Written evidence from the British Dental
Association (COM 70)
1. EXECUTIVE
SUMMARY
1.1 The challenges of oral health commissioning
have been well documented since 2006. The BDA welcomes the opportunity
to contribute to the ongoing work of the Health Select Committee
and the new inquiry into commissioning.
1.2 The new arrangements proposed in the
White Paper "Equity and Excellence" pose opportunities
and threats to the delivery of high quality dentistry and oral
health services to all members of society. This response describes
some of the potential benefits of the proposed changes and also
the concerns that the BDA has about the transition period and
beyond.
1.3 Despite an increased focus by PCTs on
improving access to NHS dental services, access by vulnerable
groups remains an issue which the BDA is seeking to address through
its ongoing programme of work on commissioning. It is an area
that we will be urging the NHS Board not to neglect. A strong
programme of public and patient engagement that recognises the
valuable input of vulnerable groups will be fundamental to progressing
improvements in access to these groups
1.4 A significant challenge for Primary
Care Trusts (PCT) since 2006 has been to ensure system stability
of dental services and this will be equally challenging during
the transition period. Only recently has PCT local commissioning
demonstrated improvement against the World Class Commissioning
competencies yet the new proposals suggest that the NHS Board
will not be fully operational until 2012, leaving much uncertainty
and instability in the meantime for both PCTs and the dental profession.
1.5 Full and meaningful engagement with
the dental profession will empower clinicians to drive forward
care in the best interests of patients whilst keeping patients
at the centre of their oral healthcare. It will be important for
those commissioning dental services to use the dental public health
expertise available although this must be fully and appropriately
resourced.
2. INTRODUCTION
AND BACKGROUND
2.1 The British Dental Association (BDA)
is the professional association and trade union for dentists practising
in the UK. Its 24,000-strong membership is engaged in all aspects
of dentistry including general practice, salaried services, the
armed forces, hospitals, academia and research, and includes students.
2.2 Improving the well being of the nation
through good oral health is an aim that the dental profession
strives towards. In 2006 NHS dental services were adversely affected
when contracts were changed from national contracting arrangements
to "local commissioning" with PCTs. The dental profession
is facing yet another period of uncertainty and we have concerns
that the process outlined in the White Paper must be managed carefully
with the involvement of the profession.
2.3 The White Paper states that general
practice dentistry will be commissioned by the NHS National Commissioning
Board, although there remain considerable gaps in the detail on
the intended infrastructure to support this across England. This
new vision removes many of the existing structures through which
oral health and dentistry is commissioned and we are concerned
about the removal of relationships and services that are working
well.
2.4 Moving total commissioning responsibility
for dentistry to the NHS Board is our preferred option although
we do stress the need for the NHS Board to commission the three
strands of dentistry separately but centrally. Each strand of
dentistry—primary, community and secondary care—is
distinct in its role and function and we would urge that care
is taken to preserve this distinction.
2.5 Much specialist care, such as cleft
palate, is currently commissioned on a supra-regional basis and
it is vital that such services are not lost or commissioned inappropriately
when responsibility transfers to the NHS Board. There are other
similar services that are not easy to reconcile in the new framework.
2.6 Commissioning for good oral health is
based on robust data and intelligence, a comprehensive assessment
of need and a well-designed service with a clear focus on prevention.
A well-designed service will have in-built systematic reviews
and an evaluation of the service design to ensure that the identified
needs of the population are met. The Joint Strategic Needs Assessment
(JSNA) process is a vital part of the commissioner's information
toolbox, and understanding the oral health of a given population
is a vital element. Our view is that commissioning is "an
extremely specialised role, requiring huge skill and expertise
on the part of the commissioning team"[115]
and this is equally going to be the case for those commissioning
services in the NHS Board.
2.7 Commissioning for good oral health is
more than a simple focus on current service delivery and restorative
treatment for existing populations. It requires a strategic overview
of service needs and how they will change as the population changes
and ages. There are three key areas to address when commissioning
oral healthcare services:
— commissioning for existing patient demand
and existing but unfulfilled service need reaching out to those
who do not access care;
— commissioning for prevention and future
service needs; and
— commissioning for education and workforce
to meet those needs now and in the future.
2.8 Professor Jimmy Steele undertook an
independent review of NHS dentistry in 2009[116]
and, as part of this work, identified that different cohorts of
patients require different styles of dental treatment throughout
their life-span. The BDA welcomed Professor Steele's work and
is working with the Department of Health to drive forward many
of his recommendations. Commissioning services to follow this
approach will require intelligent and strategic planning by the
NHS Board for both existing and future needs, and must be undertaken
in conjunction with the annual JSNA process. High quality dental
services are delivered by a skilled and appropriately trained
dental workforce. The present system of vocational and postgraduate
training provided and supported by the NHS must not be reduced
although thought will need to be given to planning of the future
workforce to enable the profession to meet the challenges of predicted
demographic trends such as an ageing population and its effects
on oral health. Commissioning services for changing demographic
trends is a vital element in understanding and planning for prevention.
3. CLINICAL ENGAGEMENT
IN COMMISSIONING
3.1 Those commissioning services will need
to take a holistic view of both supply and demand sides of the
commissioning cycle. There is a rich pool of dental knowledge
and expertise: Consultants in Dental Public Health, Dental Practice
Advisers, Local Dental Committees, Oral Health Advisory Groups
and individual clinicians. Our recent research on local dental
commissioning has shown that 80% of PCTs that responded had a
dental strategy in place and of those, 77% of contributors to
that strategy were Dental Practice Advisers and 69% were Consultants
in Dental Public Health.[117]
The new arrangements must include input from all of these groups
locally.
3.2 National data sets are available on
the oral health of adults and children across the UK. The Adult
Dental Health Survey takes place every ten years and audits the
oral health of the adult population in England, Northern Ireland
and Wales. The 2009 survey was delayed and is due to report at
the end of 2010.[118]
Nationally collected data can be interpreted and analysed on a
local level by Consultants in Dental Public Health providing valuable
intelligence to help inform dental commissioning.
3.3 Since 2006 the monitoring of clinical
practice, contract and performance management has been the responsibility
of the PCT and the new arrangements must continue to have these
mechanisms in place to deal with issues as they arise. The Care
Quality Commission (CQC) will be responsible for registering dental
practices (April 2011) and will undertake targeted practice inspections.
The GDC will remain the regulator for individual practitioners
and other members of the dental team. We would like to see a stronger
role for the National Clinical Advisory Service (NCAS) as this
body has the expertise to help managers and clinicians understand,
manage and prevent performance concerns. Their service includes
providing advice on good practice and performance management and
is held in high regard by the dental profession.
4. ACCOUNTABILITY
FOR COMMISSIONING
DECISIONS
4.1 Patient and public involvement ensures
that commissioners understand current problems in care delivery,
monitor impacts of quality improvements and demonstrate accountability
to the public and taxpayers. The value of patient and public involvement
is covered in detail in the BDA local commissioning working group
report 2009. We stress however the danger of neglecting those
parts of society that are hidden from view and are unheard and
vulnerable. Older people in residential care, those in prisons,
homeless people, BME communities and those in low socio-economic
or deprived areas are all `unheard voices' and their needs must
be catered for. Those who contribute to the local HealthWatch
or online at NHS Choices, are likely to be those people who are
routinely accessing services with little or no input from the
vulnerable groups to help improve services to those sections of
society. We anticipate that the new Public Health Service will
draw on the experience of many of the dental clinical experts
outlined in paragraph 3.1 and it is important that commissioners
design services in close liaison with the Public Health Service.
4.2 Making local authorities responsible
for the commissioning decisions made by GP consortia is problematic
in itself. Maintaining a central budget will undermine the capacity
of local authorities to respond to the concerns of patients, as
they have little or no "real" power in actually commissioning
services. Commissioning decisions will be taken nationally and
yet responsibility will be felt locally.
4.3 Good IT systems will enable some patients
to make and exercise their choice of care. Significant populations
are however at risk of being further disenfranchised, should the
majority of health information and appointments move online. A
new and clinically managed commissioning process necessitates
an inter-linked clinical communications system. We are awaiting
the publication of the Information Strategy which will, we hope,
illuminate how the existing structures are to be strengthened
to support clinicians in the absence of PCTs.
4.4 The NHS Board will commission dentistry
based on input from HealthWatch. Almost three quarters of the
PCT dental contract leads we surveyed in 2010 felt that they needed
additional support in their commissioning teams and the most commonly
cited areas of support required were administration, contract
management and consultants in dental public health. We believe
that the Board will need some form of regional presence to support
its commissioning function and a balance must be struck between
central determination and local flexibility.
5. INTEGRATION
OF HEALTH
AND SOCIAL
CARE
5.1 Our 2009 work highlighted the importance
of evaluation as part of the commissioning process as key to meeting
the needs of the local population. The process of system evaluation
must not be confused with service and contract management. The
purpose of the JSNA is not to set and assess outcomes. Instead
alternative evaluation of service design must be undertaken.
5.2 The BDA is encouraged by better integration
of health and social care although we are concerned about the
pooling of health and social care budgets. Poor oral health is
strongly associated with deprivation[119],
[120]
and other social care services such as housing and transport all
affect the environment in which the patient can or cannot access
care. We would like to see a more integrated approach to service
planning across health and social care that focuses on the patient.
Identifying local barriers, such as lack of public transport in
rural areas, will ensure that complementary health and social
care are commissioned.
5.3 Many of our members work in primary
care delivering oral healthcare to a variety of citizens in a
variety of settings: residential care homes, prisons and those
living at home. The same patient may often be seen by practitioners
and clinicians in both the health and social care settings but
currently these two spheres of care delivery are viewed entirely
separately with a lack of focus on the patient. We are pleased
that the focus of care delivery puts the patient at the heart
of their care as opposed to individuals being viewed as passive
recipients of health and social care. An integrated health and
social care service design should ensure that many of the barriers
to care that currently exist because of this distinction will
be removed.
5.4 For our members, many questions remain
about the distribution of power, the authority of and accountability
between the local authority, the NHS Commissioning Board and the
local health and wellbeing board. Our questions focus on the power
balance between these organisations; which will undertake and
"own" the JSNA and who will provide the resources?
5.5 Some of the recommendations in Sir Ian
Kennedy's recent report[121]
on healthcare services for children and young people have given
a new urgency to the focus on children's services across health
and social care. This report highlights some of the lack of coordination
of service delivery and recommends a significant shift of resources
across the NHS to support services for children and young people.
The report notes that many of the children at risk of maltreatment
grow up with multiple disadvantages of which dental disease is
an integral part. Throughout the transition period and beyond,
integrated and well commissioned services that recognise the needs
of particular segments of the population, such as children, are
vital to commissioning high quality oral health services for the
future. These services must be fully resourced.
5.6 It is important not to overlook vulnerable
groups when assessing need or (re)designing services.
6. TRANSITIONAL
ARRANGEMENTS
6.1 There is bound to be uncertainty amongst
PCT staff causing instability in the system which will affect
good practice and the improving standards of commissioning. Many
PCT activities, such as providing local intelligence, supporting
clinicians in the implementation of new NHS requirements, providing
and facilitating education and training are roles that need to
be filled. A loss of corporate knowledge during the transition
will threaten services to patients. Clinical engagement has never
been more important and Local Dental Committees are one of the
few sources of local NHS corporate knowledge that will remain
under the new arrangements and will be invaluable in supporting
service providers during the transition period.
7. RESOURCE ALLOCATION
7.1 With the new proposals for much of the
NHS to be commissioned by GP consortia, family health services,
including dentistry, must not be overlooked. Our recent survey
has shown that PCT commissioning leads for dentistry spent on
average 81% of their time devoted to dentistry highlighting the
complexity of dental commissioning. Resources must be fairly allocated
to, and between, GP commissioning consortia based on robust assessment
of need and prioritisation. The NHS Board should ensure that the
remaining family services are resourced appropriately to ensure
stability of provision and the provision of valuable local services.
7.2 Unique to dentistry is the interdependence
between education, training and service delivery that is undertaken
in dental teaching hospitals. These contain specialist units for
training and educational purposes that are not found in other
acute hospital settings and include oral pathology, oral medicine,
oral radiology, restorative and paediatric dentistry. Within dental
hospitals there is shared infrastructure supporting academic training
of undergraduate dental students and dental care professionals
alongside clinical training for both undergraduate students and
postgraduate dentists. They also provide a service to patients
via a referral process from general dental practitioners. The
dual nature of dental teaching hospitals requires two distinct
and specific funding streams. This enables high quality training
of the workforce of the future, while simultaneously providing
a specialist service to patients on referral. To ensure a highly
trained dental workforce of the future and the provision of specialist
services to patients, dental teaching hospitals must be fully
and appropriately resourced and not overlooked when commissioning
dental services.
7.3 The BDA would like to see an equal balance
between commissioner and provider interests. We welcome the move
towards a clinician led system that lets clinicians care for their
patients and work together to provide the most clinically appropriate
treatment.
7.4 Dentistry should be appropriately resourced
to contribute to the holistic care of children, young people,
vulnerable adults, older people, those in prisons and secure settings
and those who do not routinely access NHS dental services, whilst
still maintaining the good oral health of those who do use these
services. The JSNA must recognise the contribution of all healthcare
professionals to the health and social care of an individual and
commissioners must ensure that this is resourced appropriately
to meet that need.
October 2010
115 Drinkwater, Professor C (2009) BDA's Independent
Local Commissioning Working Group Report. http://www.bda.org/Images/local_commissioning_report.pdf Back
116
Steele, Professor J (2009) NHS dental services in England. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_101180.pdf Back
117
BDA Local Commissioning Survey 2010 http://www.bda.org/dentists/policy-research/bda-policies/local-commissioning/local-commissioning-research.aspx Back
118
NHS Information Centre http://www.ic.nhs.uk/news-and-events/news/nhs-information-centre-award-adult-dental-health-survey-2009-contract-to-ons-led-consortium Back
119
McMahon AD, Blair, Y, McCall, DR, Macpherson, LMD, (2010) "The
dental health of three-year-old children in Greater Glasgow, Scotland".
British Dental Journal. 209:E5. Back
120
British Association for the Study of Community Dentistry (2005)
"The dental caries experience of five-year-old children in
England and Wales (2003/4) and in Scotland (2002-03). Community
Dental Health, Vol 22:44-56. Back
121
Kennedy, Sir Ian (2010) Getting it right for children and young
people, overcoming cultural barriers in the NHS so as to meet
their needs. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_119446.pdf Back
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