Health and Social Care Bill

Memorandum submitted by the British Dental Association (HS 06)

1. About us

2. Overview

3. Key points

3.1 The scope of the Board’s responsibilities for dentistry

3.2 The need for dental advice centrally

3.3 The need for dental involvement locally

3.4 The need for dental public health expertise

3.5 School dental inspections

3.6 The role of Monitor

3.7 Education and training for the healthcare workforce

1. About us

1.1 The British Dental Association (BDA) is the professional association and trade union for dentists in the UK. It represents 23,000 members working in general practice, in community and hospital settings, in academia and research, and in the armed forces. It also includes dental students.

2. Overview

2.1 The BDA welcomes the provision for dental services to be commissioned by the NHS Commissioning Board, although it must be clarified whether this means all types of services. Commissioning by primary care trusts has been of variable quality and we believe that national commissioning will lead to greater consistency of approach and will ensure that dentistry is not overlooked. Whilst there are significant advantages in central commissioning of dental services by the NHS Commissioning Board, we are nonetheless anxious to ensure that mechanisms are in place to strengthen the ability of commissioners and providers to develop services that are responsive to local needs, and to ensure that they are fully integrated with other NHS services. There will be a delicate balance to be struck between central determination and local flexibility. Local input is a key element which needs to be secured within the Bill.

2.2 There are other areas in the Government’s proposals that need clarification. These include the services to be provided for children, the role of Monitor and education and training for the healthcare workforce.

3. Key points

3.1 The scope of the Board’s responsibilities for dentistry

3.1.1 The BDA understands that it is the Coalition Government’s intention that all dental services will be commissioned by the NHS Commissioning Board. The BDA supports this as it is essential that all dental services are commissioned by the same commissioner because of the dynamic and complementary nature of the relationships between general dental services (family dentistry), salaried dental services (also known as community dentistry, for vulnerable groups) and hospital dental services. This approach would ensure consistency in commissioning and safeguard care for vulnerable groups. Despite this stated intention, the current wording in clauses 9 and 11 leaves open to question where commissioning for all dental services will sit.

3.1.2 The BDA asks that Committee members seek clarification of the term ‘primary dental services’. Primary dental services have generally been considered to be services provided by either general dental practitioners or salaried primary dental care services, but the explanatory notes to clause 11 (paragraph 128) refer to both salaried primary dental care services and hospital services as ‘secondary dental services’. It is this confusion that is causing the BDA concern, as noted in paragraph 3.1.1 above.

3.2 The need for dental advice centrally

3.2.1 For the successful commissioning of dentistry, it is essential that expert dental advice is available to the Board. The Bill states (in Schedule 1, paragraph 10) that ‘the Board can appoint such committees and sub-committees as it considers appropriate’. These appointments will be important because they will help to ensure that the right expertise informs commissioning decisions. In order for dental care to be commissioned so that it effectively meets patients’ needs, the BDA believes that a national dental advisory group should sit alongside the Board to support the commissioning of dentistry across the country. This could be added to the Bill in Schedule 1. The advisory group should include representation from all the different dental services (general dental services, salaried dental services and hospital dental services) and provide clinical input into the management of the national commissioning process.

3.3 The need for dental involvement locally

3.3.1 The BDA is concerned that there is no statutory duty on local authorities, through the Health and Wellbeing Boards, to consult local representative committees when devising a health and wellbeing strategy and joint strategic needs assessment. (clauses 176 and 177).

3.3.2 In order to ensure that dental services operate effectively, professional and local expertise must be utilised. The contribution of Dental Practice Advisers, Local Dental Committees and, in some areas, Oral Health Advisory Groups, is invaluable in supporting the quality of care and tailoring services to local needs. We suggest that the ability of Health and Wellbeing Boards to respond to dental needs, to inform the health and wellbeing strategy, joint strategic needs assessment and National Commissioning Board, and to encourage integrated working across local healthcare providers, will be significantly enhanced by a statutory responsibility to include representatives of relevant health professions in their constitutions and to consult them (clause 178).

3.3.3 In order for local experts – in the form of Local Dental Committees (LDCs) – to input into local commissioning, they must be recognised and have the resources to function efficiently. With dental services in transition and other sources of expertise ebbing away, the BDA believes that LDCs will be more important than ever. Alongside a transfer of responsibility for commissioning the full breadth of dental services to the Board, provision should be made for all providers and performers of primary dental services, not just providers of general dental services, to be represented by LDCs.

3.4 The need for dental public health expertise

3.4.1 The Bill passes to local authorities duties in relation to public health and dental public health, and a duty to appoint a Director of Public Health. There is no reference in the Bill, however, to where Consultants in Dental Public Health will sit in the new structure and how their expertise will be utilised. The BDA believes that there must be a duty in the Bill to ensure that local authorities have the benefit of specialist dental public health advice which is essential if local public health measures are to lead to oral health improvement and reduce oral health inequalities. Consultants in Dental Public Health play a pivotal role in identifying need and balancing the provision of services to provide the maximum health benefits to diverse populations. We would welcome the inclusion in clause 25 of a duty on a local authority to appoint a dentist to have responsibility for dental health (a Consultant in Dental Public Health).

3.5 School dental inspections

3.5.1 The Bill extends local authorities’ duties to provide for the dental inspection and treatment of schoolchildren (clause 13). Whilst the wording appears to provide for inspection and treatment of identified need, it is not clear if re-introducing routine, systematic school dental screening is envisaged. School dental screening has been shown to be ineffective in reducing oral health inequalities because it tends to prompt those who would arrange visits to the dentist for their children anyway to do so, rather than getting non-attenders to visit. [1]

3.5.2 Clause 13, as presently worded, puts a duty, as opposed to the ability in appropriate circumstances, to provide for dental inspection and treatment in schools. The BDA is seeking clarification of the Government’s intention and believes that a multi-faceted approach to oral health inequalities that targets pre-school children and their parents would be a more effective strategy for reducing oral health inequalities.

3.5.3 The Public Health Outcomes Framework includes one oral health indicator - the reduction in the caries (decay) rate in five-year-old children. We support this outcome and there are a number of effective measures that can be adopted to achieve it, but they must start well before the child begins school and so we do not see how they will be captured by this provision.

3.6 The role of Monitor

3.6.1 The role of Monitor in the regulation and pricing of dental services remains unclear in the Bill. We believe that it should be explicit that primary dental service providers are to be exempt.

3.6.2 Dental service providers (dentists, for the most part) are already heavily regulated by their professional regulator, by performers lists provisions, by the terms of NHS contracts and now by the Care Quality Commission. We believe that it is disproportionate to include dentists in economic regulation as there is no evidence of risk to patients or the health service from lack of competition, patient choice or lack of continuity of service.

3.6.3 We believe that licensing by Monitor would impose an unnecessary burden which, according to clause 56, is contrary to its duty to review regulatory burdens. The consequence would be increased costs for small businesses and resulting negative effects on the availability of services for patients. The explanatory notes (paragraph 607) suggest that general medical practitioners may not be covered by the licensing requirements and we seek confirmation that dentists will not be covered.

3.6.4 The BDA is also seeking clarification of whether Monitor will have a role in determining the fees and/or contract values for dental services or whether this will be determined through the National Commissioning Board. Currently, the Health Act 2006 (section 103) states that the Secretary of State may give directions as to payments under general dental services contractors. The BDA hopes that this will remain the case.

3.7 Education and training for the healthcare workforce

3.7.1 Concurrently with the Bill, the Department of Health is consulting until the end of March on proposals for transferring responsibility for the education and training of the healthcare workforce to providers (Liberating the NHS: developing the healthcare workforce). The dental workforce is educated and trained principally in university dental schools, and national responsibility, oversight and provision must be managed centrally. The BDA is concerned at the implications for dental service providers, most of whom are small family practices, if they are to take responsibility for assessing workforce need, arranging for training and paying for it by means of a levy. The consultation stresses that the changes are significant and that time must be taken ‘to develop the proposals to ensure that the appropriate legislation is in place, that the administrative arrangements are appropriate and proportionate…’. We seek assurance that nothing in the Bill pre-empts proper consultation and consideration of the implications of the proposals for the entire healthcare service provider sector.

February 2011


[1] Milson K.M et al. ‘The effectiveness of school dental screening: dental attendance and treatment of those screened positive’. British Dental Journal , Volume 200 No 12, 24 June 2006.