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.”

Community Care, News, Population Health, Primary Care, Workforce February 25, 2022

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.

All news

Delivering primary care at scale

By Professor James Kingsland

Primary care at scale (PCaS) entered the lexicon of healthcare in the NHS in England over 10 years ago. It should be regarded as a set of principles rather than an organisational form, albeit when these principles are applied, a larger provider organisation often results. However, there are many ways of delivering PCaS.

It is well recognised that a predetermined ‘one size fits all’ approach to providing integrated care to populations with diverse needs rarely delivers the desired improvement in quality, safety and consistency in the outcomes of care for patients.

Therefore, any structures created to deliver PCaS should result from these functional principles and assessment of the needs of the population being served. Population health management is now the internationally recognised approach to this analysis of need.

This approach moves away from episodic care to managing the care of a population, utilising data that is also focussed on predictive and preventative care.

A cultural shift

PCaS is predicated on an ability to provide improved first contact care to a larger population than individual list-based general practice, but is more complex than just the aggregation of local practices.

Its purpose is to extend the provision of health and care services within a community setting through an integrated team-based approach. Many providers of primary care and other public services are usually incorporated into effective models of PCaS.

To be successful, a cultural shift is required by both clinicians and patients which changes the dependency on the GP being invariably the first point of contact and creates new models of care management.

Whole population budget

The last (but by no means least) core principle for PCaS is to improve the deployment of health and care resources (human as well as financial) and so reduce per capita costs of care.

This often requires the alignment of clinical and financial drivers through the management of a whole population budget. Entitling clinicians to take responsibility for the stewardship of resources usually results in improved utilisation and productivity. Also investing in value-based outcomes rather than the historical institutional focus on quality and safety at whatever the cost will reduce overall spend in healthcare services.

Ultimately, a PCaS organisational form needs to be ‘the right size to do the job’ and its size allows for a ‘one team’ approach to the provision of care to a defined population.

These principles should direct the core purpose of primary care networks (PCNs) as designed for the NHS in England. To do otherwise may result in PCNs simply trying harder at what has already failed in previous NHS reforms.

Control by letting go

Whatever the model(s) for delivering PCaS, policymakers need to learn the ‘art of control by letting go’ and empower the service to move away from a centralist approach. Enabling the freedom to make decisions at the right level creates the right environment for effective delivery and leads to sustainable system change.

Unfortunately, this has rarely been achieved in the past. There has too often been a malalignment of behaviours and incentives in the system and ‘engagement’ of the service in predesigned models of PCaS has failed. Only through the development of a consistent set of values and promoting co-production with the service can new models of care emerge.

Moving away from positional leadership to an approach of distributed leadership within a PCaS model also promotes an attitude of collaboration by the people doing the work. The liberation of the ‘leader inside’ the individual creates a more purposeful style of practice for improved provision of care.

Emerging operational change

The transformation from current primary care provision to PCaS can eventually be achieved through learning from the past, seeking knowledgeable advice and using an evidence base for reform.

Often, multiple small-scale redesigns over long periods of time involving a series of well managed sequential experiments is necessary. Reformers need to keep testing and prepare for feedback, mid-course correction and revision if the change is unproductive. Operational change should then emerge rather than be planned. Reformers should be prepared to forgive themselves when things go wrong, as no-one gets it right first time.

Initiating care reform programmes and, in particular, developing PCaS should start where the energy is and where people are ready for change. An incremental approach to implementation should then be taken.

Co-production and use of knowledge in the service is paramount in order to develop a feeling of ownership rather than engagement in someone else’s design.

The ability to deliver the principles and requirements of improved service delivery through a PCaS approach within PCNs is achievable. However, there may need to be a reset in future design. The current environmental factors and a contractual prescriptive approach may prove to be counterproductive to the ambition of the NHS Long Term Plan.

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.