Select Committee on Health Written Evidence


Memorandum by the NHS Confederation (DS31)

NHS DENTAL AND ORTHODONTIC SERVICES

  The NHS Confederation represents more than 95% of the organisations that make up the NHS. We are the independent membership body for the full range of organisations that make up today's NHS across the UK. Our members include Primary Care Trusts, NHS Trusts, NHS Foundation Trusts and independent providers of NHS services.

  The NHS Confederation welcomes the opportunity to give evidence to the Health Select Committee on NHS dental and orthodontic services. This evidence sets out our views, based on feedback from a cross section of our members, particularly those provided by members of our PCT Network. We are also providing case studies from two of our members, which are included as appendices.

KEY POINTS

  The NHS Confederation is of the view that the contract for NHS dental services has the potential to deliver change but:

    —  PCTs have lacked the capacity to realise the potential of the contract—both in management resource and access to dental public health expertise. PCTs will be aiming to address this shortfall as part of the World Class Commissioning programme, currently underway.

    —  There is an opportunity to consider the future direction of dental services within the Primary and Community Services Strategy, which is being produced as part of the Department of Health's Next Steps Review Commissioning.

    —  PCTs need to consider dental services alongside all their other local priorities. We estimate that it would cost £2.3 billion[64] to introduce full coverage of NHS dentistry across the country.

    —  Clinical engagement is crucial; where good relations are developed, good performance management arrangements are usually in place[65]. This is especially important to improve the quality of services.

    —  Incentives for prevention and health promotion should be strengthened.

    —  Funding needs to be reviewed due to the shortfall created as a result of less income from patient charges than expected and due to the consequences of allocations based on historical activity[66]. This is particularly significant in the run up to 2009 when PCT allocations for dentistry cease to be ring-fenced.

BACKGROUND

  The origin of the problems in accessing NHS dental services stems from the reforms in 1990 which changed the way dentists were paid, lining payments to the numbers of registered patients. Due to the large numbers of patients registered, (far more than planned for) fees were cut in 1992 and significantly reduced the earnings of dentists. The consequence of this was that dentists drastically reduced their NHS work, and many turned exclusively to private practice.

  The Health and Social Care Act 2003 required that, "each Primary Care Trust and Local Health Board must, to the extent that it considers necessary to meet all reasonable requirements, exercise its powers so as to provide primary dental services within its area, or secure their provision within its area."

  The protracted nature of the negotiations between the Department of Health and the British Dental Association meant that this only came into effect from April 2006.

  However, these reforms probably represent the most radical reform of NHS dentistry since 1948. The devolution of funding to PCTs, alongside the statutory duty to commission services provides opportunities to tailor services to meet local health needs. This potentially enables PCTs to redress the uneven distribution of dental services in some areas which has arisen because previously dentists have been able to set up practice in areas of their choice rather than in areas of greatest need.

  The reforms are intended to address three key issues:

    1.  Access to services—by putting PCTs in charge of commissioning.

    2.  Remuneration reform.

    3.  Simplify patient charges.

  Patients now pay standard changes (3 bands) and dentists have a contract with the PCT to provide an agreed number of units of dental activity (UDAs) per year. This replaces the 400+ different patient charges in the previous contractual arrangements.

  The financial allocations for the contracts were based on historic spend in 2003-04 and have been ring-fenced for dental services until 2009. No additional resources were made available to areas with higher needs. PCT budgets were also adjusted (downwards) in line with anticipated income from patient charges. This has caused additional financial pressure in some areas of the country.

  From 2009 the resources will be part of the PCT general allocation.

1.  The role of Primary Care Trust's in Commissioning Dental Services

  1.1  There is no consistent national picture on the implementation of the reforms. This may be due to a range of factors, not least that the changes coincided with the reconfiguration of PCTs, but also the following:

    1.1.1  A wide variation in the financial pressures that have resulted from the implementation of the new contract have been of major concern to some of our members and could potentially affect their future commissioning plans. The principle reason is the new arrangements for patient charges. PCTs had their resource allocation reduced based on the anticipated income from patient charges. This was predicted to be £634 million, however only £475 million was actually payable during 2006-07. The lack of revenue from patient charges appears to be due to dental practices seeing more "exempt" patients (including children) than predicted, who make no contribution to their treatment. This has led to a significant financial shortfall for PCTs, who are faced with uncertainty in relation to which patients will require NHS treatment. This has affected many areas with high levels of deprivation and, therefore, high levels of need. In a few cases PCTs are facing the possibility that they may have to reduce the current level of services.

    1.1.2  The capacity of PCTs to use the new contract has been raised by our members as a key concern. In the light of the wide range of performance measures faced by PCTs there is a danger that dental services commissioning is not necessarily regarded as a mainstream issue.

    1.1.3  Many PCTs have historically allocated limited resources to manage dental services. Dental contracts are often the responsibility of relatively junior managers, who have a contract management role and little involvement in strategic planning within their organisations. Their initial focus has been to ensure that contracts were in place. Where dentists have left NHS provision, new contracts have been let, but on the whole these have just re-provided the previous services. In some areas only two staff are responsible for managing 120 practices with 140 contracts. Should these staff leave, a lack of organisational memory could compromise the commissioning and performance management role of the PCT.

    1.1.4  The limited access to dental public health advice is also of concern to some members. The number of Dental Public Health Consultants is decreasing at a time when their input is of increasing value as PCTs are required to make the shift from contracting to commissioning.

    1.1.5  Some PCTs have extremely good relationships between the PCT, Local Dental Committees and/or dental contractors. Despite low levels of human resource, these areas have put good performance management arrangements in place. Other areas have extremely poor relationships and have limited arrangements.

  1.2  Some members feel that the contract itself offers sufficient opportunities for local commissioning and that the utilisation of a balanced scorecard approach, which measures whether the activities of an organisation are meeting its objectives in terms of vision and strategy, alongside a clear commissioning strategy, provides the potential to develop services appropriate to local needs. However, other areas are not so positive, and the key appears to be long standing good relationships with their contractors.

  1.3  The commissioning of dental services must be considered as part of the Department of Health's World Class Commissioning work programme or they will continue to be regarded as a separate responsibility outside of mainstream commissioning.

2.  Numbers of NHS dentists and the numbers of patients registered with them

  2.1  Our members report that they have few concerns about the number of NHS dentists, but are concerned about the lack of information about the availability of NHS dental services[67]. In areas where contractors have not signed contracts, or have since left the NHS they have had no difficulty in re-tendering the contracts. In many cases they have been able to commission extended services.

  2.2  In London, where dentists did not take up new contracts for 3% of services, PCTs have already been able to replace all of these services by commissioning new or extended services from other dentists.

  2.3  National and SHA level information on dental activity is provided by the Information Centre, who publish statistics quarterly. It should be noted that the information on the new contract is not directly comparable with the information collected under the old contract.

  2.4  We have used a simplistic calculation to give an indication of the cost of covering the entire population (100%). 55.7% (51.5% of adults and 70.7% of children) of the population in England were seen by an NHS dentist in the two years to March 2007, which equates to 28.1 million people (20.3 million adults and 7.8 million children). Treating these patients amounted to a maximum total expenditure of £2,3978 million. Therefore, it would cost £4,656 million if 100% of the population were to be covered, which would require an increase of £2,258 million in funding. We readily acknowledge the simplicity of this argument. A large number of patients, perhaps as high as 20%, never access a dentist, although we would like to see this figure fall. Some will choose to go privately and the way in which the figures are reported is not necessarily indicative of need. However, we thought it might be of interest to the Committee to have a rough estimation of the cost of providing NHS dental treatment to all. Clearly, PCTs would need to consider this call on their resources alongside all their competing priorities.

4.  The work of allied professions

  4.1  Allied professions are an underused resource and, as Western Cheshire PCT note in their case study under Appendix B, it is necessary to have the benefits of a larger scale operation in order to take full advantage of the benefits of team working.

5.  Patients' access to NHS dental care

  5.1  Improved access to NHS dental services is one of the key aims of the new contractual arrangements. Responsibility for this has now been passed to PCTs from the dental profession. It is important to recognise that not all PCTs have problems with access. In fact, PCTs in London are addressing the issues raised by a shortage of people coming forward to seek dental care rather than a shortage of service provision.

  5.2  An important part of the problem of patient access is the lack of easy access to information about the availability of NHS dental services, which is well documented in the Citizen's Advice Bureau report "Gaps to Fill". Many patients are unclear about how to find a dentist, despite some PCTs managing central waiting lists and national campaigns on NHS Direct and NHS Choices websites. Recent media reports with examples of a patient resorting to superglue for dental treatment actually occurred in an area where the PCT reports no difficulties with access to NHS services.

  5.3  PCTs are finding innovative ways of addressing access problems. The benefits of operating a central waiting list are documented in Appendix A, which is a case study provided by Lincolnshire PCT, which has been able to offer 46,000 patients an NHS dentist. There are also many examples in London where PCTs have implemented specific schemes aimed at improving access. Tower Hamlets PCT has a dental access project which uses mobile dental surgeries staffed by the salaried service. People are dentally screened, and, if living in an area of low provision of dentistry receive NHS treatment. This pilot has proved to be very popular with the public.

  5.4  In addition, all London PCTs directly provide or commission a Salaried Primary Care Dental Service which is able to deliver special care dentistry for vulnerable groups and people with special dental needs. These services are variable in their ability to respond to local needs, working to varying access criteria.

  5.5  Tackling inequalities to access to dental care will require a range of initiatives to address the barriers towards dental care and may require additional resources over time to address uptake in areas of social deprivation and higher unmet need and amongst vulnerable groups.

6.  The quality of care provided to patients

  6.1  Ensuring the quality of care provided to patients is a key issue for PCTs. The first year of the contract has naturally focused on agreeing contract values with practitioners, and re-tendering contracts where dentists chose to leave the NHS. In order to address quality issues many PCTs require additional capacity. It is essential that PCTs engage with the profession and their current capacity does not always support this. Further improving the quality of care will be addressed as PCTs increase their capacity to use the contract imaginatively.

7.  The extent to which dentists are encouraged to provide preventative care and advice

  7.1  All PCTs have groups working on local oral health strategy and will be working with key stakeholders on implementation.

9.  The recruitment and retention of NHS dental practitioners

  9.1  PCTs have not encountered problems with the recruitment of NHS practitioners. Members report healthy levels of competition when re-commissioning services. They also report that contractors have been able to recruit to posts when they have become vacant.

NHS Confederation

December 2007



64   See paragraph 2.4 for further detail. Back

65   See sub-paragraph 1.1.5 for further detail. Back

66   See paragraph 1.1 for further detail. Back

67   See paragraph 5.2 onwards for our views on this issue Back


 
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