Agenda item

The Committee will receive an update on NHS Dentistry from the Coventry and Warwickshire Integrated Care Board (ICB). This will respond to reported concerns over local services and the transfer of dentistry from NHS England to the ICB.

At 12.55 pm the Committee voted that the meeting should continue beyond three hours in duration.

The Committee received a briefing from Ali Cartwright, Chief Integration Officer and Tim Sacks, Director of Primary Care of the Coventry and Warwickshire Integrated Care Board (C&W ICB).

The update provided national context and background, including the transfer of dentistry, amongst other services to the ICB with effect from 1 April 2023. The report outlined the ICB’s roles in relation to dentistry. The six West Midlands ICBs had agreed to maintain the specialist dental (and pharmacy & optometry) commissioning team as a single team, hosted by the NHS England Office of the West Midlands to maintain the specialist knowledge and function.

In February 2024 the government published ‘Faster, Simpler and Fairer: our plan to recover and reform NHS dentistry’. This contained initiatives to improve oral health and access to dental care. It included plans to incentivise dental teams to provide NHS dental care and take on new patients. There were plans to increase the dental workforce and make it easier for practices to recruit new staff.

An overview was provided of dental services, which comprised primary care, community services and secondary care. A section was included on the national dental contract, implemented in 2006 and reviewed at a national level each year. The ICB had no ability to alter this overarching dental contract. It could commission additional services to address health inequalities. Dental providers were paid via a ‘unit of dental activity’ rate which fell into bands with the rates and example services detailed in the update. There was a recognised need to reform the dental contract.

Information was provided on dental services in Coventry and Warwickshire, with data on general dental services, orthodontic services and other services. A map showed the location of services across Coventry and Warwickshire.

The update included information on performance of providers. Services in C&W continued to perform well when benchmarked against other ICBs nationally. Key indicators of performance included the number of new patients registered with an NHS dentist and units of dental activity, compared to the data prior to the Covid pandemic. Coventry and Warwickshire was one of only two systems in England which had returned to pre-2019 levels for both new patient registrations and activity. Graphs were included to illustrate this.

Next, the update focussed on the dental services equity audit needs assessment. There were health inequalities across the ICB footprint. A report by the regional dental public health team had highlighted a number of these gaps, which would form the basis of a future local dental strategy. Data was provided in tables, highlighting:

• The prevalence of tooth decay in 5-year-olds in Warwickshire over the period 2008-2022, as compared to the West Midlands region and nationally. Whilst good overall, there were some areas with significantly higher tooth decay rates.
• The wards with comparatively poorest dental access across Warwickshire. Some areas of Stratford-upon-Avon were referenced.
• Rates of oral cancer and mortality in Warwickshire, compared to other West Midlands areas and nationally.

The report concluded with the challenges and opportunities identified for dental services in Coventry and Warwickshire. Member questions and comments were invited, with responses provided as indicated:

• The data and mapping showed the availability of NHS dentistry services, with a concentration in Coventry and gaps in parts of Warwickshire. There was a significant difference in the fees dentists received for providing NHS services to working privately. It would be a challenge to incentivise and increase the NHS services. Ali Cartwright agreed that this was supply and demand driven. The ICB could try to procure more NHS dentist services. Patients could access dental services in different areas or ways. An example was a dental bus travelling around the County. There was a need to focus on areas for improvement like child tooth decay. Tim Sacks added that people could attend any dentist, whilst recognising the access challenges for some, especially those in rural areas who were reliant on public transport. NHS dentists were available in Coventry, and to a lesser extent, the south of Warwickshire, but this was not publicised well, and availability changed frequently. 
• Dr Shade Agboola explained the close working with dental public health consultants and the various Public Health preventative initiatives. Effective tooth brushing prevented the need for dentistry in the longer term. She sought further information from NHS colleagues about support in areas without NHS services, known as ‘dental deserts’ and links to poor dental health. Tim Sacks advised this information wasn’t readily available. He did mention the good NHS dental provision in Nuneaton and Bedworth, but some areas had really poor access, so there was an education element.
• It was confirmed that each dentist could provide a specified number of units of dental activity. This was both historical and linked to the budget available. The funding covered 35% of the population, the same as for all parts of the country. There were options to flex the ‘cap’ slightly or to move the NHS services to the areas of greatest need. Councillor Holland considered it was unfair to blame dentists working privately if they were limited on the number of NHS treatments they could provide.
• Ali Cartwright said the ICB needed to focus its budget on areas where there was poor dental care for people of all ages, to improve their outcomes.
• Councillor Holland replied that it had been suggested dentists were taking more lucrative private patients, but this was actually due to the system limiting NHS dental treatments. Tim Sacks clarified that many dentists did not wish to provide NHS dentistry and had that choice. There were many more dentists than the 99 delivering NHS services in C&W. Also, there was a finite budget of £35m for dental services. Increasing the amount of NHS dental services would require a corresponding saving from other health services. Councillor Holland considered that the shortage of NHS dentists was not due to them wanting higher paid work, it was due to the cap on the number of NHS appointments. The Chair heard this not as a cap on appointments, it was the number of treatments within the time dentists were paid for. Ali Cartwright clarified in some areas there was a dearth of dentists who would do any NHS work. In other areas there were a range of dentists and caps were applied, so it varied by area.
• Councillor Holland referred to a ‘postcode lottery’ asking if there were reasonable public transport links to the areas where NHS dental appointments could be found. Tim Sacks replied that the NHS had no influence on public transport services. Related points were the rural locations involved, and reliance on having a car. Councillor Holland said two out of every three people in the County did not have the use of a car and there was no point in having NHS appointments in places which people could not get access to. He considered the service to be inadequate, which the Chair thought was a little harsh.
• Councillor Shenton commented that the budget limited activity. To increase services would require a repurposing of budgets for other NHS services. He could not see how dentists would be incentivised to undertake more NHS services. He noted that oral cancer rates had increased and asked if this may be linked to the budget restrictions. He commended the ICB for its endeavours in what was a considerable task but could not see how this would be achieved without a significant increase in funding. Ali Cartwright replied that this was not just about increasing the budget. Some dentists would not want to do NHS work for financial reasons and personal choice. The incentives proposed were funded separately. She touched on the national reforms, including review of the dental contract.  Warwickshire was the second best nationally in provision of dentistry, whilst recognising there was still much work to do. Tim Sacks spoke of the challenging position and the work with colleagues on new patient premiums. Within the budget available, there was a prioritised approach to focus on the areas of greatest need. An offer was made to revisit the committee to update on the plans as they developed, which the Chair welcomed. She touched on deprivation, the absence of services in the areas she represented and was concerned how the targeting would take place.
• In response to a question from Councillor Humphreys about ensuring children brushed their teeth properly, Shade Agboola spoke about the Public Health ‘brushing for life’ programme. This was targeted to the areas with the highest rates of decayed and missing teeth. Additionally, via range of professionals, toothbrushes and toothpaste were distributed, again in a targeted way. 
• Councillor Rolfe said her dentist did not undertake NHS services due to the differential in costs. There were no available NHS dental services in Stratford. This area was considered affluent but did have areas of deprivation and some people could not afford dental care due to the lack of NHS services. Similarly, they could not afford to travel to the north of the county or Coventry. This would result in the deterioration of their teeth. The focus on areas of greatest deprivation would not include Stratford, exacerbating this. The NHS officers advised that patient outcomes were also considered. The targeting of services was more focussed than just areas of greatest deprivation and included areas with health inequalities too. This would include where people could not access services. Councillor Rolfe stated this was not just about children.
• Councillor Sinclair sought clarification about the NHS dental services in Stratford. He asked for the total number of dentists serving the county, in addition to the 99 NHS dentists. Patients needed better information on NHS dentists with availability and he asked if a simple website could be created with this information. Tim Sacks confirmed there were NHS dentists in Stratford, but the point was their capacity to meet demand. There was an NHS choices website showing NHS dentists, but no system currently showed where there was capacity for new patients. This suggestion for such information would be taken on board. The total number of dentists serving the county would be researched and a response provided.
• Chris Bain of HWW referred to the statement that dentist provision in Warwickshire was the second highest nationally. This was true for adults, but was not for children, being 59% and twelfth highest in England. HWW repeatedly called dentists across Warwickshire to check if they had NHS provision and it published the findings fairly regularly. The position in Stratford remained difficult, there being no dentists currently taking on NHS patients. In Rugby this had been the case for some time, with patients having to travel to Coventry. In Rugby there was a problem for primary care generally, for dentistry, pharmacy (especially community pharmacy) and GP access. This needed to be addressed on a system basis, rather than looking at individual services. He referred to the HWW ‘State of Care’ event held in Rugby in November 2023 which demonstrated this and could see no changes having been made since. He did not consider the people of Rugby were being served as well as they could be, and this area had the fastest growing population in Warwickshire.
• Councillor Humphreys asked if data could be obtained via schools on the numbers of children attending dentists, to give localised information. Shade Agboola replied that headteachers could be approached to see if they were willing to provide this information. There was a need to be clear on what the information would be used for, perhaps to send information to parents, encouraging registration with a dentist. It was critical as regular check-ups and treatment would help to prevent tooth decay. She offered to pursue this with education colleagues.

The Committee noted the briefing and presentation.