline past bureaucratic and individualistic hurdles, ICS frameworks are key to facilitating transformational change in every region of the country.

If you would like to find out more about the Yorkshire & Humber AHSN, please contact info@yhahsn.com

All news

LDC Confederation: taking an active role in combatting discrimination

By Martin Skipper

Martin Skipper, Head of Policy for the LDC Confederation, discusses how the organisation is taking an active approach to addressing racism, working as part of the London Workforce Race Equality Strategy (WRES), to ensure that the dental profession benefits from the programme of work.

The aim of the London Workforce Race Equality Strategy work is to address the inequality experienced by a large proportion of the NHS workforce. The experience of professionals from black and minority ethnic backgrounds continues to lag behind that of white colleagues.

To address this imbalance, the objective is for the NHS in London to be a more inclusive place to work. The workforce strategy aims to create a step change by increasing the diversity of the workforce and promoting equality, diversity and inclusion strategies. This includes improving the leadership culture and growing and training the workforce. In a recent survey undertaken by the London WRES for Equality and Discrimination in Primary Care, around half of respondents said they had faced some sort of discrimination or harrasment at work, with 39 per cent saying that they had received this from patients. The remaining 29 per cent had been on the receiving end of discrimination or harrasment from colleagues. Of these cases only one third were reported.

Colleagues from Asian or African backgrounds were most likely to be on the receiving end of discrimination, and also less likely to know where to turn for help. Additionally, while ethnicity was the main factor reported to underlie discrimination and harrasment by a considerable margin, gender was the second most common factor. Unfortunately, responses from dental practice were very low, so few conclusions about issues specific to dentistry can be drawn.

Registration data from the General Dental Council, however, shows that many of the issues reported above can be expected to be true in dental practice. Over 50 per cent of dentists on the register are women, leaping to almost 93 per cent of dental care professionals (DCPs). At least 31 per cent of the dental workforce identify as Asian, Black, Chinese, mixed or other non-white ethnicity, with a further 17 per cent unknown. Around nine per cent of DCPs by contrast, identify as non-white, with a further 14 per cent whose ethnicity is not known.

There will be sizeable groups within both parts of the dental profession with at least one characteristic strongly associated with discrimination and harrasment. With 60 per cent of DCPs and 52 per cent of dentists being aged under 40, expectations of professionals will vary considerably from this younger cohort of professionals to their more established colleagues.

The LDC Confederation is supporting dental teams in several ways to make sure that their workplace is inviting and supportive to everyone. One these is working with the National Guardian’s Office to ensure that all practices in member LDCs have access to a clear pathway to a dental guardian. This impartial champion provides support and guidance to those in the dental team who are unsure of where to turn when they have a concern.

As many dental practices continue to be independent providers with relatively small teams, the LDC Confederation act as an impartial body able to support practices and practitioners alike. By providing this opportunity for confidential and impartial support we hope that a more open and accepting culture will be developed in dental practice.

We will continue to work with the London WRES to embed their plans for increased awareness among teams of the issues and behaviours, as well as providing a trusted environment for all members of the dental team to seek support. We will also maintain a campaign of zero tolerance towards harrasment and discrimination from patients. Individual LDCs will be working with their local training hubs to embed training opportunities at the local level and with EDI leads in the Integrated Care Systems to align practice processes and outcomes with those of system wide strategic objectives. Through these combined efforts, the LDC Confederation will continue to take an active approach to promoting equality, diversity and inclusivity in the dentistry profession.

New white paper seeks to clarify what integration means for patients

By David Duffy

The government has published its eagerly awaited Integration white paper, designed to clarify exactly how integrated services will improve care for patients and end users across England.

The paper outlines a series of priorities for integrated care systems to improve health and care delivery. These include enhancing transparency and choice of care increasing earlier intervention of care, as well as increasing flexibility and developing clearer communications between different service providers and enhancing overall value for the taxpayer.

Commenting on the paper, Prime Minister Boris Johnson said: “These plans will ensure no patient falls between the gap [between services], and that everyone receives the right care in the right place at the right time.”

This sentiment was echoed by Health and Care Secretary Sajid Javid, who said: “Our Integration white paper is part of our wider plans to reform and recover the health and social care system, ensuring everyone gets the treatment and care they need, when and where they need it.”

The Integration white paper follows a day after the NHS published its Elective Care Recovery Plan, outlining how the health service intends to bring down ominous backlog figures and repair waiting times following Covid-19 disruption to services.

Proposals outlined in the recovery plan include a focus on community diagnostics and new approaches to care that will only be possible to deliver through integrated care systems (ICSs). This new white paper seeks to outline how health and care systems will draw on the resources and skills from across NHS and local government to “better meet the needs of communities, reduce wating lists and help level up healthcare across the country”.

Also commenting on the Integration white paper, Mathew Taylor, Chief Executive of the NHS Confederation said: “As these proposals are developed further, it is important that we recognise the differences that exist in local areas including in local relationships. They will need to evolve in their own way if we are to crack this agenda.

“Finally, for integration to work there needs to be joined up thinking across government as well as at local level. Ensuring this will allow local leaders the freedom to work with their communities to identify what will provide the best outcomes for the public.”

Hugh Alderwick, Head of Policy at the Health Foundation, highlighted the importance for adequate funding if these system reforms are to be possible: “Better integration between services is no replacement for properly funding them. The social care system in England is on its knees and central government funding over the coming years is barely enough to meet growing demand for care – let alone expand and improve the system.

“More integration is also little good if there aren’t enough staff to deliver services. Staffing shortages in health and social care are chronic, yet government has no long-term plan to address them.”

Analysis

For those who have been close to the integrated care agenda in recent years, or indeed attended virtually any event around integration, there will be little new insight within this white paper – nor will there be much to disagree with. Health and care integration is not a new concept, and so the broad concepts within the government’s latest paper come with little in the way of new proposals. The paper is more of a clarification on what integrated care seeks to achieve rather than an explanation as to how it will be delivered (the absence of additional funding proposals and clear strategy to address workforce shortages is telling).

Not that the document isn’t useful, public perception and understanding of integrated care is still very poor. Delivering integrated care in practice will be difficult unless this understanding is improved and, to this end, the white paper provides some useful clarifications.

But the timing of the paper is as important as its contents. Building on the recent publication of the Levelling Up white paper and published a day after the NHS elective care recovery plan, the Integration white paper is an attempt to show that the government are looking beyond the acute sector and are serious about “Levelling Up”.

The white paper also comes as the Prime Minister is desperately trying to build some policy momentum and move away from what has been a disastrous period for his premiership. Time will tell whether this series of flagship policy proposals (which will precede a further paper outlining specific plans to address health disparity) will provide the antidote to the partygate scandal.

Key priorities of the white paper:

Better transparency
More personalised care
Earlier intervention
Clear communication
Improved access to social care services through NHS data sharing
Better treatment
Better NHS support to care homes
Coordinated services
More flexible services
Better value for money

If there is a Cinderella in health infrastructure, it is primary care

By Chris Green MP

Chris Green MP, Chair of the APPG for Healthcare Infrastructure, calls for the government to properly prioritise the primary care estate in its upcoming refresh of the Health Infrastructure Plan.

In recent years, attention has been focused on a national level on the government’s headline hospital building programme. While investment in acute infrastructure is imperative, we have been waiting with bated breath for a year for the refresh of the Health Infrastructure Plan (HIP).

Addressing the NHS England and NHS Improvement National Estates and Facilities Forum in March 2021, Health Minister Ed Argar MP promised it would set out “the direction of travel for the primary care estate”.

Since then, the radio silence from Whitehall has been one of the factors behind cross-party parliamentarians coming together to revive the All-Party Parliamentary Group for Healthcare Infrastructure.

Our mission is simple: to highlight the importance of high-quality healthcare infrastructure to support the NHS in meeting the demands of the future, including post-pandemic care.

The state of the primary care estate and the lack of a long-term strategic framework is holding back everything from modernisation and integration of NHS care, to tackling the maintenance backlog and embedding new roles into primary care. A YouGov survey of healthcare professionals conducted last autumn found 40 per cent saying the premises they worked in constrained the services they could provide to patients.

In a report published in February on integrating additional roles into primary care networks (PCNs), The King’s Fund concluded that a lack of adequate estate was becoming an issue across primary care and would require expertise in the design and use of space to support multidisciplinary teamworking. This is just one area where the refresh of HIP must offer concrete solutions.

The direction of travel for the primary care estate must reflect the lessons we have learned throughout the Covid-19. A survey of professionals working in hospitals, health centres, GP surgeries and mental health sites at the height of the pandemic found that half felt the sites they were using were fit-for-purpose. In addition, 70 per cent called for more flexible space and 49 per cent for external space for patients and staff.

Work is going on to achieve these aims at primary care facilities across the country like Gracefield Gardens in Streatham or Lowe House in St Helens or at Bolton One which serves my constituents. But we need the refresh of HIP to prove NHS infrastructure is about more than just hospitals.

An analysis of PCN clinical directors conducted by the NHS Confederation last year found that more than 90 per cent felt a lack of estates infrastructure was hindering their progress, while more than 98 per cent felt more funding for primary care estates was needed.

One the important questions that the refresh of HIP must address is what the first iteration identified as a “significant unmet demand for capital in the system”. We need clarity how the necessary investment in primary care estates fits with the post-pandemic public finances.

There are steps that the emerging ICSs can take. Karin Smyth MP and I proposed an amendment to the Health and Care Bill to empower the new Integrated Care Boards to reclaim their stake in projects delivered under the NHS Local Improvement Finance Trust programme. We hope ICBs will take back their share in these vital schemes to ensure they are best used to serve the needs of the primary care estate in their local areas.

The APPG will be launching a call for evidence on meeting short, medium, and long-term health infrastructure needs shortly. We want to hear from those at the centre of ICSs responsible for primary care.

A refreshed version of HIP will be the bedrock for the return to normality as we move on from Covid. We want to hear what you need to succeed.

To get in touch, please write to healthinfrastructureappg@connectpa.co.uk or to receive regular udpates from the group, please visit our website.

Spring Statement 2022: Key takeaways for health and care

By Gabriel Blaazer

While many of the measures in Rishi Sunak’s statement were welcomed, health leaders warn the government must go further to safeguard public health amid a spiralling cost of living crisis.

The Chancellor delivered his Spring Budget to the House of Commons today, in a statement dominated by events in Ukraine and the rising cost of living crisis. While there was little mention of health or social care directly, several measures announced pose significant implications for the health of the nation and the NHS workforce.

There was welcome relief for many of the lowest-paid, as the government announced the raising of the NI contribution cap by £3,000 (rather than the £300 initially suggested), from £9,500 to £12,500. According to the government’s own figures, this will take around 2.2 million people out of contributing to the Health and Social Care Levy entirely. Some 50,000 businesses (those who employ four or fewer people) are also projected to become entirely exempt from the contribution, thanks to an increase in the Employment Allowance.

Although welcome to those continuing to be hit by the cost of living crisis, these tax cuts represent an annual £6 billion reduction in treasury tax receipts. With the Health and Social Care Levy initially aimed at raising £11.4 billion a year over the years 2022-2025, the details of the Spring Budget seem to imply a 52 per cent reduction in that figure, at least in the short-term.

In mitigation, the government also announced “that it will double the NHS efficiency target from 1.1 per cent to 2.2 per cent a year, freeing up £4.75 billion to fund NHS priority areas over the next three years, and ensuring that the extra funding raised by the Health and Social Care Levy is well spent.”

Mr Sunak also announced a 5p per litre cut in fuel duty, a move that will benefit healthcare staff, such as district nurses, physiotherapists and midwives, who rely heavily on their cars to deliver domiciliary and community-based care. The cut, however, falls short of action called for by the NHS Confederation and NHS Providers in a recent statement.

Health leaders welcome tax cuts but call on government to do more

Responding to the Chancellor’s Spring budget, NHS Confederation Chief Executive, Matthew Taylor, said: “Health leaders broadly welcomed the additional funding for health and social care in the Chancellor’s Budget last October and recognise the importance of putting this investment to best use but the world around us is very different now.

“This comes as the NHS is already operating with reduced capacity, very high bed occupancy, and 110,000 vacancies, which will compound how much its services can identify further efficiency gains. Also, our members are very concerned by how hard individual NHS staff members will be hit by this cost-of-living crisis.

“A concession has been made in the fuel duty reduction, but we need to see the Treasury go further to shield community-based healthcare staff from soaring prices at the pumps as they rely on their cars to see their patients, including those who are housebound. A lot is uncertain but as the cost-of-living impact bites the Chancellor must be live to the increased strain and pressure it will put on the NHS in his next Budget this autumn.”

Nigel Edwards, Chief Executive of the Nuffield Trust, said: “Amid a cost of living crisis, it is not surprising that the Treasury will be scrutinising the increased spending on the NHS raised by higher taxes and looking for cost efficiencies.

“Changes to national insurance threshold announced today will provide some welcome support to low earners and will not reduce the amount of money already committed to health and care. But by choosing to put tax cuts above spending the Chancellor has made it less likely that health and care will see any further increases in funding during this parliament.

“This underlines that, despite a boost from the levy, the NHS will still face tight budget constraints. Funding increases to the NHS’s core budget become less generous in each of the next three years, which is why the Chancellor has doubled the annual efficiency target to 2.2 per cent. In reality, however, NHS trusts will need to find even more room for efficiency than that, as at the same time there will be steep reduction in Covid support despite the fact this cost pressure is likely to remain in place for some time yet.”

Jo Bibby, Director of Health at the Health Foundation said: “Today’s announcement shows that the government has yet to fully grasp the pandemic’s stark lesson that health and wealth are fundamentally intertwined. Despite the measures set out today, household incomes are set to fall by 2.2 per cent in real terms in the coming year.

“The pandemic has stretched the financial resilience of many families to its limit. Many have run down their savings or increased debts to cope with the impact of Covid-19 and measures to contain it. And there is no sign that there will be any let up with CPI inflation set to peak at 8.7 per cent at the end of the year. This continuing rise in cost of living will force increasing numbers to choose between essentials that are vital to living healthy lives – such as housing, heating, and food – or being driven into problem debt.

“A government that truly valued the nation’s health would have gone further today to protect the most vulnerable families from this latest economic shock. The increase to National Insurance thresholds is significant but fails to target the poorest households. There has been no action on benefits, while the additional £500 million for the Household Support Fund falls well short of what is needed. Higher inflation will also erode planned spending on public services which support health. The government should be investing more to protect people in the here-and-now, as well as building greater resilience against future threats to our health.”

Claire Fuller to take stock of community pharmacy in primary care view

By Integrated Care Journal

Members of NHS team running review of primary care within integrated care systems met with National Pharmacy Association representatives this week.

Members of the NHS team running a ‘stocktake’ of how primary care is currently engaged in local systems met with community pharmacy representatives this week, at a roundtable organised by the National Pharmacy Association.

Discussions ranged across prevention, urgent and complex care and will feed into the ‘Fuller Stocktake’ – a review of how primary care (including community pharmacies) can best be supported within the emergent integrated care systems (ICS) to meet the health needs of people in their local areas.

Professor Claire Fuller, who is overseeing the stocktake which bears her name, said: “This roundtable brought together pharmacy leaders and other experts to inform the stocktake, focusing on practical next steps ICSs can take as they assume a statutory footing from July. We’re delighted that the National Pharmacy Association is helping to engage its members and the wider sector in this process.”

NHS England and NHS Improvement Director Gina Naguib-Roberts, who took part in the roundtable, said: “There was real power in what people said at this event. We covered an enormous amount of ground and heard some incredible case studies which help to lift people’s eyes and show what is possible. We don’t want to leave it to chance that community pharmacy is in the right conversations within ICSs.”

The NPA’s Local Integration Lead, Michael Lennox, said: “The Fuller team wanted to know what is needed from system leaders to fully engage community pharmacy in planning and delivery at a local level. Just as importantly, they need to know what pharmacy representatives can contribute to this objective.

“We went into detail about enablers such as data, leadership development, training opportunities and IT interoperability. This whole process is about finding solutions together and effecting change – not only visioning the future but also making it happen in a very practical sense.”

Those attending this week’s event included pharmacy bodies, NHS England officials and the NHS Confederation.

Meanwhile, pharmacists, pharmacy teams and “anyone with good ideas of knowledge of effective practice” is invited to join the conversation at #FullerStocktake and www.fullerstocktake.crowdicity.com/hubbub/communitypage/120958.

The ‘Fuller Stocktake’, commissioned by NHS England Chief Executive Amanda Pritchard, will review how primary care networks can be best supported within ICSs, with the aim to ensure that primary care remains the lynchpin of community-facing healthcare.

About 1.6 million people visit a pharmacy every day in England, and many are open for long hours when other healthcare services are unavailable. As such, they are a vital component of primary care, particularly in deprived areas.

Later this Spring, the stocktake team will make recommendations directly to NHS England Chief Executive Amanda Pritchard.

A practicing GP since 1995 and highly respected ICS leader, Professor Claire Fuller is also a member of the ICJ Advisory Board. The Advisory Board oversees our content pipeline, ensuring that our content is insightful, practical and credible. The board is made up of some the country’s leading health and care experts and features system leaders at the very forefront of UK integrated care.

Cheshire & Merseyside ICS teledermatology innovation helps relieve system pressure

By Niamh Macdonald

Cheshire and Merseyside ICS have launched a suite of new teledermatology technology as part of an initiative to streamline the triaging and referral of dermatology patients.

The initiative has been rolled out across four Acute Trusts in Liverpool, Wirral, and Cheshire, including Liverpool University Hospital NHS Foundation Trust. The regions primary and secondary care services have been under extreme pressure with backlogs and record service demand. The aim of the technology is to support 228 GP practices in the delivery of timely, effective and collaborative dermatology care.

The solution consists of a smartphone-compatible Dermatoscope, a connected app and an integrated digital platform, funded by the National Teledermatology Investment Programme (NTIP). Cheshire and Merseyside ICS also partnered with Cinapsis SmartReferrals to make the initiative possible.

The 228 participating GP practices have all been provided with Heine dermatoscopes, with a universal adaptor that attaches to any smartphone camera. GPs are able to use their own phones to capture high-quality clinical images of moles and other skin lesions in a data-compliant manner.

The clinical images can be attached to dermatology referrals or Advice and Guidance requests made through the Cinapsis SmartReferrals app. A secondary care specialist is able to review the case and suggest the best next steps for the patient. The images, and the outcomes of the referral or advice and guidance, are automatically updated in the patient record via an NHS ERS and EMIS integration.

Paul McGovern, Elective Care Programme Manager at Cheshire and Merseyside Health and Care Partnership said: “This technology roll-out is the product of two years’ worth of planning and trials; several solutions were rigorously tested before the ICS team settled on Cinapsis SmartReferrals as selected as the most impactful teledermatology solution.

“The resource commitment and genuine partnership approach taken by Cinapsis has been first-class, enabling us to build a proof-of-concept model within the Liverpool area, secure further investment, then take the project forward across the city and into neighbouring Clinical Commissioning Groups (CCGs) within the ICS model.”

One important benefit of the initiative is that it is reducing the high number of benign moles and skin lesions being referred into secondary care via the Two Week Wait (2WW) cancer pathway. This has previously been a drain on resources and also caused needless concern for thousands of patients.

Prior to the technology roll-out 30 per cent of dermatology 2WW referrals in the region were being referred unnecessarily. This was amounting to approximately 7,000 unnecessary referrals a year, costing over £1 million. Since the Cinapsis technology was launched, 49 per cent of cases submitted on the platform are successfully managed with advice and guidance alone. Clinicians resources have been freed up to tackle wait times for other dermatological conditions, such as inflammatory dermatoses.

Dr Stephanie Gallard, GP & Primary Care Lead for Elective Dermatology within Cheshire and Merseyside Health & Care Partnership, said: “Historically, my GP colleagues and I had to waste hours wrestling with clunky, poorly-integrated photo-sharing technologies if we were able to attach photos at all in a data compliant manner. Aside from the heavy burden it was placing on our time, this was leading too many dermatology referrals to be made without high-quality images. This meant that patients were often called in for a face-to-face specialist appointment when they did not need special treatment, or when they could have been more appropriately managed in primary care.

“Now that I can use the Cinapsis SmartReferrals platform to manage patient referrals and access specialist second-opinions within days, I’ve been able to work more efficiently and treat patients more effectively.”

Dr Owain Rhys Hughes, founder & CEO of Cinapsis, said: “As a surgeon with over 20 years of experience, I know exactly how important streamlined communication is to the delivery of the NHS’s world-class patient care. That’s why the Cinapsis team has worked very closely with the Clinical Leads and the Teledermatology Programme team in Cheshire and Merseyside to build this bespoke, tailored solution.

“We’re passionate about delivering technologies that save time for clinicians, save money for the NHS, and ultimately could save patients’ lives. This partnership will make collaborative working between primary and secondary care teams a reality, and Cinapsis is proud to be playing a part in that.”

The local voice is key to dental success

By Martin Skipper

To achieve the NHS Long Term Plan goal of preventing health inequalities and improving health outcomes, the voices of those delivering and receiving dental care on a local level must be prioritised.

Top-down change, if not informed by local experience, will fail to address issues faced by service users and service providers. Therefore, the voice and experience of local councils, local Healthwatch and local service providers is key to creating an environment through which NHS dentistry can play its part in reducing health inequalities and improving health outcomes. This is why building strong relationships with these bodies is central to the role played by Local Dental Committees (LCCs).

The LDC Confederation is a membership body for LDCs which represent primary care dentists delivering care under an NHS contract. We actively support our member LDCs to engage with local stakeholders, to take the time to explain the complex NHS dental contract and to make clear how, if properly supported, NHS dentistry could help meet their local objectives. These local relationships have created sympathetic alliances and a strong desire at the local level to see a reformed dental contract introduced that would remove barriers to care, which in turn would help to reduce health inequalities and improve health outcomes.

The local councils and local Healthwatch know their populations, understand their issues and seek to identify areas for improvement. Even before the pandemic, we were pleased to see a growing interest in NHS dental services from local stakeholders. Since then, of course, we have seen access to NHS dental services and appropriate provision of NHS dental care grow into a burning issue for almost every local authority.

Member LDCs have enjoyed close working with their local Healthwatch partners, helping with reports and speaking at events throughout London. During the pandemic we provided updates and patient facing information for our local partners to help them and their communities to navigate NHS dental services. This interest has increased dramatically throughout the pandemic as services have struggled to meet patient demand.

Barriers to access

The barriers to access exacerbated by the pandemic have existed since 2006. The pandemic simply brought them to the fore and demonstrated the historic neglect that NHS dentistry has suffered, but also the huge importance that the public place on NHS dentistry. Time and again we have seen reports which show clearly that dental services are highly valued and that satisfaction with the quality and outcome of the care received is high.

NHS dentistry should be one of the great success stories within the wider NHS: a high achieving clinical specialty, with high patient satisfaction, providing clinical care able to give instant pain relief and rapid functional outcomes. Instead, sadly, it is treated as an ancillary service which is not vital to health and wellbeing.

Local stakeholders know differently. They hear stories from patients in pain on a regular basis, from parents of children in pain, from those who are ashamed to go out or eat in public, from people who are afraid to access care because of the NHS charges and those who simply cannot navigate the system and end up at the GP or in A&E. We have been working hard with local partners to press for improvements to holistic care, especially for the most vulnerable such as those in residential care homes and those with conditions such as Alzheimer’s and other dementias, diabetes and stroke rehabilitation. These groups in particular need the system to work with them and for them if they are to lead lives free from avoidable pain and discomfort. Integration of services at the local level will support a holistic approach to care which would pay dividends in improved general health outcomes and quality of life.

Dental contract pilots

Dental contract pilots, later termed prototypes, have been the great hope of the profession since they began in 2010. These pilots were testing new models for the contracting of NHS dental care and were based on blends of capitation and activity. Appointments were longer and the focus was on prevention.

According to the Department of Health’s own press release in 2018:

90 per cent of patients had reduced or maintained levels of tooth decay
80 per cent of patients had reduced or maintained levels of gum disease
97 per cent of patients said they were satisfied with the dental care they received

At the start of 2022 the NHS announced the end of the prototypes and all dental practices operating as prototypes for the NHS are now reverting to their previous contracts. Despite the models showing such promise it is not clear how much of the valuable information taken from these pilots will be applied to a reformed contract in the future.

Local voices are vital

The current Units of Dental Activity (UDA) contract, is based on activity and the NHS is heavily reliant on recouping funding for dentistry through patient charges. This creates a disincentive for the system to increase access among those with the highest need, as a greater number of treatments take longer and in doing so will reduce the amount of activity delivered, throughput of patients and the amount of funding the NHS can recoup from patient charges. The current activity based contract is not able to support local objectives of reducing health inequalities, and the focus on treatment rather than prevention does not support the local objective of improving health outcomes.

If the local councils, and in the future local care partnerships and Integrated Care Boards, want to see a reduction in health inequalities and improvement in health outcomes then a dental contract which supports those objectives is needed. The LDC Confederation ensures that local stakeholders understand NHS dental services and the role they can play in meeting these priorities. We will continue to work with our local partners to make sure local voices who know their populations best will be heard at the national level. Local voices are vital to inform dental contract reform and to make sure that the dental contract is fit for purpose.

The Minister for Primary Care, Maria Caulfield, recently outlined the aforementioned problems with the dental contract on BBC Radio Sussex, and also affirmed the importance of contract reform. Both of these statements are to be welcomed but real improvements will only be seen if that reform is based on the experiences and priorities of those delivering and receiving care at the local level.