Agenda item

To receive a report and presentation from NHS England in respect of access to routine and emergency dental care.

Consideration was given to a report and presentation presented by NHS England. Background regarding dental commissioning was provided and information covering the full pathway of access to dental care through primary and secondary pathways. Information was also included around recommissioning of dental services. The Key Stakeholder Bulletin was referenced as a place this information is made available widely.

The presentation clarified that patients do not register for a dental practice. This is unlike the process for attending a GP which requires registration with a particular GP. Patients will be seen at a specific dental practice over a course of treatment, but the pandemic introduced significant difficulty, which was described. Details around national closures of dentistry practices for 3 months were provided. These closures were required by national instructions. From July 2022, GPs have been operating at 100% of activity. Infection control and national guidance have been limiting factors for dental provision.

Descriptions of services commissioned in Rotherham were provided, and an explanation of how NHS appointments are commissioned as units of dental care was also given, noting that current reforms are changing how dentists are paid to perform units of dental care. The NHS England representatives described pathways for LAC and foster carers to receive dental care.

The impact of the end of the Outbreak Management Fund in March included the end of access to out of hours and weekends NHS appointments. The extended access had provided between 400 and 600 additional appointments in Rotherham. It was noted that the remainder of the investment could not be used. It was observed that many people needing dental care had complex needs, and some practices had dropped off the list of flexible providers. The Oral Health Needs Assessment for dental is an ongoing piece of work. Existing funding would continue.

It was noted that commissioners were able to work with dental providers to use the unique skills mix of the practice with preventative measures performed by oral hygienists. This flexible approach to commissioning was outcome focused. Currently there was an expression of interest to expand wider in Rotherham. 100 practices had come forward to be part of the flexible commissioning scheme, which involves specific performance criteria and training in oral health prevention in collaboration with Health Education England and NHS England. More practices in Rotherham were expected to be added. Meanwhile, NHS England was working with Integrated Care Boards (ICBs) to help inform commissioning decisions of local authorities going forward.

NHS England representatives described the anticipated impact of the Health Equity Audit which would determine the equity of access and would lead to new commissioning decisions. A further review of services would take place ahead of the end of the contract next September, with findings coming forward and recommendations expected in autumn 2022.

It was noted that Rotherham care homes are reasonably well looked after, with one dental practice serving 16 of 34 care homes in Rotherham. A few dentists also do ad hoc work as needed for care home residents. Care levels differ.

It was observed that benchmarking for South Yorkshire fares well. The 19 July outcome of 2022/23 contract negotiations had ushered in a first stage of change to the contract which had previously been in place since 2006. Initial reforms address challenges in delivering care to high needs patients and improving access.

In discussion, members noted the rates of extraction among children had decreased. The response from the Chair of the dental network noted that the drop in extractions was due to children not accessing dental services rather than an improvement in children’s oral health.

Members requested more information about prevention work in schools, children’s centres and as part of parents’ days. The response noted that oral health prevention would sit within the local authority. With the flexible commissioning, there is an element of prevention, and the money is allocated from the contract specifically to provide prevention schemes. Members expressed desire for NHS England to work more closely with the local authorities on prevention.

Members requested assurances that care home residents receive the right care despite not always being able to say if they have a problem. Members wanted to know about how practitioners know whether someone has a dental issue. Assurances were provided that a close relationship between the local authority and dentistry is maintained. It was the role of NHS England to commission. It was confirmed that people with dementia cannot explain when they are in pain. Often, people can experience more confusion because they are in pain. Practitioners can see if there is a problem when they are doing check-ups.

The Director of Public Health pointed out that 40% of adults and 30% of children were not getting NHS appointments currently. In view of this, assurances were requested that the commissioners knew where those people are, and that actions are being taken to improve access for these people. The response from commissioners indicated that dental practices accepted people who ring up; however, the waiting list may be 2000 people. There was a cohort of patients who have not seen the dentist in two to three years who have high treatment needs. The issue was that more work is needed now on patients who would have been seen every year or every few months.

Members highlighted the misconception that people have to register. Some dental practices seem to perpetuate the misconception by giving the impression that they are full. Assurances were requested around a plan of action to fix this, noting that the investment of £50 million was not spent which was very unfortunate. The response from commissioners noted that significant workforce challenges outweighed the monetary problems because the money could not be spent.

Members requested clarification of the investment in terms of the allocation for Rotherham. The unspent investment had been UK-wide, and could only be used for out of hours, weekend, or evening appointments. The combination of factors had contributed to the inability to spend including national shortage of nurses and dentists and high treatment needs. The adding of the extra hours had been a voluntary service.

Members requested more information as to reason for the lack of dentists and dental nurses. The response from commissioners identified causes including leaving the EU, when a number of Spanish, French, and Portuguese dentists and nurses were lost from the UK workforce. Furthermore, in some areas, insufficient numbers of dentists had been trained to sustain the needed workforce levels. High treatment needs were observed, but it had also been seen that people expect more. Whereas 30 years ago, people would go to the dentist only when they had a toothache, people now keep their natural teeth for longer which is associated with more care needs. Not enough resilience and not being able to spend the 50 million has shown that throwing money has not solved the problems or resolved challenges associated with units of dental activity. It was noted that during COVID-19, dentists were told what to do by government bodies, and they were pay protected.

Members requested clarification of whether dentists were paid during COVID-19 irrespective of provision levels. The response offered clarification that dentists were obligated to provide NHS work during the period. For example, whereas there routinely may have been 10 or 20 people in the waiting room ordinarily, during COVID-19, one patient waited outside. The masked patient was escorted into the building. The treatment was performed in full specialised Personal Protective Equipment (PPE,) and the surgery had to be left fallow for 30 minutes with specially installed air purification. This meant a 15-minute appointment would take half an hour. Less dental work took the full schedule of of hours.

It was observed that the 0-19 service recommends 5 contacts within first 5 years of life, and it was noted that cavities were already happening at that age for Rotherham children. It was noted that during health visits, opportunities may be missed that could be used to promote oral hygiene and dental health. Therefore, assurances were requested that a review would be undertaken to re-evaluate the service.

Further clarification was requested as to the shortfall of dentists in Rotherham and whether the outlook for recruitment is cause for concern. The response from commissioners noted that there was no upward trend to suggest recruitment rates would be picking up.

In response to requests from Members to receive the commissioners professional opinion of how the future looks for dentistry, the commissioners explained that in the current contract, dentists are limited by the NHS and are given so many numbers over which, if they take more patients, they will not be paid. In private dentistry, however, the dentist does only private work. A July request for an appointment related to a cavity will likely yield a September NHS appointment. If someone has a problem such as a toothache or uncontrollable bleeding, a patient can get an appointment, although travelling to the flexible commissioning location may be required. If the dentist is offering flexible commissioning, the person will be placed on the waiting list. The commissioners expressed sympathy and regret, noting that most dentists will try to see children and anyone in pain. It was acknowledged to be a real problem, which was expected to gradually ease as the COVID-19 crisis clears. It was down to the individual to decide whether to hold on for NHS treatment in their case.

Members averred the importance of early intervention with children, including very young children, and emphasised a joined-up prevention response. Members requested further assurances that the changes to the contract would address capacity issues. The response from commissioners noted that the new reforms would mean one pot of money for dentistry, and the reforms would help to facilitate dentists within the NHS. It was not known how much this would help access, as this was the first part of anticipated reforms. This part would adjust how dentists are remunerated and had been decided based on feedback from dentists. The reform was an attempt to make things fair for dentists, as currently they are paid the same amount for one filling or five fillings in terms of how much time they take. Recall systems will aim to adjust the expectations of needing to attend an appointment every six months where this is not required. There will still be a mix of staffing as part of flexible commissioning to find ways to increase access.

Members requested to know more information about any discussions of approaches to clearing backlogs, and whether special provision would be needed. Members expressed concerns that the reforms sound like tweaked contracts with existing dentists. The response from commissioners noted that the reforms would help high risk patients who need to be seen for longer because a practice will be able to take the time needed. The cessation of nonrecurrent money suggested the commissioners now needed to look at other areas to improve access, to examine and better understand waiting lists. Practices are currently focusing on urgent needs, and the reforms will enable them to focus on high needs patients.

Members requested further information around how people might be signposted to where there is NHS availability, given that most people do not know all the practices. The response noted that people seeking NHS availability can ring 111 to learn which practices are accepting new patients, but possibly new patients may spend time on a waiting list.

Members requested more information about how oral care had been provided in schools. It was noted that the Councils do check-ups in schools; there have been schemes in schools which have encountered a few problems with obtaining consent from parents. Schools generally do not want to get involved in oral care provision because of this need to obtain consent from parents or carers. Whilst difficult to get started, it could be looked at and is working in other areas. How oral hygiene education and treatments needs could be addressed in educational settings was an area that could be explored. Members recognised that dental care in schools is not without challenges, but it was observed that something must be done because there are real failures. The commissioners observed that there would need to be dentists available to go into schools, but there were not any readily available.

Members noted that whilst access to dental care was a national problem, Rotherham’s situation was slightly worse than the national picture. Members requested assurances that a plan was in development to address the expanding cohort aged 85+ for the future. Members requested more information around the movement of some providers leaving NHS and going totally private. Assurances were requested that the reforms are not putting off dentists and trainees and are addressing the real problem. The response from commissioners noted that the new reforms are the first stage. There is only one pot of money for dentistry. The aim of these reforms is to make it more attractive to dentists to take on the high needs patients.  Members noted that even if what is coming in the door is heart breaking, patients are sometimes being asked to go to practices far away that cost travel time and money to people in desperate need. Members emphasised the need to know where the areas of greatest deprivation are in making commissioning decisions.

Resolved:-

1.    That the report be noted and that an update be received in 12 months’ time, to include the outcomes of reviews for Homebound and Care Home residents as well as contract changes that affect provision of dental care to Rotherham Residents.

2.    That consideration be given to expanding links with area schools to help children develop good dental habits from a young age.

3.    That Early Help pathways prioritise dental health for inclusion in support offered to families with young children.

4.    That future updates around flexible commissioning arrangements show how these have taken into account the need for access in the most deprived areas of the Borough in order to tackle health inequality in dental provision.

5.    That a review be undertaken in respect of place-based strategic approaches to improve oral health among vulnerable Rotherham residents, including children and older people.