Memorandum by Hillingdon PCT (DS 32)
1. The introduction of the new general dental
contract in Hillingdon has been relatively trouble free. It was
backed up by an oral health needs assessment which has proven
useful in directing where any freed up resources were most needed.
A history of good collaboration between the commissioner and general
dental practitioners meant that the problems which were widely
anticipated were not realised locally. Teething Problems: A
review of NHS Dental Care in London published in November
partly explains the Hillingdon experience in terms of access and
take up of dental services.
PCT AND DENTAL
2. Hillingdon has a population of around
250,000 and is situated in outer North West London. It has a mixed
population, with greater affluence towards the north of the Borough,
with increasing diversity and deprivation towards Heathrow and
the South of the Borough.
3. In recent years, Hillingdon PCT has been
notable for the size of its financial problems, and it has pro
rata one of the biggest accumulated deficits in the country. This
has put pressures on its management, with frozen posts and considerable
turnover in the executive team. The new dental contract could
hardly have been introduced at a more challenging time for the
4. For years, there has been reasonable
NHS general dental provision in the more affluent parts of Hillingdon,
but less so in the more deprived areas. However, complaints about
the inability to access an NHS dentist have been few, even though
data suggests poor oral health is widespread in the south of the
borough and there are wards with no NHS dental surgery.
5. The PCT was encouraged to write to the
committee with its experiences, to help balance the "submission
bias" from areas where the introduction of the new contract
proved more problematic. The reasons for the ease of introduction
locally are assumed to lie in (a) good long term liaison between
the lead commissioner, public health and the dental fraternity
and (b) the earmarking of dental funds so these changes were insulated
from the more general financial pressures. What has not yet happened,
however, is any substantial shift in provision towards the more
needy areas nor towards prevention.
PCT IN COMMISSIONING
6. There have been several changes taking
place which have affected the PCT's involvement with dental services,
of which the new contract for general dental practitioners has
been only part but perhaps the most significant. The PCT also
has nearly £2 million of spend on hospital dentistry, which
now comes under tariff and in theory under the increasing influence
of practice based commissioners.
7. There are also dental services provided
by the Community Dental Service (CDS) for patients with special
needs and a limited range of specialist services. Some oral health
promotion activities also take place within this team.
8. An oral health needs assessment was undertaken
in 2005-06 and will be extended in 2008. It was promulgated to
dentists, was featured in the Annual Public Health Report 2005
and made available on the PCT's website (www.hillingdon.nhs.uk).
It also formed the basis of a presentation to the UK Public Health
Association (UKPHA) in April 2006, and an update has appeared
in the latest Hillingdon Annual Public Health Report (also on
9. The oral health needs assessment provides
the background for decisions about distribution of any freed up
UDA. It proves very helpful in dealing with challenges from dentists
who want to set up practice in an area that is already well served
by dentists. As an example, appendix 1 presents the arguments
used at the time, in a case that went to appeal. Appendix 1 also
gives a flavour of the financial pressures on the PCT at the time
the new GDS contract was introduced.
10. In spite of good intentions and some
exceptions, in practice the PCT has had little influence on general
dental provision due to the income guarantee extended to those
GDPs who decided to take up the new contract in April 2006. However,
the main tasks to ensure a smooth hand over from the old contract
to the new and manage the primary care dental spend within its
envelope were achieved successfully. This has been facilitated
by the close working between dental professionals themselves and
commissioners at the PCT.
11. Although the PCT has hosted a Dental Advisory
and Liaison Group for over 10 years, in 2005 a Steering Group
was also established with the task of introducing the new contract.
Although this group has now served its purpose and only meets
on a quarterly basis, it has forged ongoing links with the dental
profession and has been recognised by the Local Dental Committee
(LDC) as an excellent example of joint working.
12. Through this joint working, the PCT
has over the last 18 months organised a series of clinical governance
events aimed at supporting dental professionals achieve the standards
set out in Standards for Better Health (2004).
Using the national Clinical Governance Framework,
these events have covered a range of topics and have attracted
large audiences. Evaluation has been positive and the PCT expected
to continue these events into 2008.
13. The PCT also commissions unscheduled
care slots from local dentists. This service is designed for people
who need to see a dentist urgently during normal surgery hours
but either cannot get an appointment with their usual dentist
or they do not routinely go to the dentist.
14. In terms of Out of Hours care, the PCT
has been fortunate in joining with the other seven PCTs in North
West London to provide its out of hours service. The dental nurse
triage service operates between 6pm and 10pm weekdays and 9am
to 10pm weekends and bank holidays. The triage provider works
with NHS Direct and the PCT's GP provider of out of hours services,
Harmoni. All patients are filtered through triage before accessing
the dental service. The joint working between the sector PCTs
has afforded greater economies of scale and provided a service
that Hillingdon alone could not afford to commission.
NHS DENTISTS AND
NHS DENTAL CARE
15. The PCT has 39 contracts for general
dental services and four contracts for orthodontic services. In
addition there is one contractor who only provides domiciliary
services. One NHS GDP opted not to take a new contract in April
2006 which represented 0.4% dental activity in the whole of Hillingdon.
Since April 2006, no GDP has terminated his NHS contract for reasons
other than sale of premises.
16. A recent review of NHS dental care in
London (London Assembly, 2007) illustrates the percentage of residents
accessing NHS dental care pre and post the introduction of the
new contract. In Hillingdon's case, 51.6% of residents accessed
care in the two years to March 2006 compared with 53.2% in the
two years to March 2007.
17. Although the PCT has not conducted a
user survey to find out what patients think of NHS services provided,
we do monitor calls into our PALS department and/or complaints.
|Total number of people who contacted PALS with queries or issues regarding general dental services broken down into:
| Access to Treatment
| Complaints process
| Request for Dental List
|Number of people who contacted PALS and made a complaint regarding general dental services
18. Although the quality of care provided has not been
compromised by the introduction of the new contract, the banding
system seems to have affected the types of treatments offered.
Similar to that reported in NHS Dental Reforms: One Year On,
the PCT has noticed a marked reduction in Band 3 treatments. Some
might argue that this reduction in complex activity is clinically
appropriate, the more cynical might suggest that fewer dentists
are prepared to do the complex work for little return. The PCT
will be monitoring this situation carefully and will consider
building in stipulations to its commissioning intentions once
the transitional period is over.
19. The new contract was funded to free up a dentist's
time by 5% to allow them to offer more preventative advice. Anecdotal
views given by Hillingdon commissioners suggest it is too soon
to see whether the 5% incentive provided has been enough to encourage
dentists to do more preventative work. Informed thinking is that
dentists are unlikely to provide an enhanced service without additional
funding and that a drop in activity has already occurred.
20. In 2006-07 the PCT commissioned 353,142 UDA from
contractors and 338,827 were delivered. This represents 96% achievement
against target. The small shortfall will either be made up by
the contractor concerned or funding will be clawed back. In terms
of funding, the total ring-fenced allocation for commissioning
primary care dentistry in 2006-07 was £6,912k and actual
spend was £7,476k. Although when the services were commissioned
at the beginning of 2006-07 the PCT remained within its ring-fenced
allocation, shortfall on recovery of patient charges has meant
the PCT sustained a cost pressure of £564k.
21. Similar to other PCTs, Hillingdon does not expect
to see a marked improvement in the collection of these charges
as the formula used by the DH to make the calculation seems to
have been flawed. In acknowledgement of this, the DH has increased
funding allocations slightly for 2007-08. However, the PCT will
have to take measures to ensure this shortfall is covered and
it is likely that when ring-fenced budgets end in 2009, the dental
budget will be top-sliced to pay for the shortfall thus reducing
the PCT's ability to commission services according to need.
22. Despite the uncertainties regarding funding, the
PCT is confident that similar levels of NHS funded dental care
could continue to be provided beyond 2009.
23. Patterns regarding how this activity will be provided
will change with a greater focus on commissioning services according
24. The PCT sees itself at the fulcrum of delivering
NHS care and the new contract offers greater opportunity to delivery
care in innovative ways.
25. The PCT will continue to support its local dentists
to achieve high standards of clinical governance through its development
programme which would not have been possible without the joint
working established as part of implementing the new contract.
Professor Yi Mien Koh
Acting head of primary care
Professor Hilary Pickles
Director of Public Health
London Assembly (2007), Teething Problems: A review of NHS
dental care in London, London, Health and Public Services
Department of Health (2007), NHS Dental Reforms: One Year On,
London, Department of Health Back
Primary Care Contracting (2006), Primary Care Dental Services:
Clinical Governance Framework Back
Department of Health (2004), Standards for Better, London,
Department of Health Back