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    We were interested in the BBC’s news topic “More children having teeth out in hospital” on Saturday 13.1.18. The president of the British Society for Paediatric Dentistry, Claire Stephens, was interviewed and correctly identified that dental caries (decay) is an entirely preventable disease. This is demonstrated in England, in 2014/15, 75.2% of five year old children had no visible decay. In Wales, at the same time, only 64.6% of five year olds had no visible decay.

    Jonathan Ashworth, the shadow Secretary of State for health, was also interviewed and correctly pointed out that dental disease was associated with deprivation. Indeed Professor Jimmy Steele’s 135th anniversary lecture at the British Dental Association in July 2015 sent a clear message that dental caries is no longer a significant disease in higher socio-economic groups.

    With this in mind we investigated the problem of caries in young primary school children using a qualitative methodology, interviewing parents, in order to identify issues and highlight possible solutions. Our results showed that parents felt responsible for their children but were poorly informed and not supported to act responsibly. The parents were not aware of the need for toothpaste to be of an adequate strength and for the need to avoid rinsing following brushing.

    With regard to those parents who had experienced their children having multiple extractions under general anaesthesia, they felt blamed. Attempts from professional personnel delivering the service were unhelpful to nurturing future positive behaviours. Furthermore, instructions to find a dentist for future care were followed by the parents but it was impossible to find an NHS dentist to facilitate this instruction.

    However the campaign Design to Smile in Wales, a school supervised toothbrushing scheme, has been of value in supporting responsible behaviours in two ways. Firstly, parental consent was obtained following pestering from the child to be involved in the activity. Secondly, home tooth brushing was promoted by the child, when prior to involvement in the scheme the parent was unsuccessful in directing home tooth brushing.

    It seems to us that in order for improvements in oral health to be facilitated and thus impact on the need for hospitalised extractions it is necessary to:

    1. Improve access to services for deprived populations through primary care policy and implementation. The access should include long term continuing care and not only pain relief.
    2. Target supervised tooth brushing to schools servicing high need populations.
    3. Improve the clarity of oral health education to include the need to attend the dentist, use fluorides of adequate strength and avoid rinsing following tooth brushing.

    This begs the question “Has the power given to primary care organisations through the legislation enabling the new contracts of 2006 and beyond been effective?” Claire Stephens holds the government to account for the increase in hospitalised extractions even though the mechanisms for developing services are localised and have a dental professional input.

    It is possible that improvements in oral health could be achieved through implementing the above. These could be facilitated within the current structures provided by government since 2006, if managers and dental care providers choose to administer and deliver services appropriately.

    (Three authors Wayne Richards, Anne-Marie Coll, Teresa Filipponi)

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    Should the Government Consider a U-turn?

    The public health field is never short of controversies. On 22nd October 2015, Public Health England (PHE) published a report on Sugar Reduction: The Evidence for Action. The report recommends inter alia, an introduction of a sugar tax of between 10% and 20% on high sugar products such as soft drinks (PHE, 2015b). This has sparked endless debates within the academic and public domains. The vociferous debate sustains when subsequently, the government guarantees that there will be no tax imposition on sugary products, whilst insisting that there are other workable alternatives for tackling health issues, particularly obesity, as a result of overconsumption of products with a large amount of sugar.

    Borrowing from the Nudging Theory, tax is seen as a ‘shove’, capable of prevailing the ‘upstream approach’ in public health (policy approach that can affect large populations, such as economic disincentives) through the preventative route (Local Government Association, 2013). This blog post seeks to explore whether the government should reconsider its initial decision not to impose a taxation on sugary products. It will take stock of the evidence that links sugar with obesity, and consider the success of a sugar tax in various countries in addressing the population’s health. It then goes on to explore the power of taxation in changing people’s behaviour and the potential benefit of such a measure on the NHS, before considering whether the tax on sugary products can address the failure of the Public Health Responsibility Dealbetween the government and the food industry.

    Firstly, the evidence linking sugary products and obesity is nearly impossible to ignore. The PHE publication highlights that almost a quarter of all adults, one in ten children aged 4 to 5, and nearly two out of ten children aged 10 to 11 in England are obese, with significant numbers also being overweight. Sugar intakes of all population groups are also above the recommendations. Unsurprisingly, the most disadvantaged sections of society have a higher prevalence of tooth decay and obesity.

    One may ask: Will taxation on sugary products ever work? Evidence from Mexico suggests that following a 10% tax, there was a 6% reduction in the sales of sugary drinks (Instituto Nacional de Salud Pública, 2015). Following such a success, our European Union counterparts including Denmark and Hungary were quick to follow suit (European Commission, 2014), with overwhelming support from Ireland (Irish Heart Foundation, 2014). It will therefore be difficult for the government to maintain its initial reluctance to imposing a fiscal restriction on the products with a high sugar content considering the magnitude of obesity in this country, and the initiative of European allies on the economic control of sugary products.

    Secondly, the fiscal approach presents us with a powerful opportunity to change people’s behaviour towards their sugar consumption. Scholars talk about the obesogenic environment and its causes, which consists of a tangled web of dietary, lifestyle, environmental, and genetic factors. However, rather than seeing its key role in persuading people to alter their sugar intake, the government reasoned that the tax would raise the cost of living, mediated by the aspiration to increase the productivity and economic growth in the food sector (Petitions – UK Government and Parliament, 2015).

    On the surface, the government’s U-turn on the sugar tax is didactic – it should be left to individual choices to make the best decisions with regard to their health, in an attempt to avoid nanny-statism. Nevertheless, this assumption will only work in an ideal world. Some people need support to lead a healthy lifestyle, particularly those who are the most disadvantaged within the society. In this instance, a sugar tax would nudge (or in fact, shove) people into making healthier choices and thus preventing people from having complex health needs at a later stage, in line with the preventative agenda of the government in the health sector.

    The annual cost of obesity is now greater than the cost of treating health problems arising from smoking (Scarborough et al., 2011). Perhaps tellingly, the estimated annual cost of obesity to the NHS is approximately £5bn, and is growing (Public Health England, 2015a). The introduction of a tax on sugary products will ensure that the pricing structure of the sugar-related products is more reflective of the external and wider costs of the substance to society and the health system as a whole. As such, it may also create a ripple effect on tackling other non-communicable diseases such as those caused by poor nutrition, physical inactivity, and alcohol dependency.

    Thirdly, the tax on sugar will overturn the government’s failure on the Government Public Health Responsibility Deal with the food and drink industry (see Gornall, 2015). The core commitment of the Responsibility Deal is to ‘support and enable people to adopt a healthier diet’. However, the Responsibility Deal seems like a temple built on a faulty foundation; it relies upon the goodwill of the industry to keep their pledges and there are no penalties attached for failure to observe the pledges. Positioning the debate within the mainstream media, the celebrity chef, Jamie Oliver, challenged the Prime Minister to ‘act like a parent’ with food manufacturers, as ‘the industry has to be kept in line’ in tackling the rising obesity problem (House of Commons Select Committee, 2015). Here, there is a window of opportunity whereby the tax will empower the industry to take charge and materialise their promises in tackling the rising obesity epidemic in the UK.

    Let us turn back to our initial question. Should the government consider a U-turn on its initial reluctance to impose tax on sugary products? This blog post has argued the affirmative. Clear correlations between sugar and obesity and success stories within and outside of the European Union should prompt the government to reconsider its initial stand. In addition, assistance from the state remains relevant particularly for those who are at a significant health disadvantage, in the name of the preventative agenda. Imposing a tax on sugary products will also reflect the wider costs of obesity on health and the wider environment. At the same time, it has been argued that the imposition of a tax will put the food industry in the driver’s seat to make genuine efforts in combating obesity in this country.

    The taxation route is not a panacea, nor should it be viewed in isolation from other initiatives. Future theoretical and critical debates will benefit from further studies on the impact of a sugar tax on health in the short-term and long-term, and the acceptance of the population towards the tax imposition. This, then, will reinforce the value of taxation in addressing the obesity epidemic in this country.

    First published on the Policy & Politics blog on 17th February 2016.


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    Fizzy drink companies should put child-friendly labels on the front of their products spelling out the sugar content in teaspoons, in a bid to beat tooth decay and child obesity. The Local Government Association (LGA), which represents more than 370 councils – with responsibility for public health – says many youngsters and parents are unaware of the high level of sugar in fizzy drinks.

    The call, which comes ahead of the Government’s forthcoming child obesity strategy, follows research that shows some energy and sports drinks have 20 teaspoons of sugar in a 500 ml can – more than three times the daily allowance for adults – while some popular juices and soft drinks contain between five and 15g of sugar per 100ml. A typical can of fizzy drink has around nine teaspoons of sugar.

    As well as being a key driver behind obesity, sugar is also a major cause of tooth decay, with a recent survey finding that 12 per cent of three-year-olds in England suffered from poor dental hygiene.

    Tooth decay was the most common reason for hospital admissions in children aged five to nine in 2012/13. Damning figures also reveal that in the same year, more than 60,000 children under 19 were admitted to hospital for removal of decayed teeth – half of which were aged nine or under.

    Treating obesity and the effects of oral diseases costs the NHS a combined £8.4 billion a year in England.

    With research showing it takes an average of just 15 seconds for shoppers to decide on an item, the LGA is calling for prominent and clearer labels on the front of fizzy drinks – spelling out the sugar content in teaspoons so that all shoppers can see it instantly.

    Youngsters in the UK are the biggest soft drinkers in Europe – with 40 per cent of 11 to 15-year-olds drinking sugary drinks at least once a day. Poland is the second highest at 27 per cent, and Germany third with 18.5 per cent.

    Under-10s get almost a fifth of their sugar intake from soft drinks and for 11 to 18-year-olds, that figure is nearly a third.

    Better labelling of sugar quantities will raise awareness in children of sugar levels, and ensure people are as informed as possible to help them make healthier choices.

    Unless radical action is taken now to tackle obesity, councils are warning that the next 20 years will see the number of obese adults in the country soar by a staggering 73 per cent to 26 million people.

    Cllr Izzi Seccombe, LGA Community Wellbeing spokesperson said :

    “While we acknowledge that many soft drinks manufacturers are heading in the right direction with sugar reduction, the industry as whole needs to go further, faster and show leadership on the issue.

    In many cases, parents and children are unaware of exactly how much sugar these fizzy drinks contain, which is why we are calling on manufacturers to provide clearer, front-of-product labelling that shows how much sugar soft drinks have in teaspoons.

    On average it takes just 15 seconds for shoppers to decide on an item, so we need to have a labelling system which provides an instant at-a-glance understanding of sugar content.

    Raising awareness of sugar quantities and giving families a more informed choice is crucial if we are to make a breakthrough in the fight against tooth decay and obesity.”

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    We are greatly saddened to announce that Professor Aubrey Sheiham, one of our most distinguished members,  passed away on the 24th November 2015.

    Aubrey was a pioneer in public health globally and a highly respected and loved colleague. He was a driving force and constant advocate of evidence-based medicine and had the courage to challenge professional orthodoxy and powerful vested interests in order to promote oral health in the broader context of general health. In his 1977 Lancet paper, he challenged the then recommended routine 6 monthly dental recall as lacking any scientific basis and risking over-treatment. His seminal public health research on the harmful effects of sugars consumption on oral and general health has greatly influenced the recent WHO and UK recommendations on sugars reduction, as an important public health priority. Aubrey led international programmes of research on oral health inequalities and his work on social gradients has been fundamental in determining global research and policy agendas.

    Over his career he published more than 480 papers and books and supervised 52 PhD students from 20 different countries, many of whom are now leading senior academics and policy makers. He received many national and international awards, including honorary doctorates from the University of Athens and University of the Western Cape, and the Distinguished Scientist Global Oral Health Research Award from the International Association of Dental Research.

    Aubrey was a very kind and remarkable person that generously passed on and shared ideas and his passion for dental public health, thereby being an inspirational figure for many colleagues. He was also a committed advocate for human rights, actively involved in social movements for equality and social justice. He was always conscious about helping the next generations and gave considerable donations to promote research in Africa, such as the Cochrane Collaboration Aubrey Sheiham Evidence-based Health Care in Africa Leadership Award and the support to the Wits School of Public for research and development on policies to address health inequalities. A unique and visionary academic, he was without doubt ahead of his time. He will be greatly missed by friends and colleagues around the world.

    Obituary first published by the European Association of Dental Public Health


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    1. Executive Summary

    In anticipation of the Government’s intention to develop a strategy for NHS dentistry, the Socialist Health Association has produced its own proposals for radically improving NHS dental care. The aim is to re-establish dentistry as a fully integrated part of the NHS meeting the needs of the population.   Our proposals are rooted in the proposition that poverty is the most significant influence on dental health and that reducing inequalities of access and outcome should be at the core of government action.

    The main preventive measure that would considerably improve oral health and benefit the most disadvantaged is water fluoridation. A targeted action programme aimed at extending the fluoridation of water supplies across the UK is urged on government.

    Dental health education, as part of health education generally, should become a key factor in early years development and in the school setting. Such an approach should form the basis of the development of preventive dental care and be extended through the work of health professionals to all vulnerable groups in the population.

    Patient access to information should be improved and the information itself enhanced and clarified. Patient charges for dental check should be removed and the disincentives inherent in the system should be successively removed with charges eliminated or at least reduced for certain groups.

    The aim should be that everyone becomes registered with a general dental practitioner, as with general medical practitioners. This means government tackling the problem of the lack of availability of NHS dentistry and ensuring that the service is provided in adequate premises properly staffed and equipped.

    The contract for dental practitioners should be adjusted to put the emphasis on quality and increased registrations rather than on piecework on teeth – the current unsatisfactory situation. A salaried option for dentists in general practice should be made available.

    Government should ensure that dentistry gains the benefit of the new initiative on clinical governance. An evidence based approach should be developed. Improvement in quality within dental practice should be encouraged. Support should be given to the full dental team to improve their skills and practices encouraged to use a more appropriate skills mix. Better funding should be provided for training, development and postgraduate education.

    The importance of the Community Dental Service is recognised and proposals made to extend its role. The paper emphasises the importance of integrating dentistry with other services through Primary Care Groups, the need to ensure that oral health forms an integral part of all Health Improvement Programmes and, critically, the need for accountability to Health Authorities within a national framework – the whole underpinned by a strong dental public health base.

    2. Introduction

    2.1  In April 1998, Alan Milburn, Minister of Health, announced the development of a new strategy for NHS dentistry in which he stated that the challenges are:

    • to reduce inequalities in oral health
    • to improve the population’s access to NHS dental services
    • to play a part in providing more integrated health services to patients
    • to guarantee the high quality of service that patients expect
    • to allow all members of the dental team to use their full potential to improve patient services.

    The SHA stands by its vision of dentistry being re-established as a fully integrated part of the NHS. In our view there is no reason why teeth and gums should be treated in any different way from treatment of any other part of the body.   Dentistry should be as free at the point of need as is generally the case for the whole of NHS health care. We believe in a salaried service for dentists as we do for general medical    We believe that registration with a dentist should be as much a part of life for our citizens as is registration with a family doctor. The SHA’s aim is of a given population receiving continuity of dental care on the basis of an assessment of their oral health needs. To this end, dental services should be working to clear health objectives, accountable to Health Authorities within a comprehensive framework set by government.

    We recognise however that, at least in the short-term, government is not going to change radically the major factors that influence NHS dentistry, viz:

    • the independent   contractor   status   of   dentists   (as   for   GPs, pharmacists and opticians);
    • the system of patient charges; and
    • the freedom for dentists to provide private dental treatment.

    Notwithstanding this, the SHA believes that there is a great opportunity for Government to act to improve both the oral health of the population and the delivery of dental care. This paper proposes a number of measures to address the challenges/aims set out by the Minister which if acted on as a whole would constitute an effective strategy for the delivery of NHS dentistry, with an emphasis on primary care.

    This statement builds from the oral health strategy produced by the SHA in 1991. It sets out as context the national background on oral health and on dental services.    In seeking to influence government policy we identify the barriers that need to be overcome to ensure that an effective strategy can be implemented. The main narrative, dealing with the Minister’s challenges, describes the elements which the strategy needs to contain and makes    recommendations for government action necessary to deliver the strategy.

    Full implementation of the proposed action programme would bring NHS dentistry back into the mainstream of the NHS and re-establish an NHS dental service of which the nation could be proud.

    1. Context

    3.1      The State of Oral Health

    Children’s dental health has improved considerably over the past two decades. However, six out of ten children still have experience of tooth decay by the time they are 15 years old. Children’s dental health varies across the country with a clear north/south divide with significantly more tooth decay in the north, particularly in Northern Ireland and Scotland.    Children living in areas of social deprivation suffer greater decay than those living in more affluent areas. The trend of improvement in children’s dental health bottomed out in the mid to late 1980s and there is evidence of some rise in tooth decay in the early to mid 1990s, particularly in deprived areas.

    Adults are nowadays keeping their own teeth far longer than in the past. The numbers of adults over 16 years retaining some of their natural teeth has increased significantly, from 63% in 1968 to 80% in    In this area too there is a clear geographical trend in favour of the south as against the north.    There is also a significant social gradient in favour of the higher socio economic groups (14% of those from non-manual occupations have no natural teeth compared with 31% of semi and unskilled manual workers). It is clear that dental care as for other health care is now needed for the increased proportion of the population in older age ranges.

    3.2      Fluoridation

    In the United Kingdom fluoridated water is supplied to around 5.5 million people or 10% of the population. In the Irish Republic 70% of people benefit from this public health measure. This explains why the Republic’s Eastern Health Board is top of the European child dental health league table. The most extensively fluoridated region in Britain -the West Midlands – has the lowest level of dental caries, comparable to that of the Irish Republic. In the United States 70% of the population benefit from fluoridated water. The USA has a target of 75% coverage by the year 2000. There is as yet no target in the UK.

    3.3      NHS Dental Provision

    Over four-fifths of dentists work in general practice with only about one in nine working as dental practitioners in hospitals. The remainder either work in public health or in the Community Dental Service (CDS). This compares with NHS medical services where general medical practitioners provide about a third of doctors with nearly two-thirds working in the hospital service.  The funding of these services reflects this balance.

    These stark figures show how vital to NHS provision are the general dental practitioners working in the General Dental Service. The annual spend on the CDS in England and Wales amounts to over £3 billion. On average there is one dentist for nearly 3,000 persons but this figure varies enormously from place to place and is distorted in its relevance by the fact that private dentistry is commonly practised to a variable extent across the country.

    3.4      The Use of Primary Dental Services

    60% of children under 18 are registered with a dentist in England and Wales. Only 50% are registered in London. Whilst three quarters of children aged 6 to 14 are registered, the proportion for children under two is only about a fifth.

    50% of the adult population in England and Wales are registered with a dentist – about 20 million people. Registration figures vary being lower in the south than the north. Registrations for 18 to 24 year olds and over 75 year olds are low (49% and 32% respectively) whereas they are highest in the 35-44 age group (58%). The most recent national dental health survey recently showed that half the population claimed to attend for regular check ups. However, whereas about three fifths of non-manual occupation groups attend regularly only about a third of those from semi and unskilled manual backgrounds do

    It can be seen therefore that the current range of dental services is not being adequately provided to or received by those in greatest need.

    4. Barriers to progress

    4.1 Set out below are some of the difficulties in the current situation that can only be tackled within a government strategy. These are:

    • The failure to fluoridate water supplies.
    • That dentistry has been and continues to be on the margins of the NHS.
    • The lack of a concerted research and development programme designed to achieve the necessary evaluation systems that will lead to effective evidence based dental care.
    • The lack  of a   national  and   local  emphasis  on  dental   health education.
    • That access to NHS dental services is often difficult and, in many places, even impossible. The availability of NHS dentistry is therefore inequitable.
    • The patient charge system is not targeted on people’s ability to pay. It discourages access to dental care by those least able to pay.
    • General Dental Practitioners (GDPs) receive much less support from the public purse than GPs do, despite much higher capital costs.
    • The independent contractor status of GDPs.
    • The freedom of GDPs to provide private care – in contrast to GPs who cannot – virtually as and when they want – dependent only on their ability to attract paying patients.
    • The current system of remuneration under the General Dental Service (CDS) provides encouragement for quantity of treatment rather than its quality.
    • Dentists and their teams are given totally inadequate support for postgraduate education, training and development.

    5.The basis of a strategy

    5.1 Any strategy for NHS dentistry should contain the following elements:

    • Conversion to a needs-based service.
    • Dental public health as a key national and local target, including establishing its role in all Health Improvement Programmes (HIPs) and Health Action Zones (HAZs).
    • Incentives/requirements to achieve quality outcomes.
    • An emphasis on a preventative system of dental care.
    • A patient-centred approach within general dental practice.
    • A supportive and developmental approach to dentists and their teams to enable greater professionalism.
    • The development of a partnership approach, including, for example, between GDPs and the CDS, linkage to Primary Care Groups (PCGs), close working with Health Authorities (HAs), Local Authorities and involvement of the public.
    • Health Authorities to require providers of dental services to tackle oral health inequalities in their area and to be held accountable for the results.

    6.What needs to be done

    6.1      Poverty

    There is a wide recognition that poverty is the most significant influence on dental health as it is for health in general. This particularly applies to caries in young children where the inequalities of oral health vary hugely across the country and within towns and cities. An economic cause requires an economic solution. A government strategy aimed at reducing disparities of income and wealth would do most to alleviate this problem.

    6.2      Fluoridation

    There is well established evidence that the level of tooth decay in young children is reduced by up to half five years after fluoridation and that this measure gives greatest benefit to the most disadvantaged children in society.

    Fluoridation is the first essential preventive measure that must be taken by a government committed to improving oral health and reducing oral health inequalities. This is the only practicable means to improve dental health rapidly and cheaply and reduce operative A national government directive to require fluoridation of water supplies to a concentration of 1 part per million would be the appropriate public health measure.    Failing this, a change to the present law is essential to ensure that HAs, rather than private water companies, take the decision to fluoridate following full   public consultation involving Local Authorities and the community.

    Based on implementation of this proposed legislative change the government should then ensure that there is a programme of fluoridation across the country starting with those areas with the poorest dental health and so achieving the most effective and cost effective outcome. A target of 25% of the UK’s population covered by, say, 2000 would be appropriate and achievable – and should form a key part of any government action programme.

    6.3      Dental Health Education

    There is a serious absence, both nationally and locally, of dental health education.

    Dental health should be an integral part of parenting education initiated by midwives and developed by health visitors for children in their early years. Dental health education needs to become a key issue in schools and local communities and should be addressed in the school curriculum.  Schools should be supported in this work by health professionals including school nurses and dental health educators working within the CDS. This should form part of the wider health education perspective in schools which appears of late to have become downgraded in importance. Such an initiative could be helpfully linked to government food/health policy initiatives including healthy eating and the prevention of obesity and heart disease.

    There should be dental health education initiatives for carers of the elderly and those with learning disabilities and mental health The demographic facts indicate far greater need by older frail people for dental services as most will be retaining their dentition into old age. Care establishments of all kinds, both in private and public sectors (including hospitals, old people’s homes, nursing homes and day centres) should be required to produce a dental health policy for their residents/users – and be held accountable for its delivery.

    Dental practices should be encouraged to provide dental health education for patients on a one-to-one basis in order to allow the patient to make choices in the formation of an agreed treatment plan. There are different ways in which this might be achieved, one possible method being by some adjustment in the national contract under the GDS. Perhaps the most appropriate approach would be by means of properly funded oral health promotion training made available for dental nurses, therapists and hygienists who would be the most appropriate members of the dental team to provide this service to

    Oversight of a national dental health education policy could be provided through the Heath Education Authority with local programmes becoming an integral part of the CDS’s remit.

    6.4      Patient Information

    The SHA welcomes the Government’s local Helpline initiatives. The government should ensure that the Helpline provides patients with information on how to access local NHS dental services while at the same time enabling patients to distinguish between the private and NHS systems. Patients should also be enabled to understand the NHS charges system: the Helpline should be able to identify the maximum and minimum NHS probable charges for specific core service treatments, e.g. the basic charge for a full set of dentures and the cost of “extras”, so as to give patients a choice. As well as explaining the charges, patients on low incomes should be advised of how to claim for exempt or partially exempt status. The patient registration system should also be explained.

    6.5      Patient Charges: Penalising the working poor

    The first step in a programme to address inequalities flowing from charging should be to remove the patient charge for dental checks. This is a major disincentive to the take-up of dental services, e.g. by young men and women after leaving school and by people reaching pensionable age. Its removal would encourage more people to register and therefore be given greater continuity of care.

    Further, charges should be removed or at least reduced incrementally for a wider range of people, such as the over 60s (as for prescription charges),   and the 18-25 age group whose dental attendance needs to be encouraged because their needs are greater.

    The introduction of the Working Families Tax Credit (WFTC) will increase the number of working people who are eligible for help with NHS charges. Whilst we welcome this the patient charge system itself, if not removed, needs to be revamped. For those people on low income who are not automatically exempt the system is too costly and bureaucratic (it costs £40 to process each application) and it is not well advertised. Many poor people are deterred from seeking treatment for fear of cost, not realising they would qualify for help. Poor people who are not working – those dependant on Incapacity Benefit for example -are not helped by WFTC. To reach these people, charges need to be more acutely targeted on ability to pay. This should be in a non-bureaucratic fashion which encourages take-up. Self-declaration is perhaps a possibility.

    It is time that the NHS low income scheme is reviewed to ensure that it contributes positively towards the reduction of inequality and the achievement of public health gain.

    For those on very low incomes, free dental supplies, on prescription or from clinics should be considered.

    7.Access to primary care dentistry

    Primary care dentistry is, as indicated, on the margins of the NHS. The urgent need is to re-establish NHS provision across the country. The public has a right to an NHS service that ensures their dental fitness.

    7.1      The dentist’s contract with society

    Dentists have gained a valuable education at the expense of the taxpayer, a situation only recently clouded by the introduction of student loans. GDPs should in general be required to repay society by providing a core NHS service for a minimum number of patients – the core service to be established nationally, the numbers of patients and dentists involved to be determined locally by PCGs and HAs according to local oral health needs.

    7.2      Distribution of dentists

    Distribution of GDPs is patchy. Dentists are concentrated in large cities and affluent areas, many in private practice. In some parts there are more dentists available to provide treatment than might be needed for the local population but, where this applies, many of the dentists practice privately and only offer a highly selective NHS service. The result is that people who require basic NHS care (and can only afford this) are discriminated against and fail to gain access to any form of service. In other areas, there is a dearth of dentists providing NHS care because of the environment, e.g. inner city deprived areas where dentists do not wish to live or rural areas where dentists will only provide private care because they consider it non-viable to do

    Recognition should be given to the fact that there are no controls as to where dentists can set up practice. Controls apply to pharmacists by Regulation and to general medical practice through the Medical Practices Committee. Over time a form of regulation could end the lack of available NHS dentists in certain areas, e.g. under­privileged pockets within urban areas and rural areas such as Shropshire, Cornwall and the East Riding.

    These difficulties could be tackled by introducing direct means of controlling distribution. Alternatively, incentives could be used to GDPs to set up in areas badly served in NHS terms.   This could take the form of set-up grants, funding of premises and staff and enhancement of payments for NHS provision.  Dentists do not get the advantages of subsidies for staff and premises that apply to GPs. Vocational trainees could be encouraged, with support from PCGs and HAs, to establish themselves in under-provided areas.

    Further consideration should also be given to the provision of a salaried service in such areas. The schemes undertaken by the previous government should be re-evaluated with a view to making adjustments that will ensure effective NHS provision. Many young graduates would welcome opportunities to work on a salaried basis. What is needed is government action to provide attractive terms and conditions, including pay – to achieve this the relevant Health Service Guidelines need to be replaced by a less restrictive regime.

    The government’s Investing in Dentistry initiative should be used to support dentists who make a living through private practise but are now prepared to commit to NHS service in future. The scope of IID should be extended to supporting NHS dentistry in deprived urban

    7.3      Registration

    Patient registration with GDPs is low and reducing. Various means need to be found to encourage higher registration, particularly of young children and infants, and maintenance of patients on dentists’ This could be achieved through the dentist’s contract, through multi-disciplinary work with other health professionals, e.g. school nurses and health visitors, and via a high profile public service advertising campaign.

    Reregistration at nationally set arbitrary intervals has resulted in deregistration of many patients. This selectively deletes those patients least likely to understand the difference between registration for dental and medical care. In its place should be a requirement placed on GDPs to examine each patient on a yearly basis.   We see no reason why registration should not follow the same pattern as for registration with family doctors. This would be more comprehensible to patients. When primary dental and medical care become more closely associated, joint registration could be considered.

    It would be appropriate for government to set targets for child registration aiming to achieve 100% of under 5 year olds and, say, 90% of under 16 year olds registered and being examined at least annually. This should become part of a programme designed to achieve for the population as a whole the same feeling of normality in being registered with ‘their’ dentist as it is with their general practitioner, following the same administrative pattern.


    The SHA welcomes the recent consultation paper on “Quality in the new NHS”. In particular it welcomes the framework for setting, delivering and monitoring standards. It is assumed that the remit of the National Institute for Clinical Excellence covers GDPs as well as the other primary care independent contractors. This will ensure that all NHS dental services come within the clinical governance framework.

    The approach towards establishing criteria for effectiveness and quality which is now beginning to be applied to medicine is equally needed within dentistry. A programme should be established to determine evidence-based dental practice. Government funding should be earmarked to commission research and evaluation to this end. Areas to be examined could include the clinical effectiveness of osseo-integrated implants, the effectiveness of oral health promotion and the most effective means of delivering dental care to deprived The implementation of established guidelines, such as on the removal of third molars (wisdom teeth), should be monitored to find out the effect on the quality of outcomes where there has been a change in practice.

    Achieving a more appropriate skill mix in dental practice would make a significant contribution to the quality of care. Ensuring that a greater emphasis is given to the dental team as a whole should help to establish a more appropriate skill mix. Action should be taken to increase the numbers of those in professions complementary to dentistry, i.e. dental therapists and dental hygienists.  In time, this will help to achieve a better balance within qualified dental personnel as between dentists and dental auxiliaries – an issue that will need to be

    Appropriate referral should be encouraged by dentists who are aware of their limitations and know that they have not acquired a critical mass of experience in a particular procedure. They should be made aware of the enhanced role of the CDS in providing specialised services and also encouraged to appreciate when it is appropriate to use Hospital Dental Services and when not. Referral for second opinions should be encouraged for more demanding procedures.

    On the other hand, it is quite feasible that a proportion of the work previously referred to dentists in hospitals could now be performed equally well in the community, more accessible to patients and probably at lower cost. However, it is essential that this be carried out by qualified and experienced GDPs. The more demanding procedures should be performed under consultant supervision, perhaps through outreach clinics.

    Now that the Department of Health recognises the importance of clinical governance funding in this area should be increased. This will allow for the expansion of peer review and improvement of the facilities for clinical audit.

    The framework of the GDS contract should be altered in order to reduce the current emphasis on piecework on teeth and replace it by an emphasis on quality and increased registrations. Over-invasive primary care dental procedures should be discouraged and a preventative approach encouraged and rewarded. It is the fee driven system under the GDS that gives rise to some bad and inappropriate   This should be changed to a capitation based system of remuneration as a step towards a fully salaried service.

    The Personal Dental Services pilot schemes should be used to develop quality indicators and to encourage more evidence-based

    9. Integrating Services

    9.1      The Community Dental Service

    The SHA believes that the services provided by the CDS should be at least protected and, where necessary, enhanced to meet local dental need.   The role of the CDS should be very much seen as complementary to that of the GDS rather than in competition with it. The two services should together ensure an effective integrated primary care dental service for the local population.

    The CDS should provide screening for disease in schools, centres for the disabled and homes for the elderly, referring those needing care to local GDPs. The service should also provide a safety net primary care service for those unable to obtain treatment from the This requires domiciliary care for the homebound and mobile surgeries for rural areas and certain inner urban schools and centres. The dental public health role of the CDS, including epidemiological surveys, should be maintained (see the section below).

    The CDS should ensure that patients can obtain their care in dental specialities at the appropriate level of expertise. This would be more cost effective than in hospitals and provide treatment nearer It will be noted (see below) that in the process of achieving more integrated dental health services a case is established for expanding the role of the CDS. These developments would need to be properly funded.

    9.2      Integration of service providers

    An integrated approach achieved through the three dental services is crucial to effective delivery of the service as a whole. The Health Authority has the overall responsibility for achieving this and is empowered under the new White Paper arrangements to develop greater dentist involvement in PCGs and HIPs.

    Establishing effective partnerships between dental services and effective alliances with other health professionals and local authority departments (education and social services) are essential to achieving a comprehensive dental service for the local population as a whole.

    Partnership should be achieved by enabling GDPs to be the key influence in the commissioning of dental care. This could be based on the CDS providing the necessary epidemiological and screening support and being required to act as the dental public health agency under the auspices of the Health Authority. The information thereby gained will determine the needs of the community and enable PCGs to commission services to meet these needs. This role of the CDS should be extended to all types of homes and centres catering for older people and those with physical or mental health problems. The CDS should also be commissioned to carry out surveys to establish special needs within the   community, e.g the housebound within the community, ethnic minorities and those covered by the new Care in the Community schemes.

    Within this framework links can more readily be developed between dental practice and general medical practice, between dentists and school nurses and health visitors. A recognition will develop between all dentists (both in the GDS and CDS) and their teams that they are providing dental care for all parts of their local Setting out the roles for each service will enable effective partnership to be established particularly between GDPs and the Community Dental Service.

    To ensure that public awareness and involvement in dental services is maintained, Community Health Councils should be encouraged and enabled to be a key player in the alliances.

    The above approach can only be assured through a re-evaluation of the funding of the CDS to enable it to fulfil its enhanced remit. A concomitant strengthening of its accountability to the Health Authority is an essential element particularly in its dental public health function, including both epidemiology and dental health education. Directors of Public Health, supported by public health specialists, should be enabled to ensure a needs based approach across all aspects of dental provision.

    10. Professionalism

    The overall approach set out above should encourage greater professionalism within dentistry, in primary care in particular. The present postgraduate education system for GDPs is haphazard, duplicates available topics and is unnecessarily competitive. The encouragement to GDPs to attend is inadequate. The system needs to be thoroughly overhauled and enhanced.   Consideration should be given to allowing GDPs with 100% NHS provision to have at least five paid days’ leave for approved postgraduate study and pro rata for those with reduced NHS commitment.

    It will be seen that our aim is to achieve a patient centred approach with the emphasis on preventive care. An essential requirement must be the encouragement of and funding for training and development of all members of the dental team, whether in dental practice, community dentistry or in hospital. The overall effect must be to improve morale across the profession. Whilst this paper does not deal with the issue of pay and conditions, SHA believe that low pay amongst dental auxiliary staff both in the NHS and in general practice militates against the provision of an efficient service, creates recruitment and retention problems and, in doing so, contributes to weakening the quality and range of service whilst undermining morale.


    The SHA is very concerned at the risk the country faces at the continuing marginalisation of NHS dentistry and, in consequence, the danger of its diminution until the public can only receive minimal NHS dental care. Determined action must be taken to avoid this danger becoming a reality.

    This paper has set out a number of proposals which, taken together and implemented as a planned programme, could ensure a reinvigorated NHS dental service providing care for the whole population.  It is of course recognised that its achievement would take some years but it does present the outline of a programme for the next

    The programme depends initially on establishing a very strong public health base to ensure that dental services are provided on the basis of local needs assessment. The development of effective partnerships and alliances should form the cornerstone of this approach and would ensure that dentistry is given its fair share of attention and resources that are planned under the government’s current proposals being development for the NHS as a whole. A crucial part of this is the recognition that proper funding and support should be given to a strengthened CDS to ensure they carry out the range of activities indicated.

    Essential to the whole exercise is the way in which effective use is made of the main resource, GDPs working in the CDS. They are the key providers of care. They need enhanced support in making a contribution but will be required to adjust their approach over the coming years if the changes required and envisaged are to be achieved. Hence the emphasis on partnership and the importance of accountability at all levels.



    1. Government should   ensure   through   legislation   that   water supplies are fluoridated when required by Health Authorities following public consultation.  (para 6.2)
    2. Government should set a target of 25% of the UK’s population covered by fluoridation by 2000 and ensure a programme of fluoridation across the country covering  areas with  poorest dental health first,  (para 6.2)

    Health Education

    1. Dental health education should  become part of the school curriculum and set within the wider health education programme in schools, (para 6.3)
    2. Carers in  establishments  providing  health  and  social  care should   be   given   dental   health   education   and   all   such establishments should be required to produce a dental health policy for their residents/users,  (para 6.3)
    3. General dental practice should be required to provide dental health education for patients. (para 6.3)
    4. Dental health education policy should be overseen nationally by the Health Education Authority with local programmes being an integral part of the Community Dental Services’ remit, (para 6.3)
    1. Government should build on its local Helpline initiatives by requiring Helplines to provide patients with information on how to access local dental services, how to distinguish between private and NHS systems and how to understand the systems for patient charges and patient registration (para 6.4).


    1. Patient charges for dental checks should be ended, (para 6.5)
    2. Patient charges for treatment should be removed or at least reduced incrementally for a wider range of people needing
      dental care, (para 6.5)
    3. Dental supplies should be available free to those on very low incomes (para 6.5)

    Dentists Contract with Society

    1. General dental practitioners should be required to provide a core NHS service for a minimum number of patients varying depending on need in each locality. (para 7.1)

    Distribution of Dentists

    1. Government should take action to ensure effective distribution of general dental practice to meet needs across the country. (para 7.2)
    2. Government should ensure that a salaried primary care dental service is available in areas where there is a need (para 7.2).
    3. The Government’s Investing in Dentistry initiative should be expanded to support more dentists prepared to commit to NHS service (para 7.2).


    1. Targets should be set to increase patient registration with general dental practitioners. Targets of 100% registration for
      under 5 year olds and, say, 90% for under 16 year olds registered should be set. Dentists should be required to examine registered patients at least annually (para 7.3).
    2. Re registration procedures should be abolished and registration should then follow the same pattern as for general medical The long term aim should be to establish for the population as a whole the same sense of ownership of dental
      services through registration as has been achieved for general medical practice (para 7.3).


    1. Government should establish a programme to determine evidence based dental practice and fund research to this end (para 8).
    1. Dentists should be encouraged to ensure that specialised services and demanding procedures are carried out in the most appropriate location (para 8).
    2. Government should provide adequate funding within dentistry for peer review and facilities for clinical audit (para 8).
    3. Government should replace the contract for General Dental Practitioners with its current emphasis on piecework on teeth by requirements to achieve quality outcomes and increased registrations (para 8).

    Integrating Services

    1. The Community Dental Services should be enhanced where appropriate to meet local dental need. The role of the CDS should be expanded to enable dental services as a whole to meet the oral health needs of the local population (para 9.1).
    2. Government should require Health Authorities to encourage the development of effective partnerships between the dental services and effective alliances with other health professionals, local authorities and the public to ensure effective comprehensive dental services for local populations (para 9.2).
    3. The commissioning of dental care should be based on comprehensive needs assessments carried out by the Community Dental Service with oversight and   professional support by Health Authority Public Health Departments  (para 2).
    4. Health Authorities should be required to ensure that primary care dentistry provides dental care for all sections of the local community (para 9.2).


    1. Encouragement should be given to develop appropriate skill mix of professionals within the primary care dental team (para 10).
    2. The post graduate education system for general dental practitioners should be overhauled and significantly enhanced (para 10).
    3. A patient centred approach with an emphasis on preventive care should be developed within primary dental care (para 10).
    4. Adequate funding should be made available for training and development of all members of the dental team whether in
      dental practice, community dentistry or in the hospital service (para 10).

    Ref: SHA Nov 1998

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    Part of our response to the Labour Party Policy consultation June 2012

    What aspects of your local NHS could be improved upon?

    1. The local NHS is expected to tackle problems associated with the consumption of alcohol, tobacco and other addictive drugs, too much fat sugar and salt and a sedentary lifestyle with little support from central or local government.
    2. GP services that provide proactive and responsive primary care – they seem to provide ever less.
    3. Mental health services that are effective, have a social model of mental distress (while treating biological problems) and are integrated into he wider social and health support systems.
    4. Proper public dentistry system rather than the anarchic patchwork of profit seeking private contractors.

    Are there positive examples in your local NHS that others could learn from?

    1)     Cooperative Commissioning: Lewisham have agreed to implement this new approach to collaborative work.

    2)     LINk database: Lewisham LINk has designed and used a database into which all patient experience is placed. We now have 1000s of comments which can be used to guide commissioning decisions in the patients’ interests.

    3)     A Patient and Public Involvement Strategy that is simple, cheap and effective in Lewisham – and very collaborative, bringing together all the key players.

    4)     Community Development that works with local people and local organisations to improve health and behaviour change.

    5)     Collaborative partnerships in Oxfordshire between health and social care in the areas of learning disability (intellectual disability), rehabilitation of older people; community (salaried) dental service. Walk in clinics before the PCT axed them!

    6)      North Lancashire CCG is pioneering a self care project to try and change Health Professionals and patients attitudes to this. It is a supertanker to turn round but can be done. If Labour grasp this one they could be streets ahead on this issue.

     What kind of service do we want to see for carers and families are there any examples of local services that are working well?

    1. We don’t think there is perfection anywhere. The key principle is to create channels of communication and the opportunity to challenge what the services do – the major improvements in our experience have all come about as a result of this. Some of this can be mandated via policy but a lot comes from local commitment and hard work – easier if there is an enabling policy context.
    2. There are far too many stories of carers of people with learning difficulties or dementia being completely ignored by hospital services


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    Oscar's teeth

    Oscar’s teeth

    I took my son recently to the Manchester Dental Hospital.  It’s part of Central Manchester NHS Foundation Trust where he was born and where the regional genetics centre diagnosed his condition – which affects both his fingers and his teeth

    The very charming dentist knew nothing about his medical history and didn’t have access to his hospital notes, because the Dental Hospital have their own paper records,  so I had to give her what was doubtless a garbled version of his medical history.  They took a very fancy X-ray of his teeth, but when I asked for a  copy I was told

    1. They didn’t have a printer
    2. They weren’t allowed to send emails to anyone outside the NHS
    3. It was against Trust Policy to give any patient information from their medical records unless they made a written application under the Data Protection Act.

    When I complained (to the Hospital Pals service, where the first person I talked to do didn’t even know there was a dental hospital)  I was told that the records were not yet integrated.  The Dental Hospital only joined the Trust in 1991, so I suppose it’s early days yet.

    It took me nearly 6 months to get a copy of his X-ray.  I had to produce his birth certificate to demonstrate that I was his father – they don’t ask you any such questions when you appear in person.

    Joining organisations together has little to do with integration.  I’m not sure its much to do with culture either.  It’s more to do with access to records.


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