NHS dentistry is never far from the headlines with reports of patients resorting to DIY treatments as they can’t see a dentist. Integrated Care Boards took over dentistry commissioning in April 2023. Kathy Oxtoby talks to Eddie Crouch, chair of the British Dental Association principal executive committee, about how the system is responding to the current challenges
Kathy Oxtoby (KO): It’s been nearly a year since ICBs took on commissioning of dentistry. How have ICBs been doing?
Eddie Crouch (EC): In certain areas, they’ve been quite innovative. They’ve been working alongside local dental committees and dental professionals to actually develop some ideas.
The current contract pays on what we call units of dental activity (UDAs) which is the major flaw in the contract because the unit doesn’t totally remunerate for patients who require an awful lot of treatment. Where ICBs have commissioned a morning or an afternoon for the practice to deliver urgent and emergency care – and were prepared to pay a standard fee for that session – practices have found it far easier to recruit dentists.
In those areas, patients phoning 111 are directed to dentists who can deal with their urgent and emergency care. So that’s been one of the success stories.
KO: Are there any other examples of ICBs taking different approaches?
EC: In Manchester, the ICB negotiated a scheme with a federation of local dental communities where they would offset some of the contracts for those practices to take on new patients. Tens of thousands of new patients in the Manchester area have been taken on through that scheme whereas the BBC report that, in other parts of the country, only one in 10 practices are taking on new patients.
There was quite an innovative piece of work done in Cornwall, where they’ve moved a significant amount of the contract outside the UDA to focus on certain patients. It got quite a lot of bad publicity in the local area because it meant that the healthy well was no longer able to go to that practice under the NHS. While it’s not perfect, it has focused the amount of NHS dental spend to those least able to afford private care.
I do worry that ICBs are now the potential whipping boys for government failure in policy. In the recent debate in Parliament, it did appear that there were lots of people on the Conservative benches laying the blame at the door of the ICBs for the current issues facing patients. That’s pretty unfair.
KO: Do you think ICBs are being scapegoated?
EC: That’s exactly what I thought in recent Parliamentary debates. The Prime Minister talks about £3 billion being invested in NHS dentistry as though that’s something to be proud of, but that’s the same figure it was a decade ago.
Then, even more recently, dentistry hit the front pages because hundreds of people were queuing outside a new dental practice in the Bristol area. Was it a coincidence that the recovery plan was announced in a week where dentistry was causing embarrassment to the Government?
KO: What does the BDA think about it the government’s recovery and reform plan for dentistry?
EC: It’s not an ongoing recurrent plan. It comes into force from the last month of the financial year for only the next financial year. So that’s 13 months’ worth of a plan.
We’re disappointed that it’s being presented to the public as additional investment when it’s not – the £200 million that was quoted is coming out of existing contract values. So, there isn’t an increase in the dental budget; it’s utilisation of existing funds.
They’re talking about an additional 2.5 million appointments for patients, but we haven’t seen the working to see how they’ve calculated that.
And the new patient tariffs, whilst welcome, are going to help a very small amount. Many new patients are presenting with much more extensive disease and a few extra UDAs won’t make a significant difference to the security of dental practices.
The golden hellos to attract dentists into some areas have been tried already by a significant number of ICBs who’ve found that the dentists taking them up are actually moving from adjoining areas. So, it’s a redistribution of the workforce, not an increase in the number of dentists delivering NHS care.
And rural areas being served by dental delivery through vans is something charities have been doing for a while. While it will add to the capacity to provide urgent and emergency care, it’s not a long-term solution.
My take home message is that we’re still going to have significant problems going forward.
KO: Are there any positives in it?
EC: The BDA are encouraged by an expansion of fluoridation. And the utilisation of dental teams going into establishments so young children can receive preventative care, either through supervised tooth brushing or applications of fluoride varnish, is something to be welcomed.
KO: How do the financial challenges faced by ICBs affect dentistry?
EC: At the outset of the year, ICBs were informed that they ought to ring fence the dental budget. So, if dentists in a particular area weren’t delivering NHS dentistry at the levels that they want, the ICB could use some of the underspend to recommission services in that area. This was welcomed by the profession – the money wouldn’t be lost to other areas of the health service as it has been done previously.
But in November, NHS England wrote to ICBs and said that the government would not be bailing out overspends and if they had any unspent or unallocated money, they would be expected to use that to prop up the overspends elsewhere. It’s meant that a lot of plans for dentistry have been stopped – if they hadn’t committed the money to the projects, those projects are not going ahead – which is hugely upsetting.
One of the things suggested at the beginning of the year was that ICBs could fund more activities than the dentists had in a contract. They could fund an additional 10% activity and many colleagues believed that was an offer that they were working to.
But now the ICBs have reversed that decision. At least 12 ICBs have written to dentists about this. In some cases, they are doing no dentistry at all for one or two months before the end of the financial year because they’ve run out of funding.
KO: Last summer, the Health and Social Care Select Committee published its report into NHS dentistry. What did you think of the Government’s response?
EC: A major recommendation of the report was a fundamental move away from the current contract in UDAs and that has not been accepted by the Government. From the profession’s point of view, that’s extremely disappointing.
The Health Select Committee also said they want dialogue with the profession over the government’s proposal to tie new graduates from dental school into the NHS for a period of time. The government says it costs a significant amount of money to train dentists so it’s only right that they stay in the NHS for some time after they qualify. My argument would be that if you make the system attractive, you won’t have to handcuff anyone to it. But if there was some write-off of student debt for new graduates who committed to the NHS for a period of time after qualifying, that might be quite attractive to a lot of people.
One of the things that we were happy to see in there was the fact that they wanted ICBs to do needs assessments in their area. As a profession, we’d like to work alongside ICBs to make that as robust as possible.
KO: What would you say are the current and ongoing issues for dentistry and ICBs?
EC: The NHS Confederation report that many ICBs are frustrated by the core contracts that they have inherited. The flexibility that they want isn’t there and they’re hampered by contracts that are unattractive to the workforce.
And they’re also frustrated with NHS England because of its flexible commissioning guide for ICBs which came out late summer. They were warning them of the risks of stepping outside the current NHS contract and I think many ICBs believe was a slap across the wrists for being too adventurous.
KO: What can ICBs do to improve the situation with dentistry?
EC: I would ask ICBs to step up their contact with the profession at a local level in 2024.
There’s been a huge variation in ICB communication at a local level with the profession. In some areas it’s been exceptionally good and, in others, it’s been sporadic.
I know the health select committee said in their report that there should be dentists on ICB boards, but I don’t think we’re going to get to that stage because most ICBs want to keep their board fairly small. If nurses, pharmacists, and opticians have to have equivalent positions, you’re going to end up with large boards that aren’t as effective. But that makes it more important that they have a dialogue with their local professionals.
KO: What potential is there for dentistry in the system? What role might it play?
EC: We could work at a local level with needs assessments, spotting areas where we really need to focus urgent care on.
There are huge opportunities for the future. It would be great to properly integrate dentistry into the rest of primary care and the health service in general. We could take some of the pressure off GPs. Simple things like, for example, when a patient is in the waiting room for their dental appointment, a member of the dental team could check for atrial fibrillation or early diabetes. That’s integrated care at its best.
But the problem at the moment is ICBs and local dental committees are fighting the fire of a lack of access to routine dentistry. So, these nice add-ons are a long way down the track because we need to solve the problems we’ve got in front of us.
KO: What are the consequences if nothing changes?
EC: The footprint of delivery for ICBs may significantly worsen going into the next financial year without any change of attitude to how some practices are stabilised.
Last year, NHS England moved the goalposts for clawback money. Normally, if dentists don’t deliver 96% of activity, they pay back whatever the percentage of the contract hasn’t been delivered, and that’s called clawback money. But last year, they moved the goalposts down by 6% to 90%. But it wasn’t a write off – it was an IOU.
So dental practices will have to deliver more activity this year to avoid paying clawback. For a lot of dental practices who are struggling to remain viable, that will probably be enough to force them to close.
A company that provides private conversions for NHS dental practices told me that they did as much business in January this year as they did in the whole of 2019. So, in one month they were seeing as many practices leave the NHS as they saw in the whole of 2019. That’s quite shocking.
KO: Anything that would be on your wish list for ICBs and dentistry?
EC: To make ring fencing really mean ring fencing and not allow the dental budget to be swallowed up by overspends in other areas. The population needs the money that’s allocated to dentistry to be spent on dentistry.
And to focus on working together. When people look at the problems facing dentistry, they look at it as unsolvable. But by working collectively with the local profession, ICBs will definitely see some significant improvements. That’s been evidenced in areas where that has happened already, even in the early days of ICBs. So, I think they should be encouraged by that.
This interview took place on February 12.
