Evidence to the Health Select Committee 2007
The Socialist Health Association was founded in 1930 to campaign for a National Health Service and is affiliated to the Labour Party. We are a membership organisation with members who work in and use the NHS. We include doctors and dentists and other clinicians, managers, board members and patients. Our members are involved in a wide variety of consultation and involvement processes in health and social care. We are particularly concerned that dental services are available to all who need them and that they contribute to improved oral health and reduce inequalities.
This submission is made on behalf of the Association. The sections relate to the issues identified by the Health Select Committee.
• The role of PCTs in commissioning dental services;
In April 2006 PCTs were not, for the most part, able to decide what dental services to commission to meet locally identified local needs. They were, rightly, obliged to offer contracts to existing dental practices based on the amount of NHS activity and NHS earnings by the practice during the reference year. This facilitated an element of stability for dental practices.
Overall some 4% of NHS capacity was lost through practices refusing the new contract, although many of the practices that rejected the contract were largely private and had a comparatively small NHS base.
One of the advantages of the new dental contract has been that if a dentist reduces his/her NHS commitment, or ‘goes private’, the funding is not lost but is retained by the PCT which is then able to recommission dental services to replace that which has been lost and it can decide what services to provide to meet the needs (as opposed to demands) identified in the local oral health needs assessment and oral health strategy.
PCTs, however, realised early in the year that the level of Patient Charge Revenue (PCR) that they had been advised by the Department of Health that they could expect, was not going to materialise. This seems to have been an error in the calculations that the Department of Health had made in setting the levels of patient charges, which were supposed to provide the same income as the previous year ie a level playing field. It had been made clear that it would be the PCT that carried the risk if PCR fell short. This resulted in some PCTs deciding not to recommission all of the lost capacity in order to offset some of the shortfall in PCR.
Dental service utilisation is a classic example of the inverse care law, where those with the greatest oral health needs often receive less dental treatment than those with much lower levels of need. Dental practices are frequently concentrated in more affluent areas where dental needs are less and private transport more available. The PCTs now have the opportunity to commission services to provide a more equitable provision.
PCTs have had to build expertise in commissioning dental services very rapidly and have succeeded in doing so to varying extents. All PCTs should have regular oral health needs assessments and produce oral health strategies as the basis for commissioning plans. It is essential that all PCTs have access to specialist dental public health advice in order to commission services which are based on needs rather than just demand and which will contribute to improving oral health.
• Numbers of NHS dentists and the numbers of patients registered with them;
The number of dentists with an NHS contract at the end of the first quarter (ie 30 June 2006) was 19385, that is one dentist to 2,602 population. At the year end (31 March 2007) there were 21041 dentists with an NHS contract, a dentist to population ratio of 1:2397 (source NHS Information Centre).
Registration with an NHS dentist was introduced in the early 1990s in order to pay dentists for a continuing commitment, including out of hours cover, for patients. The period of registration was initially up to 2 years but was subsequently reduced to 15 months. The responsibility to provide out of hours cover has now been transferred to PCTs and patients no longer have NHS registration with a dentist, although dental practices are encouraged to have their own lists of patients which they consider are ‘their patients’.
Recent guidance from the Institute of Health and Clinical Excellence (NICE) has recommended that 6-monthly check-ups, which was appropriate when oral health was poorer, was no longer appropriate for everyone and that dentists should assess the best interval for individual patients according to their needs and risk status. NICE recommended that the longest interval between check-ups should be 24 months. Dental attendance is now measured by the number and proportion of patients who have attended a dentist within the previous 24 months.
As at 31 March 2006, a total of 28,144,599 patients had attended within 24 months (55.8% of the population). At 31 March 2007, this figure was 28,097705 (55.7% of the population). There had thus been a small reduction in the number of people who had seen a dentist. However, bearing in mind the initial lost capacity and the fact that it took a while to recommission the lost service it might have been expected that a greater reduction would have been seen. We would hope that there might be an increase in 2007/08.
Although the proportion of adults who had seen a dentist within 24 months fell from 51.7% to 51.5% the proportion of children increase slightly from 70.6% to 70.7% (Source NHS Information Centre).
• Numbers of private sector dentists and the numbers of patients registered with them;
Most dental practices have both NHS and private patients, whilst a small number are exclusively NHS or exclusively private. It is also possible for dentists to mix NHS and private treatment in a single course of treatment, for example to provide a white filling in a back tooth at the request of the patient. We have no knowledge of the numbers of patients treated privately.
Whilst we are content for patients to chose to pay privately for treatment if they wish to do so, we are concerned that some patients are ‘forced’ to pay privately, or join one of the private capitation type schemes, because they think that they will be unable to receive dental care under the NHS.
• The work of allied professions;
We support the continued development of a team approach with the dentist leading a team of dental care professional (dental therapists, dental hygienists, dental nurses etc). Further developments of appropriate skill mix is supported.
• Patients’ access to NHS dental care;
Most PCTs have established dental advice lines to assist patients obtain NHS dental care. In most PCTs there are adequate out of hours arrangements for patients who need advice and/or treatment at night, weekends or Bank Holidays. Many PCTs have commissioned urgent slots in dentists’ appointment books for patients who need urgent treatment and who do not have a regular dentist. We commend such practice to PCTs that have not already commissioned such arrangements.
We are concerned that the media reports of large numbers of patients being unable to receive NHS dental care does not accord with information from PCTs. One possible reason for this dichotomy is that too many patients are unaware of the PCTs’ dental advice lines and are not making use of the service established by PCTs to help them find an NHS dentist. We are also aware that some PCTs have not updated the information about available services on a regular basis. PCTs should do more to publicise these services and ensure that the information available to patients is kept up to date.
• The quality of care provided to patients;
During the first year of the new contract the PCTs have concentrated on ensuring that the quantity of dental care was maintained. We are very strongly of the opinion that it is essential that PCTs now give a greater emphasis on the clinical governance / quality aspects of the service and how this might best be performance managed. Before April 2006 the UK had, probably, the best database in the world of what treatment dentists carried out. It is regrettable that the minimum data set now collected from NHS dentists is now so minimal that PCTs only know what treatment band of treatment has been provided. We understand that the Department of Health is planning to require more information on the treatment provided from April 2008.
• The extent to which dentists are encouraged to provide preventative care and advice;
One of the principles behind the changes was to make NHS dental care more preventive oriented. There is, however, no measurement of what preventive treatment and advice is undertaken, although we understand that the expanded data set from April will include information on the application of fluoride varnish treatments.
The Department of Health, in conjunction with the British Association for the Study of Community Dentistry, has recently published a Prevention in Practice Toolkit, which has been sent to all dental practices. It is essential that PCTs monitor the extent to which practices include prevention in their dental care. This must be part of the quality performance management agenda.
In May 2007 the Department of Health published Smokefree and Smiling which set out guidance on how members of the dental team should be involved in smoking cessation activities, ranging from brief intervention advice (30 second) and, where appropriate, referral to Stop Smoking Services by all practices, to a higher level of individual advice where members of the dental practice had undergone smoking cessation training. PCTs need to monitor smoking cessation activities (and also advice on chewing tobacco, which is common in some Asian communities, and which is a major factor, together with excessive alcohol, in causing oral cancer)
Dentists see patients who may not go to their GP because they consider themselves to be healthy. Some dental practices perform other health checking procedures such as taking blood pressure. Consideration needs to be given to whether this should be more common and how such additional activities could be remunerated.
It must be recognised that the provision of NHS dental care services is one aspect of improving oral health. PCTs also need to provide or commission community based oral health promotion programmes eg water fluoridation, other fluoride use such as fluoride varnish programmes, fluoridated milk programmes, dental health education programmes in schools, anti-natal sessions etc. The successful implementation of such preventive programmes, in conjunction with practice-based prevention will reduce the future need for treatment.
• Dentists’ workloads and incomes;
The number of Units of Dental Activity (UDAs) for which GDS dental providers were contracted to deliver was based on the historical pattern of provision at that practice, reduced by 5%. It was somewhat more complex for providers that were previously Personal Dental Service Pilot practices as they has already reduced the amount of treatment provided. Modern dental practice puts emphasis on a minimal intervention approach ie to do only what needs to be done and adopt a preventive approach to reducing future dental disease.
Dentists who delivered the UDAs for which they were contracted and paid had their contracts rolled over. If the number of UDAs was 96% of the contracted level they could agree with the PCT do have a contract that required the same number of UDAs plus the shortfall from 2006/07. If they provided less than 96% it was a matter for PCT / provider discussion whether the PCT would reclaim the excess funding or whether additional UDAs would be required in the current year.
Clearly the PCT has a duty to ensure that the tax-payer receives what the dentists contract to deliver, whilst at the same time being reasonable in understanding the reasons why some practices under-performed and giving them the opportunity to make up the shortfall. We are concerned that there are anecdotal stories of some PCTs being unreasonable but it has to be recognised that they are custodians of the public purse.
Those living in the most deprived areas have, on average, much poorer oral health than those living in more affluent areas. It needs to be recognised that practices in areas with the most disadvantaged communities are likely to have to provide more treatment within Bands 2 and 3 than practices in richer suburbs. There are two ways of dealing with this differential. One would be to divide Band 2 (3 UDAs) into two with more UDAs awarded where a larger number of fillings needed to be provided (patient charges could remain as they are or set at two differential levels). However, it is already possible for PCTs to set the payment to the dentist per UDA higher where dental needs are greatest in order to recognise the greater amount of treatment that has to be undertaken for each UDA. The expanded dataset to be introduced from April 2008 will facilitate this process.
• The recruitment and retention of NHS dental practitioners.
As already stated most of the NHS capacity that was lost through dentists rejecting the new contract has now been replaced, and some PCTs have commissioned additional capacity using some of their general funding. It is understood that those PCTs that have sought tenders for replacement services have had no shortage of interest. It is important that PCTs recognise that the lowest bid may not provide good value for money if the quality of the service they provide is poor. We have already stressed the importance that needs to be given to further developing the performance management of quality.
The three year transition period ends in 2009. In order to maintain the confidence of the dental profession it needs to made very clear, both by the Department of Health and the PCTs, that NHS dental services will not suffer a cutback when the ring-fencing of the dental budget ceases in 2009.
Other issues
1.NHS Information technology
Dental practices are still not linked to the NHS IT systems. Indeed not all dental practices are computerised. This results, for example, in delays in dentists obtaining medical histories from, and sharing information with, GPs when necessary, delays in referrals to hospital from dentists, difficulty in PCTs and others communicating with dental practices. Medical practices have received financial assistance from the NHS to ensure that they are integrated into the NHS IT systems. We believe that it is important that dental practices are also part of the NHS electronic communication systems.
2.Prison dental services
Over the past few years there has been an improvement in the prison dental services. However, the level of service varies from prison to prison. We recommend that Strategic Health Authorities should performance manage the prison dental services in their region and take steps to ensure that PCTs implement improvements where the prison dental services do not match services generally available to the community.
3.Water fluoridation
Mention has been made above to water fluoridation. It is now over 3 years since parliament passed the fluoridation clauses of the Water Act 2003 and yet only one PCT has asked its PCT to undertake public consultation on implementing new fluoridation schemes. Although there have been improvements in the general level of dental health there remain totally unacceptable inequalities with those in the poorest communities and those from certain ethnic minority groups having the greatest amount of dental disease. Fluoridation is the most effective community measure to improve the dental health of children and adults, and in the medium / long term will reduce the need for expensive dental treatment. Ministers should ensure that all PCTs and SHAs review the need for fluoridation without delay and, where the need for fluoridation is established, use the new legislation to consult their local communities on possible fluoridation proposals.