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What if…

What if there was a huge wave of ambition and positivity to completely upend how healthcare in England was delivered? What if all things could be put on hold while a new system was introduced? What would that system look like? How would it actually help people?

While it is not possible to start from a blank slate, and not possible to pause the need to access healthcare while a new system is introduced, it is nonetheless an important and interesting exercise to attempt to understand and deliver a new ambition. From great ambition can come practical changes which improve services. In order to drive realisable change we need to combine the dreamer with the realist and support each in their role. Without the realist dreams remain just that, without the dreamer the realist will never develop. Combining both dream and reality leads to a coherent strategic vision which motivates while delivering clear objectives which can be realised within a structured framework.

The NHS has often been criticised as a sickness service. A service which waits until people need help before stepping in. On the other hand much public health information is derided as nanny statism and providing messages which are all well and good but not so easy to put into practice. 

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But, what if the NHS was a real prevention focussed service? By the time someone calls a GP or goes to a pharmacist they already have an issue they are concerned about. What if there was a way to encourage people to be more aware of early indicators of health in a structured environment which encouraged early intervention and health management? The two prevention focussed primary care professions are dentistry and optometry. 

Since the inception of NHS dentistry the message has been given to the public to attend a dentist for check up regularly. Funding on the NHS has not kept up with this message and so the recent insistence has been on dentists to increase the amount of time between check ups in order to increase access without increasing the dental budget. If the priority is budget management and not healthcare this makes sense. If, however, the intention of the NHS was actually to reduce health inequalities and improve outcomes, as we are told is the priority for Integrated Care Boards, then a primary care system built on prevention would make the most sense. 

If access to dentistry was properly funded for the whole population to attend on a regular basis many issues could be picked up before they developed; rather than waiting to get an appointment with a GP when sick, then being referred on for additional tests. 

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Imagine a system where dental practices were the default mode of engagement for primary care. Properly funded to provide not only dental care but additional advice and support. Point of service data capture could be used to capture information about patients, highlighting relevant information and prompting them to look into additional services, be they health or Council funded. If every person was registered with a dentist but didn’t attend, or didn’t engage with additional services this would be easily picked up and the most vulnerable identified quickly and easily. If dental practices, already regulated for medicine storage and trained to provide injections, provided the flu jab then not only would contact with this cohort be easily facilitated but a dental check up at least once a year supported. Combined with information gathered from point of service data capture any vulnerable or isolated older adult would be easily identified and help provided. The knock on effect would be a reduction in isolation and therefore an improvement in quality of life and reduction in the development of Alzheimer’s and other dementia, which are exacerbated by isolation. Those with already diagnosed health conditions, such as diabetes and COPD, recovering from a stroke or managing Parkinson’s would receive additional information in a safe and supportive environment. Those at risk of developing conditions would receive personalised information in the presence of health professionals.  

Joined up personal health records, accessible through point of service data capture, would give more power to the patient. They could see in real time information about their lifestyle and other information such as blood pressure rates. More information connected and interpreted through AI would empower people to reduce or manage risk as well as place any health questions within a managed context. A smart system bringing this information together would automatically triage patients and refer to a GP or additional Council services as required. Not a replacement for human agency, but a prompt to anticipate disease and reduce the burden on the patient. 

None of the above has to be delivered by a dentist per se. What is important about the dentist though is what they represent: A regular, prevention focussed point of contact. Satisfaction rates with dentists, when patients can get access, are very high. Trust levels for dentists are also high. The message to the public for so long has been to attend a dentist regularly to prevent dental issues. This message should be built on and developed so that people regularly attend a dentist to reduce ill health for their whole health. 

Instead what we see at present is a lack of ambition, no clear vision for dentistry or health in general. 

The above model is not easily implementable, or indeed implementable at all. It would require significant investment which is needed to manage issues in the here and now. It would require a significant mindset change from patients, the NHS, dentists and a range of other stakeholders involved. But that is not to say that there aren’t, as a result of this speculation, some implementable aspects that can be delivered quickly and at cost. 

When dreams meet reality a set of plans can be developed:

Flexible commissioning for dental services can be used to:

  • Deliver access for those aged over 50 from September onwards;
  • Administer the flu vaccine to the this cohort;
  • Link dental practices to schools and Councils to ensure that when children register at a school they provide details of their dentist and if they don’t have one the school is partnered with a dental practice which commits to providing access to that child within 6 months.
  • Automated referrals for those with diabetes, Parkinson’s, dementia and recovering from stroke to a properly funded and trained practice. 
  • Automated referrals for those noted as requiring domiciliary medical care to all NHS domiciliary services.

Additional points that need to be supported in the medium term are:

  • Dentists to have access to summary care records;
  • Ancillary services to be funded to be delivered from dental surgeries (but not by dentists, perhaps extended duties dental nurses) such as blood tests and blood pressure;
  • Increased use of point of service data capture which patients can use to check eligibility for exemption from NHS charges as well as confirm that they are accessing other support locally available which they may be interested in but unaware of such as those provided by the Council or local voluntary services. 

Longer term priorities which should be looked at based on the above model:

  • Significant reform of patient charges for dentistry to encourage access;
  • Funding to deliver a dental appointment for everyone in England at least once every two years. 

All the above points can be and should be delivered within the short, medium and long term. They would not result in the revolution of care proposed above by moving the NHS away from a sickness service to a prevention one, but they would be a significant step in the right direction. 

The opportunities presented by greater integration of the whole of the NHS to other parts of the health and social care system are significant but, to be meaningful, they require ambition and vision, which so far have been even more scarce than funding.