Written evidence from the British Dental
Association (CFI 14)
1. BACKGROUND
AND INTRODUCTION
1.1 The British Dental Association (BDA) is the
professional association and trade union for dentists practising
in the UK. Its 23,000-strong membership is engaged in all aspects
of dentistry including general practice, salaried services, the
armed forces, hospitals, academia and research, and includes students.
1.2 The BDA is pleased to contribute to this
follow-up inquiry, which addresses many of the issues that we
raised in our written submission of evidence. In particular, we
have long advocated the value of local clinical expertise in the
commissioning process, greater patient and public involvement
and integrated health and social care patient pathways.
1.3 The Health and Social Care Bill 2011 states
that the NHS Commissioning Board will commission primary care
dentistry. In a recent statement, Lord Howe confirmed that the
NHS Commissioning Board would also commission secondary care and
community dentistry. Our members very much support this arrangement,
as we have long pressed for a national contract with room for
local flexibility both prior to and following the implementation
of the 2006 dental contract.
1.4 We strongly urge the Committee to consider
the need for clarity of the role, function, authority and accountability
of the NHS Commissioning Board and its relation to local authorities
and Public Health England. This clarity at an early stage is essential
to ensure continuity of service and patient care in an uncertain
transition.
1.5 The burden of regulation is a threat to commissioning
appropriate services and we ask the Committee to consider the
practical working relationships required to ensure that the Commissioning
Board and consortia function with appropriate reference to the
relevant regulatory bodies. The BDA advocates a reduction in the
burden of regulation - both financial and administrative - that
has the potential to compromise dentists' ability to provide essential
services to patients. We believe there is a growing recognition
that the regulatory burden is now excessive.
1.6 There is a concern that education of the
dental team is heavily reliant upon practice placement and actual
care provision by undergraduates and dental care professional
students. The need to coordinate service change and reconfiguration
and at the same time to assure continued access to workforce development
is essential to deliver a modern and efficient dental health service.
2. BOARD AUTHORITY
TO DISCHARGE
DUTIES
2.1 We support the Committee in seeking clarity
about the authority of the Board to deliver its objectives and
we recommend that the Committee consider this as a matter of urgency.
2.2 This issue is particularly important to dentistry,
as the Department of Health is in the process of piloting a new
dental contract, which is due to be rolled out in 2014. With the
introduction of the Care Quality Commission to an already significant
regulatory framework, we are operating in an information vacuum.
The Coalition is yet to publish appropriate guidance on the structure
and responsibilities of the Commissioning Board, and at a time
of such significant change, this lack of information is unacceptable.
It is essential that we receive clarity on how services will be
commissioned in order to ensure that there is no compromise to
the availability and accessibility of care for patients and the
public.
2.3 Restricted NHS budgets and the increased
focus on public health mean that workforce planning becomes even
more important. Without knowledge of how the NHS will operate
over the coming years, we risk missing an important opportunity
to review how best to provide services to a population undergoing
significant demographic shifts and changing oral health needs.
The ageing of the "heavy metal generation" will put
an increased demand on the need for complex restorative dentistry,
and we need assurances that the Board will consider these demands.
2.4 We ask that the Committee consider the need
for appropriate representation of the various healthcare professions
on the Commissioning Board to ensure that key areas of care are
not overlooked.
3. ASSURANCE
REGIME
3.1 In agreement with the Committee, we require
clarification on the proposed lines of accountability between
the NHS Commissioning Board, the Department of Health and the
Secretary of State, particularly in light of the proposed new
powers for public health of the Secretary of State. We have concerns
that the Secretary of State is delegating powers to the board
for issues that will become ever-more complex during the transition
period while accepting greater responsibility for public health
issues that may not yield results for several years. Our main
concern is there will be no ministerial accountability for short-term
transitional issues that beset the NHS. NHS clinicians and front-line
staff are the life-blood of the NHS and they deserve a full and
fair system of accountability from their political masters.
3.2 Because of this distinction between responsibility
and accountability, we are concerned that high quality and evidence-based
commissioning will not be underpinned by solid public health and
epidemiological data, knowledge and expertise. In seeking to strengthen
the role of public health, the government has instead separated
the core foundation of health and wellbeing from health service
provision and we must caution the government, through the Committee,
to think very carefully about creating a distinct divide.
3.3 With regard to future service design, we
question the management of data collection during the period of
transition when PCTs and SHAs are abolished in 2013 and the commissioning
consortia become operational. We have concerns because the consortia
boundaries will be different to the PCT boundaries and therefore
much existing health and demographic information will no longer
be relevant. Although dentistry will not be part of the GP consortia,
all boundary changes, for the purposes of data collection, will
have major implications for continuity of care based on robust
data collection, as it will not be possible to monitor any changes
over time.
4. INTEGRATION
OF FULL
RANGE OF
CLINICAL RXPERTISE
4.1 We wholeheartedly agree with the Committee,
"it is essential for clinical engagement in commissioning
to draw from as wide a pool of practitioners as is possible in
order to ensure that it delivers maximum benefits to patients".
Our 2009 local commissioning report[41]
advocated clinical engagement and during the transition period,
we restate our view that "clinical engagement has never been
more important". Sir David Nicholson[42]
stressed on 17 February 2011 in a letter to the NHS the value
of clinical expertise to support the NHS Commissioning Board when
he stated that the "Commissioning Board will have strong
clinical input across all of its functions".
4.2 NHS dental services have long had clear networks
providing clinical expertise on commissioning high quality services
despite the recent problems with the dental contract. These networks
involve consultants in dental public health, Local Dental Committees
(LDCs), dental practice advisers and individual practitioners
and there is a huge wealth of social capital within NHS dentistry.
We are seeking to ensure that the Commissioning Board has formal
mechanisms through which to benefit from appropriate expert professional
expertise through a dental advisory committee.
4.3 We would like to see managed clinical networks[43],
as in the example of oral surgery in Croydon[44],
being established and promoted to support effective commissioning
and for the Board through its local structures to make full use
of the long established network of LDCs.
5. PRIMARY CARE
COMMISSIONED SERVICES
5.1 The Board must bear in mind the other services
that it will commission that are outside the potential remit of
consortia and local primary care providers. It must not simply
focus on medical services. We have recently raised concerns about
the economic climate leading patients in England to cancel dental
appointments and defer treatments they need, according to our
research. The unfortunate knock-on effect of these decisions is
an increase in the number of patients presenting at surgeries
requiring emergency treatment. Our survey[45]
showed that 59% of dentists questioned had seen their patients
cancel appointments, while 68% reported decisions to defer treatment.
The Commissioning Board cannot afford to focus purely on the conflict
between primary medical care and consortia; they must also consider
the wider healthcare economy.
5.2 There is also a lack of clarity in how secondary
care dental services will be commissioned. It is recognised that
it would be inappropriate for GP commissioners to commission secondary
dental care. The Board will need to have understand the intimate
relationship between secondary dental provision and dental education
as the majority of secondary dental care is undertaken in dental
schools/hospitals
5.3 In commissioning specialist care such as
orthodontics and oral surgery, which currently takes place in
primary care, the Board will need specialist advice and knowledge
and understanding of local population needs. As previously stated,
this means there is a need to ensure the Board has knowledge of
local expertise.
5.4 The NHS Commissioning Board will need to
be very aware of the increasing burden of regulation on healthcare
professionals and in particular dentistry. There are a growing
number of oversight bodies regulating healthcare professionals
and the number of these bodies is ever increasing. We believe
that it would be disproportionate for dental services to be subject
to licensing by Monitor.
5.5 As stated in paragraph 1.3, access to the
salaried/community services via the NHS Commissioning Board is
essential to guaranteeing appropriate access to care for vulnerable
groups.
6. HEALTH AND
SOCIAL CARE
INTEGRATION
6.1 We draw the Committee's attention to the
needs of vulnerable groups when considering the issues described
in paragraph 107. Many vulnerable members of society will encounter
both health and social care services and we support the Committee
in its aim to promote the development of new arrangements for
fully integrated services whilst reviewing those already in place.
7. MAJOR SERVICE
RECONFIGURATION
7.1 Major service reconfiguration has affected
salaried or community dentistry in the last few years under the
transforming community services mandate. As a basic position,
we have stated our concerns about full adoption of social enterprise
options: namely, the likely lack of NHS terms and conditions for
new starters, the loss of NHS status, the potential fracturing
of the cohesiveness of care for vulnerable patients and the governance
structures of such institutions. Again, we have long advocated
clinical engagement in all discussions with PCTs about service
reconfiguration and we continue to urge open dialogue during the
transition.
8. PATIENT CHOICE
AND COMMISSIONING
CONFLICT
8.1 The Any Willing Provider model is the current
status quo in the mixed economy of dentistry. However, some PCTs
have already commissioned postcode-limited contracts for specialist
care. This restricts patient choice and distorts waiting lists
in a locality.
8.2 The adverse effect of this model comes from
the fact that small and single-handed practices, which have established
running costs that are currently acceptable to the NHS and provide
high quality service to patients, may be under-cut by corporates
who are able to provide a service for less. We want to ensure
that patients have continuity of access to high quality care but
we have concerns about the impact on dentists currently in practice.
Every effort should be made to balance the effects of producing
a "cost efficient" service with safeguarding the interests
of those who have dedicated years of loyal service to the NHS
and its patients.
8.3 This is likely to have a subsequent impact
on disadvantaged communities in low socio-economic areas, which
often suffer from low access and may not appear as commercially
attractive to the big corporate providers. We are concerned that
this will harm communities, and in some cases, may act as a barrier
to patient choice. This is especially pertinent given the government's
own stated aim of, "helping people live longer, healthier
and more fulfilling lives; and improving the health of the poorest,
fastest".[46]
8.4 Consequently, we would like to see a statement
on the NHS dental offer and would welcome a guarantee of adequate
provision for NHS services in all areas of the country. We have
some unpublished research[47]
on perceptions to NHS dentistry by socio-economic group C2DE.
These respondents told us that a combination of issues resulted
in a proportion of people who completely avoided visits to dental
surgeries, opting instead to "put up with" various conditions,
from missing or broken teeth to painful teeth and gums. Respondents
were either unaware of the existence of the NHS dental surgeries
in the area or believed that there were too few. We support the
commitment, in the 2011-2012 NHS Operating Framework, to improving
access to NHS dentistry for those who seek it.
9. LOCAL ACCOUNTABILITY
9.1 Alongside Consultants in Dental Public Health,
there are other important sources of local professional expertise;
Dental Practice Advisers, Local Dental Committees and, in some
areas, Oral Health Advisory Groups.
9.2 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 a joint strategic needs assessment.
9.3 We suggest that their ability to respond
to dental needs, to inform the joint health and wellbeing strategy,
the joint strategic needs assessment and the National Commissioning
Board, and to encourage integrated working across local healthcare
providers will be significantly enhanced by the statutory responsibility
to include representatives of relevant health professions in their
constitutions and to consult them.
9.4 The BDA believes that LDCs have much to offer
Health and Wellbeing Boards, joint strategic needs assessments
and health and wellbeing strategies, but they can only do so if
they are formally recognised and have the resources to function
effectively. The 2006 NHS dental contract regulations severely
affected the ability of LDCs to recruit members and to collect
the required levy. We therefore propose the strengthening of the
arrangements for LDCs.
10. DEBT RRADICATION
10.1 We remain very concerned about how PCTs
will ensure all debt is eradicated before the changeover to the
NHSCB and how this will be handled. Dental money is ring-fenced
although we know anecdotally that savings made in NHS dentistry
are being used to reduce deficits in other areas. Until the NHSCB
assumes responsibility, PCTs have a statutory duty to provide
NHS dental services to anyone who seeks it, and we urge that debt
eradication should not take priority over dental service provision
for local communities.
10.2 PCTs are currently re-commissioning millions
of pounds worth of specialist care provision in orthodontics in
the form of PDS contracts. These contracts will be for five years
or more, yet the organisations that will have commissioned these
services will not be in place for audit, accountably or responsibility.
The Committee needs to obtain clarity in how the handover of the
responsibilities will occur for orthodontic PDS contracts and
to ensure that specialist services are not decommissioned in favour
of eradicating PCT debt.
10.3 The Coalition government has a clear commitment
to reduce the incidence of dental decay in five-year-olds. This
commitment will be impossible to meet without investment, yet
given the anecdotal evidence above, we are concerned that PCTs
will look to reduce their deficits and will not invest heavily
enough in this commitment.
February 2011
41 BDA (2009) Local Commissioning Working Group report Back
42
Nicholson, Sir D. (2011) Equity and excellence: Liberating the
NHS - managing the transition. Gateway ref 15594.
Available:http://www.dh.gov.uk/en/Publicationsandstatistics/Lettersandcirculars/Dearcolleagueletters/DH_124440 Back
43
Skipper, M (2010) Managed Clinical Networks. British Dental
Journal 209(5), 241-2. Back
44
Kendall, N (2009) Improving access to oral surgery services in
primary care. Primary Dental Care, 16(4):137-42. Back
45
BDA (2010) Omnibus survey Back
46
Department of Health (2011) Healthy Lives, Healthy People: our
strategy for public health in England. CM7895 Back
47
Dental non-attendees qualitative research report (2010 - unpublished)
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