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.

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

Is the answer to improved health hiding in plain sight?

By Dr Anne Elliott and Professor Tim Evans

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

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

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

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

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

A gap in provision

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

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

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

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

Upskilling the workforce

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

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

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

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

Workforce planning

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

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

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

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

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

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

References

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

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

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

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

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

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

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

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

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

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

All news

Mind the Cap: choices & consequences for financing social care

By Francesco Tamilia

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

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

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

Lack of funding a chronic issue

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

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

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

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

Where’s the money?

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

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

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

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

Risk pooling a welcome step

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

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

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

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

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

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

3. The Social Care Workforce: Averting a Crisis

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

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

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

By Louis Holmes

vaccination as a condition for deployment

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

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

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

The VCOD timeline:

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

Equal partners

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

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

Listening to the care sector on vaccinations

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

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

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

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

Getting from understanding to true collaboration

By Dr Masood Ahmed

Dr Masood Ahmed, Chief Medical Officer for NHS Black Country and West Birmingham CCG, reflects on how a shared vision helps health leaders make better and more collaborative decisions.

I was once invited to a leadership training programme while chair of the negotiating team for the BMA Junior Doctors’ Committee; facing my own team were colleagues from NHS Employers. The negotiation, for a new national deal, was a successful one, although events in recent years make that hard to believe.

The focus of the training was ‘principled negotiation, based on Getting to Yes: Negotiating an agreement without giving in by Roger Fisher and William Ury.

Essentially it boils down to this: rather than trying to ‘win’ the negotiation (traditional ‘positional bargaining’), you will deliver long-term success if you attempt to understand the issues faced by both sides and using this as a basis for working together to achieve mutual gains. Basing negotiation on ‘understanding’ also helps develop long-term trusted relationships, something that will be essential for stakeholders across integrated care system.

“The best decisions can never be made in isolation” Dr Masood Ahmed, Chief Medical Officer for NHS Black Country and West Birmingham CCG

Integrated care means integrated decision making

Across the rapidly moving parts that make up an ICS, plans will change, often out of necessity and, inevitably, unforeseen circumstances. Secondary care, primary care, mental health, social care and other community providers on integrated care boards (ICBs) will be looking to make collective decisions based on individual and shared priorities. Uniting these goals in a health and care ecosystem still reeling from the pandemic will be easier said than done.

If ICBs can truly unite around the obvious shared goal, i.e. better patient outcomes, the focus will shift to the citizen and population rather than the organisation or provider; purpose rather than position. This could mean changing suppliers, how staff work, strategy, and everything in between.

The end goal isn’t everything. Crucial to determining the quality of care delivered, and outcomes eventually achieved, is the decision-making process prompting these changes. If we as leaders cannot make better decisions then we are bound to fall short, no matter how good our intentions are.

Good decision making must be based on collaboration and the best decisions can never be made in isolation. If there is only one takeaway from this article, let it be that. To build and grow ICSs in a meaningful way, health and care leaders must listen to all stakeholders – including staff and citizens. This is all too often lost within the NHS (and indeed, the wider health and social care landscape) when executives make decisions based on their own experience, the data presented to them and what they believe to be the right call, without a broader perspective.

Establishing a meaningful vision for decision making

Decisions need to be made with a clear vision in mind: getting to a ‘win-win’. In the NHS, vision can often be seen as a tick-box exercise included in a master plan, rather than a central priority. Sure, it’s great to talk about visionary objectives and it’s great to use this vision to get employees and patients excited. But for most, can we say that our organisational vision truly translates into action? Does it have an impact? Does it guide us? Is it really driven by our values?

My own system, Black Country and West Birmingham, has developed stronger system-level decision making by setting a realistic vision – something tangible yet ambitious that staff can work towards and stakeholders can support. The introduction of primary care clinical leadership executives (PCCLEs), for instance, was driven by the idea that primary care expertise should be leveraged in a way that uses both clinical acumen and leadership ability for maximum impact and patient benefit.

This mindset helps place the population at the heart of decision making. It’s too easy to pay lip service to organisational vision, but when this approach is implemented effectively, it can transform the way one makes decisions.

Vision-driven building supports the idea of making decisions based on first principles – understanding the ‘what’ and ‘why’ of what we’re trying to achieve. In a reactive world, where everything is moving at breakneck pace, it’s easy to get caught in the moment and make decisions on the fly. This happens in too many organisations, and stakeholders end up with choices being made without the long term being considered.

We avoid this by placing vision and principles at the heart of these choices, bearing in mind the need for better decision making for both the short and long term. When we determine our vision, we’re using first principles. When we make decisions that align with our vision, we’re being driven by the ‘what’ and ‘why’, striving for outcomes that give short-term benefit and build towards long-term transformation of health and care for our communities.

Our PCCLE for digital/IT, one of the few primary care chief clinical information officers (CCIOs) in the country, approached the issue of patient information visibility with the aim of tackling the existing issues of duplication of tests, delays in diagnosis, harm from medication and inappropriate admissions to hospital.

The understanding that improving patient information sharing is key to fixing these issues, while consulting with secondary care, mental health, ambulance service, social care and voluntary sector colleagues, supports an informed approach to the procurement of a shared care record that will create lasting change across the system for all stakeholders.

If we approach decision making this way, it allows function to then lead form. How we make these changes, and how we improve things for our citizens, can be driven by how we see the future, and what we want to achieve. Initiatives are underpinned by solid principles that are substantial, accountable and considered, and have definite benefit.

Gone are the sometimes shimmery yet ineffective programmes, and in their place we have people and processes that can make a real, lasting impact. Our PCCLE for dementia was brought in with the ambition to use her field of expertise to benefit our population. She has achieved this by helping to create stronger pre and post-diagnostic support, leading to reduced risk of crisis management (which can invariably lead to hospital admission but also keep a patient well for longer in their own home). By letting function drive form, and taking a problem-solving approach, her work has led to immediate patient benefit as well as long-term improvements for our system.