Terry Chikurunhe, Senior Commissioning Manager
for NHS England and Improvement (NHSE&I)
provided a verbal update to the committee covering the following
areas:
- The change in
commissioning arrangements, moving from NHSE&I to the new
Integrated Care System (ICS).
- Key messages to
address public confusion of dental services and the difference in
patient lists when compared to GP doctors. Contractually, dentists
provided treatment and then retained responsibility for that
patient for two years afterwards, unless the patient had periodic
‘check ups’.
- The challenges for
dentists throughout the Covid pandemic, the loss of services other
than some urgent dental care.
- Dentists continued to
receive NHS funding throughout this period, providing they
maintained services at a level set nationally. NHSE&I had a
contractual monitoring role.
- Oral health promotion
and work with the new ICS for Coventry and
Warwickshire.
- There were 65 dental
practices within Warwickshire and five specialist orthodontic
practices for children. South Warwickshire Foundation Trust
provided secondary care for patients in the County, with George
Eliot Hospital providing community dental services. Specialist and
complex procedures were undertaken at the Birmingham dental
hospital and children’s hospital.
- Dental services in
Warwickshire performed well when compared to other areas of the
Midlands region. However, there were some areas of the County with
significant challenges for dental access, with Nuneaton and Rugby
referenced. There were challenges in attracting dentists and nurses
to work in rural areas. Reference to the work to promote NHS
dentist services to practitioners. There were workforce challenges
and some dentists chose to treat patients privately, even if the
same premises were used for NHS services.
- The planned strategic
review of dental services. This would be based on population growth
and tackling inequalities in current services.
- Prior to the
pandemic, 50 percent of the population accessed NHS dental
services, with the other half either using private services or not
having access to a dentist.
- The pandemic impacted
significantly on access to dentists, mainly due to infection
control. Data was provided for Warwickshire. In December 2021,
dental access was just below 44% of pre-pandemic service levels.
Now the lower threshold for services was 62% of normal service
levels, with one in 10 dental practices not achieving this level
currently.
- Oral health
improvement. Targeted work was taking place in Nuneaton, Bedworth
and Rugby to address high incidences of children with tooth decay.
A joint approach was taking place to encourage children through
programmes like ‘brushing for life’ where education and
toothbrush/paste were supplied. Reference also to training for care
home staff so they could look after their residents. A move to more
integrated services.
- Fluoridation of water
supplies. This was not preferred by all but was beneficial in
preventing tooth decay.
A lengthy debate followed with the following
contributions and themes:
- The Chair requested that a written
summary of the data be provided.
- Further discussion about dental
registration and the contractual obligations. After two years of
initial treatment, a dentist was not contractually obliged to keep
the patient registered. This was not widely known. People were
classed as a dormant patient, unless they attended for a regular
check-up. It was confirmed that people would not be removed from
registration where they had become dormant through not being able
to attend their dentist ,due to the pandemic. Reference also to the
NICE guidance, work on the dental contract and through patient
groups to ensure that patients were not deregistered
unnecessarily.
- A concern about rising living costs
and people not attending dentists because of the costs. Whilst
NHSE&I was not aware of this issue, some people had not visited
their dentist for two years due to the pandemic. Dentists were
reporting an increase in the number of more complex cases. From a
financial perspective this was causing some dentists to cease
providing NHS services.
- Due to the pandemic, the equivalent
of a year of dental activity had been lost. Addressing this backlog
would take considerable effort and time. There were recruitment
issues and staff fatigue too. Programmes were being run to increase
capacity.
- The follow up report would include
the fee structure for NHS dental services. Some people were exempt
from paying NHS fees, including for dental services, subject to
meeting specific criteria.
- Alarm that only 50% of
Warwickshire’s population were using NHS dentists, which
implied that the rest were forced to use more expensive private
services. This was challenged and patients should not be forced to
use private services. If NHSE&I became aware of such activity,
contractual sanctions were taken. Some people chose to access
private services, but it should be a choice. It was requested that
a further report be provided to give a breakdown of data for the
50% of people that were not accessing NHS dentist services.
- A view was sought on the financial
viability of dentists in Warwickshire, with reference to the
feedback received from some dentists.
This was a national issue and was based on the national contract
and financing in place since 2006. NHS dentists had continued to
receive full funding throughout the pandemic despite the reduction
in operational activity. The subsequent report to members would
include details of the incremental increases in operational targets
for them to continue to receive this funding. It was
NHSE&I’s view that dentists had been supported through
the pandemic. It could be argued that there was a need to revisit
the financing due to work and additional costs for infection
control. This was an ongoing discussion and had significant
financial implications.
- Chris Bain of HWW reported that
dentistry was the NHS service which caused patients most confusion.
The dental contract was described as impenetrable. Feedback from
patients evidenced a reluctance to use NHS services during the
pandemic, to reduce pressure on services, but this had actually
resulted in lost appointments. HWW undertook a survey of dentistry,
and the findings were published on its website. It showed a
‘postcode lottery’ in terms of NHS dentist services,
with a lack of access to NHS services in both Rugby and Stratford
at the time. The survey was being repeated this year and its
findings would be reported to the committee. Private appointments
were available at the time in both Rugby and Stratford, which
evidenced the exploitation of confusion by some dentists. Referrals
to the NHS 111 service did not result in satisfactory responses
especially for urgent dental matters. These findings were also
available via the Healthwatch website. Enquiries to HWW continued
to include many related to dental services. The plans to increase
services to address the backlog were not realistic and posed a risk
of dentists leaving the service. The points about workforce
challenges were known. The reports and assurances from NHSE&I
differed from the lived experiences reported to HWW. Chris Bain
offered to have further discussions with Mr Chikurunhe after the meeting. There was a need to tackle
both inequalities and the postcode lottery. Some people in Rugby
had not had dental appointments for over two years and there were
concerns especially for children.
- Mr Chikurunhe
welcomed the opportunity to work with HWW. He acknowledged the
access problems in Rugby and spoke of plans for more investment in
dental services for this area. It was known that newly qualified
dentists wanted to work privately, rather than provide NHS
services. NHSE&I was aware that some practices offered both NHS
and private services, offering faster appointment times and
treatment privately. Further points about the differing fee
structures and dentists wanting to work on a part time basis.
- A comparison to NHS doctors who
could also work privately but had obligations to see NHS patients.
There were different contractual requirements and funding
mechanisms for GPs and dentists, with dentists required to fund
their own premises for example. The degree of influence for
NHSE&I was much less for dentists than it was for GPs.
NHSE&I provided a contract payment to dentists who then
configured their services. Chris Bain responded that the funding
did include an aspect for facilities.
- A request that HWW provide feedback
to the committee following its discussion with NHSE&I. It was
suggested that the committee could revisit this topic at a future
meeting.
- Some specialist services were only
available on a private basis and at significant cost. It was
questioned why such treatment could not be provided as an NHS
service. Mr Chikurunhe responded that especially
where a patient was in pain, they should not be required to pay for
treatment privately. Cosmetic procedures were not available via the
NHS. An offer to look into a specific case reported. He also
outlined the secondary care services available for more specialist
procedures. Some people may elect to pay for private
treatment, if there were waiting times for treatment
on the NHS.
- Members welcomed the plans for
training of care home staff speaking about the importance of oral
hygiene. This project was being led by dental Public Health
colleagues and data would be provided as part of the report back.
Reference also to the domiciliary visits which took place for
people unable to visit a dental practice.
- A question about the proportion of
private dental services and when this became a concern. There was
no easy way of measuring this, and it was more about responding to
complaints from patients directed to private services, instead of
being offered treatment on the NHS. Such dentists were reminded of
their contractual obligations. Some patients may choose to pay for
private dentistry, but they should not be forced to use private
services due to a lack of NHS service. NHSE&I had no right to
information held by dentists about their private work.
- Councillor Cooke gave an outline of
previous roles as a councillor serving on the health authority and
spoke about the charging structures introduced for both dentist and
optician services. Issues with NHS dental services had existed for
some time and examples were provided to demonstrate this, as well
as personal experience of a practice moving to provide only private
services paid for via a monthly dental plan. He spoke about the comparative costs for NHS
treatment and was concerned at the lack of NHS dental services for
children. He considered that the NHS dental contract required
updating.
- A question about dentists choosing
to provide only private services and the impact for dormant
patients who had not visited the dentist for two years. It was
confirmed that such dentists were required to give a minimum of
three months’ notice and to complete the treatment of current
NHS patients. The councillor considered this a contributor to the
50% of people unable to access an NHS dentist as many preferred to
stay with the same dentist.
- The Portfolio Holder Councillor Bell
commented on obligations of dentists whose training was paid at
least in part by the public purse. There should be an obligation to
treat children on the NHS, free of charge. An update was sought
about the infection control requirements, also referring to the
impact of the pandemic in limiting the number of patients who could
have appointments. Addressing the service backlog would not be
achieved if there were the same requirements for infection
prevention measures. She also asked about the transfer to the ICS
and what controls it would have, such as to revisit the dental
contract.
- Mr Chikurunhe
considered the comment about training to be fair and this
was an area for Health Education England, which was responsible for
dental training. Like other students, most newly qualified dentists
had a significant debt to repay. On infection control, he confirmed
the additional risks for this service and the measures that were
imposed to protect patients and staff. A detailed response would be
provided on the rules now in place as this changed frequently. The
transfer of dentistry and other services from NHSE&I to the ICS
would include additional funding for the ICS. It was a question of
how to reconfigure services at both the place and ICS level.
However, the current issues would transfer to the ICS. He also
spoke about an unsuccessful pilot scheme to align dental contracts
to be more like those for GPs. This had actually impeded access to
NHS dentists.
- Nigel Minns added that the current
problems would transfer to the ICS and would need addressing. There
was considerable interest in dental services locally and it would
be a clear focus for the new system to address as best as it could
within the national framework.
- It was questioned if dentists were
required to offer a minimum proportion of NHS appointments. Mr
Chikurunhe confirmed that dentists received a
payment based on contractual terms, for the provision of NHS
services. He outlined the services and the additional challenges
due to the pandemic, making it difficult for new patients to
receive NHS dental care.
In closing the item, the Chair made a number
of points. The dental contract was not helping residents or
dentists, who were given a binary either/or choice. The contract
dated back to 2006 but there had been significant changes since
that time, so it required update. She referred to the contractual
requirement to deliver 65% of usual service levels during the
pandemic. To address the known backlog, dentists would be required
to work above normal service levels. If they chose to cease
providing NHS services, it was questioned if the monies provided
during the pandemic could be clawed back. She asked if there was a
view about the contract review and ministers could be lobbied about
this. Reference had been made to a strategic review for
Warwickshire and the Chair asked for the timeline for this review.
Reference also to the dental education provided previously in
school settings. It was questioned if this service was still in
place, as a reliance purely on parents may have an impact for some
children. The Chair asked about emergency NHS dental treatment
requesting that a pathway be provided to show how patients may
access the services. These points would
be communicated to Mr Chikurunhe after the meeting
for the follow up briefing note. He was thanked for his attendance
and responding to the Committee’s questions.
Resolved
That the Committee notes the update from
NHS England and Improvement on dental services and
that a further briefing note is sought on the follow up areas
outlined above.