Select Committee on Health Written Evidence

Annex A



1.  The role of PCTs in commissioning dental services—an improvement

    —  The experience of Lincolnshire PCT, as a commissioner of dental services, has been a positive one in that the PCT has seized the opportunity to undertake procurement as a vehicle for addressing the challenge of access in the county.

    —  A procurement exercise in 2006-07 resulted in the award of ten new contracts across the county in areas of highest unmet need.

    —  The reforms allowed the PCT to decide on the type of service and the location of that service, the new arrangements allowed the PCT to focus on the more challenged localities, in terms of access to mandatory dental services, within the county.

    —  Recently there has been the opportunity to align localities were there has been significant demand to those of highest oral health need. Lincolnshire PCT has developed an Oral Health Strategy and an associated draft action plan. The PCT has identified access and health inequalities as two major target areas to address within the strategy. There are areas of significant deprivation within the PCT and while access is improving, the PCT recognises that more work needs to be done in these areas.

    —  The commissioning process is now needs based and the PCT has learned a great deal through each procurement exercise in terms of quality, value for money, and the move towards an outcome based commissioning approach. A second review of access was undertaken in early 2007 and it was agreed to commission an expansion of mandatory services through current providers and secure additional capacity through a further procurement tender exercise. This has been actioned through 2007-08 along side rapid reprovision where an existing provider has decided to leave the NHS.

    —  The new reforms have allowed the PCT to drive these changes forward to address access and health inequalities within the county. Local councillors have been involved in the review and consultation process and acknowledge that the reforms have brought about improvements in the commissioning of NHS dental services.

    —  Orthodontics and minor oral surgery are an access challenge for the PCT. The PCT is commissioning services to address this: expressions of interest have been requested for additional orthodontic capacity and a scoping exercise is underway for minor oral surgery services. Again, the reforms have allowed the PCT to determine where this additional capacity should be located rather than provider.

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

5.  Patients' access to NHS dental care—an improvement

    —  There are 85 NHS dental providers in the county and due to the action outlined above this has increased the numbers of dental performers since April 2006. The number of patients registered with an NHS dentist is no longer held by the PCT but the majority of dental practices retain a practice list in order to manage their contracted activity through the provision of courses of treatment.

    —  The PCT established a dental contact list in Autumn 2005 in readiness for the new capacity planned to be in place from April 2006. The PCT, through contract negotiations leading up to April 2006, offered existing providers the opportunity to increase their contracted activity and see new patients (for example, where a practice wished to retain a VT as a 1st year associate).

    —  However, since the implementation of the new contract, approximately 55,000 patients have been offered a place with an NHS practice. The majority of these have been placed with a new provider but some existing providers have also offered NHS places. The PCT has used the contact list to populate the new dental practices as they came on line and this was strictly managed to ensure fairness and equity of provision. The contact is still used, particularly for areas where new capacity has been secured for areas of unmet need. In areas where there is a choice of NHS dental provider, patients now have direct access to these practices via practice contact details.

    —  This year there has been positive feedback from the Lincolnshire Health Scrutiny Committee on the progress made by the PCT in addressing access to NHS dentistry since April 2006.

8.  The quality of care provided to patients—under review

    —  The PCT has experienced an increase in referrals to specialist and secondary care. This in part will be due to the improvement in access to mandatory services and new patients can be seen and their needs assessed. However, the Lincolnshire LDC has asked the PCT to investigate whether this increase could be due the clinical practice of overseas dentists with little experience of the NHS. In addition, secondary clinicians have asked the PCT to investigate whether clinical practice has changed due to the implementation of the new contractual arrangements. This debate often focuses on the more complex treatments in Band 2.

    —  One particular area is oral surgery and the PCT is undertaking a process mapping exercise in January 2008 as well as looking at the inappropriate referrals received by secondary care.

    —  The PCT has developed a service specification to try and incorporate quality elements into the new services commissioned, rather than solely activity and price based, and this is reviewed after each procurement exercise. The PCT is also developing KPIs and a balanced scorecard for NHS dental service providers. The PCT has faced a challenge with information available from the DPD and FP17s to effectively monitor prescribing profiles, value for money and quality standards.

    —  Many local practitioners still believe the new contract to be activity driven, hence we are working with the LDC to develop KPIs and a balanced scorecard (such a system has been developed for primary medical service providers).

    —  PALs and the PCT complaints department receive a number of complaints about the treatment charges, which are followed up with the dental practice. Patients like the simplicity of the new charge bands but are still confused about what is available on the NHS.

    —  However, patients are reluctant to complain or pursue complaints because they are concerned that their practitioner will not continue to see them. Patient perception still exists that it is difficult to access an NHS dentist.

9.  Dentists' workload and incomes

10.  The retention and recruitment of NHS dental practitioners—under review

    —  Some local dentists have decided to leave the NHS since April 2006 and the reason given is the workload associated with the new contract (ie the UDA rate in Lincolnshire is low when compared to other PCTs in the SHA area). Their view is that their clinical behaviour has not changed since the implementation of the new contract and they continue to undertake complex treatments under Band 2 rather than focus purely on UDAs. Their view is that the contract is activity driven and just a different treadmill. Such a case was reported in the local press last week.

    —  The PCT has been able to re-provide this activity. However, we wish to develop an approach which balances workload with the quality agenda as we move towards 2009.

    —  The PCT is working with the Post Graduate Deanery to extend the current network of training practices. There is a possibility of three new applicants this year, two of which are from new practices to the county.

    —  In addition, some of the existing VT training practices have raised an issue about retaining their VT as a 1st year associate. The PCT has taken the approach not to commit growth in a locality where there is not an unmet need; hence VT training practices in these localities will not be able to retain their own VT. Local training practices affected by this approach, believe that this is a negative factor arising from the new commissioning arrangements.

    —  However, the PCT is working with the deanery to look at the role of an enhanced training practice and how the PCT may wish to remunerate such practices.

    —  Some practices have advised the PCT that retention of dentists is more difficult because of the low UDA rate. One practice has undertaken a recruitment drive for overseas dentists and has experienced significant turnover: they believe that the dentist gains experience of the NHS with their practice and then looks for another practice with a higher UDA rate to which to relocate.

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Prepared 4 February 2008