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Dentistry in the system: How bold ICBs can bring dentistry back from the brink

Dentistry in the system: How bold ICBs can bring dentistry back from the brink
By Kathy Oxtoby
26 February 2024

Nearly a year on from taking over dentistry commissioning, and with a new government plan to recover and reform dentistry, what are ICBs’ priorities in managing dentistry as part of the system? And what does dentistry think of their performance so far? Kathy Oxtoby takes a look

Dentistry is constantly in the news these days. Issues facing the sector regularly make headlines – from hundreds queuing to register for treatment on the NHS in Bristol, to the ‘hundreds of thousands of people’ who now flock to hospitals or GPs each year for treatment because they live in ‘dental deserts’.

These headlines are supported by surveys and statistics that reveal the scale of the dental crisis. A 2023 YouGov survey of 2,104 people across the UK revealed one in ten Britons have performed dentistry on themselves.

According to the survey, one in five Britons (22%) are currently not ‘registered’ with a dentist, and of those who were not, 37% said this was because they couldn’t find an NHS dentist, and 23% said it was because they could not afford to pay for treatment.

An analysis by the Nuffield Trust describes NHS dentistry in England as being ‘at its most perilous point in its 75-year history’ and ‘in terminal decline’. The report found that less than 40% of adults and 50% of children have seen a dentist within the ‘recommended timeframe’, mainly because practices were no longer accepting NHS patients.

Thea Stein, chief executive of the Nuffield Trust, told Healthcare Leader that ‘there are ‘a significant number of problems facing dentistry, because we’ve seen over a period of years a drift to the private sector, which has gone unchecked and unchallenged’.

‘We had six million fewer courses of NHS treatment last year, we have funding not being used, and we have a community that is taking to DIY dentistry, and children with extremely poor oral health. Potentially, it looks as though we have no way back,’ she says.

‘Clawback’ from practices is an ongoing issue. Eddie Crouch, chair of the British Dental Association (BDA), says this year’s clawback figure could be more than £600m, ‘and for a lot of dental practices struggling to remain viable this will probably be enough to force them to close’.

‘Losing NHS dentists to the private sector is a big problem’, says Mark Green, secretary of North Yorkshire local dental committee (LDC) and an NHS dentist based in Kirkbymoorside, North Yorkshire, who works for Riverdale Healthcare.  

But he says the ‘biggest challenge’ for dentistry is the NHS dental contract, which means NHS dentists earn much less than in the private sector. And inflation has also led to ‘a massive spike in the cost of running a practice’, he says.  

Plans for recovery and reform

The issues facing NHS dentistry have been the focus of a Health and Social Care Committee report and a recent government response to the report, followed this February by the announcement of the government’s recovery and reform plan for dentistry in England.

Under the plan – which NHS England says will be supported by ‘£200m of government funding’ – NHS dentists will be given a ‘new patient’ payment of between £15 and £50, depending on the treatment needed, to treat around 1m new patients who have not seen a dentist in two years or more.

To attract new NHS dentists and improve access to care in areas with the highest demand, around 240 dentists will be offered one-off payments of up to £20,000 – ‘golden hellos’ – for working in under-served areas, so called dental deserts, for up to three years.

To make NHS more attractive to dental teams, the minimum value of activity will increase from £23 to £28.

However, Mr Crouch says he is ‘disappointed’ that the £200m is being presented to the public as additional investment, when instead ‘it comes out of existing contract values’.

He says the new patient tariff, ‘whilst welcome, is going to help a very small amount’. ‘And many new patients coming into practices are presenting with much more extensive disease, so a few extra units of dental activity probably won’t make a significant difference to the security of dental practices,’ he says.

Ms Stein says the new patient premium is ‘time-limited, which risks bringing new patients into a broken NHS dentistry model where the funding and structures disincentivise their long-term treatment’.

Sarah Walter, director of the NHS Confederation’s ICS Network, welcomes ‘the recognition about the crisis that currently exists in dentistry in England, and that acknowledgement of historic underinvestment and decline in NHS dentists, and the impact this is having on patients’.

‘However, we feel the plan doesn’t go far enough.The national dental contract is a significant issue. We feel units of dental activity still aren’t sufficient to attract NHS dentists to do this NHS work, and a fundamental rethink is required for the dental contract,’ she says.

Fin Bason, practice owner and principal dentist at Carriage Works Lostwithiel Dental Surgery, Cornwall, supports the government’s recognition of ‘the need for prioritising dentistry’. However, he is concerned that ‘if we start incentivising private dentists to see NHS patients, without addressing the current contract issues that are preventing access, then it feels that NHS dentists are the ones being punished by the current system with clawbacks, low UDAs, and targets’.

For Mr Green, the changes are ‘too little, too late – and not enough to make a difference’. ‘And with ‘golden hellos’ – what about those dentists who’ve given their working lives to the NHS? There’s no ‘thank you’ for that,’ he says.

As to whether the government’s recovery plan will take pressure off integrated care boards (ICBs), which have been tasked with commissioning dentistry services, Mr Crouch says ‘it’s not even touching the sides of solving the problems, and it isn’t a long-term, ongoing investment’. 

ICBs: commissioning responsibility for NHS dentistry

It is almost a year since ICBs became responsible for commissioning pharmacy, optometry, and dentistry (POD). The move, on 1 April 2023, was part of a series of commissioning reforms set out in the Health and Social Care Act 2022. Under the act, NHS England still has overall accountability for these primary care functions. The aim of managing POD at a system level is to enable local decision making and a more joined-up approach to delivering services.

Since the shift, in certain areas, ICBs ‘have been quite innovative, working alongside local dental committees to develop ideas’, says Mr Crouch.

However, with some ICBs having overspent on their budgets, he says ‘a lot of plans they had for dentistry have been stopped, or are not going ahead this year’.

There’s been ‘a huge variation in the communication of ICBs at a local level with the dentistry profession’, he says. Some areas are ‘exceptionally good’ while with others ‘it’s been sporadic’.

He understands that with dentistry, many ICBs are ‘frustrated by the core contracts they’ve inherited – the flexibility they want isn’t there, because they are hampered by contracts that are unattractive to the workforce’.

‘ICBs are being asked to do an almost impossible job – improving access in areas where the tools they have, and the economic situation, don’t allow them to provide solutions to problems,’ says Mr Crouch.

Since taking on the commissioning responsibility for NHS dentistry, the NHS Confederation has heard from some of the initial early adopters that ‘ICBs lacked high quality data to really be able to monitor underspend and how budgets can be used in dentistry in the system’, says Ms Walter.

Since ICBs began running dentistry services, she says ‘we have to recognise the capacity they have had to really deliver transformation and build relationships, which has inevitably been hindered by the 20% reduction in running costs they are having to respond to this year’.

ICBs in Yorkshire and the Humber: expanding flexible commissioning

ICBs in Yorkshire and the Humber ‘inherited a challenging situation in NHS dentistry, with significant difficulties around access, workforce capacity, and morale in a sector that is struggling with insufficient national funding for dentistry’, says Andrew Hobson, deputy director for dental commissioning, Yorkshire and Humber, speaking on behalf of NHS Humber and North Yorkshire ICB, NHS South Yorkshire ICB, and NHS West Yorkshire ICB.  ‘Saying that, we believe it was the right decision to delegate dental commissioning to us.’  

‘In our first year as dental commissioners, we have focused on stabilising the system, building relationships, and maximising the use of the NHS dental budget across the three ICBs in Yorkshire and Humber,’ he says.

To do this, each ICB has taken a position on the likely value of total under delivery – compared to contracted levels – for this financial year (2023/24) and re-invested this in priority areas upfront. ‘This money is often referred to as ‘clawback’, and reinvesting in this way ensures we use the money assigned to dentistry for dental services,’ says Dr Hobson.

Across all three Yorkshire and Humber ICBs, funding has been used to secure additional urgent access sessions. This scheme provides around 90 practices with additional funding to make available weekly ‘sessions’ – approximately seven appointments – to treat patients with an urgent dental need.

Priority areas include expanding flexible commissioning, and local dental workforce plans are also being developed. ‘The plan will focus on surveying the dental workforce, introducing Centres for Dental Development, developing innovative training models, and international recruitment,’ says Mr Hobson.

Joe Hendron, chair of Wakefield LDC and chair of the Yorkshire and Humber Council of LDCs, says the ICBs in Yorkshire and the Humber have ‘engaged with the dental profession via the LDCs to try to utilise the funding allocated to dentistry as fully as possible’.

He says a more flexible commissioning approach ‘is welcomed by the dental profession in Yorkshire and Humber, which allows us to provide the care our patients need without being hampered by the bureaucracy and limited funding associated with the national contract’.

Mr Green says flexible commissioning means he is able to work on a sessional basis providing urgent dental care for high needs patients. ‘This approach helps people who are finding it difficult to access an NHS dentist, and allows the NHS dentist to receive a sensible payment.’  

NHS Cornwall and Isles of Scilly ICB: Pilot project supporting patients with greatest need

Chris Reid, chief medical officer for NHS Cornwall and Isles of Scilly ICB, says the NHS in Cornwall is ‘working hard to try and improve access for residents, engaging local dental clinicians, their representatives, and partners to offer practical support to enable dental practices to take on more NHS dentistry in the area’.

This includes a pilot project in Lostwithiel, working closely with the local dental surgery to focus the practice’s limited NHS capacity on people with the greatest need for those services. ‘This is enabling children and the most vulnerable patients to access an NHS dentist,’ says Mr Reid.

NHS services at the practice continue to be available to those whose care is a priority, including children under 18, and patients over 80, and those with medical conditions that might affect their dental health.

The practice also sees patients from the NHS waiting list and those who need urgent dental care, referred by other healthcare providers.

The changes affect around 4,500 patients at the practice, who have had the option to stay on a private basis or join an alternative dental practice.

‘Cornwall is a recognised dental desert,’ says Mr Bason. ‘We’re taking patients off long-term, centrally held waiting lists, and providing care for them.’  As well as emergency care, the practice provides these patients with a full course of treatment to return them back to dental health, as well as educating them about oral health. They can then join an NHS dentist’s list – hopefully, without a long list of needs – ‘that’s our goal,’ says Mr Bason.

The majority of the practice contract is now on a sessional basis, and ‘essentially we are on sessional pay’, he says.

Already, the pilot scheme has brought benefits – two NHS dentists have been recruited to the practice and to date, 1,300 patients have been taken off the central NHS waiting list, and around 32% of those patients have received a course of treatment.

The pilot will be reviewed on an ongoing basis throughout a minimum of two years to assess performance. ‘The pilot is a means of working with commissioners to gather data, test, and learn,’ says Mr Bason.

Other measures to increase dental access for patients across the South West include additional urgent dental care appointments that people can access by calling NHS 111.

If patients seeking urgent dental care are identified with multiple urgent dental issues that need addressing, a treatment plan is put in place with additional appointments made as part of unscheduled dental care, known as stabilisation.

And in Cornwall, the NHS is trialling a recently commissioned pilot helpline that incorporates dental clinical nurse triage, which is accessible via NHS 111.

NHS Suffolk and North East Essex ICB: Listening to dental professionals’ feedback

Peter Wightman, director lead for Dental, NHS Suffolk and North East Essex ICB (SNEE ICB), says the recruitment and retention of staff is ‘one of the largest issues in Suffolk and north east Essex and we are working with a wide range of colleagues and organisations to make NHS dentistry more attractive to dental professionals’.

The ICB has asked for expressions of interest from dentists wishing to be funded to deliver 110% of the dental activity they are contractually obligated to provide. It has offered to rebase a number of contracts, bringing the minimum UDA value up to the ICB average. 

It has asked providers for expressions of interest to be funded to open on evenings and weekends to see priority groups, including urgent and emergency care patients and high-risk patients, with appropriate remuneration offered.

The University of Suffolk Dental Community Interest Company (CIC) is training undergraduate students to enter the profession. ‘It is hoped that, in time, these students will enter the local workforce,’ says Mr Wightman. SNEE ICB has also commissioned the community interest company to provide additional appointments within Suffolk and north east Essex, including seeing more complex patients in normal surgery hours for higher remuneration.

The ICB has invested in public health initiatives with Suffolk County Council, which has recently awarded a contract for an assessment and treatment service with a mobile dental unit to operate within Suffolk later this year. ‘The new service will target vulnerable children and young people who have been unable to access dental care,’ says Mr Wightman.

He says that ‘flexibility and working collaboratively with partners is key to commissioning services’, and ‘listening to dental professionals’ feedback is also vital’.  

North East and North Cumbria ICB: Aims to protect retain and stabilise dental services

Since the pandemic, dental services have faced ‘massive challenges in meeting the increasing and more complex needs of our patients’, says Dr Neil O’Brien, medical director at NHS North East and North Cumbria ICB.

‘The ICB has plans in place which aim to “protect, retain and stabilise” local dental services, including access for patients with urgent dental care treatment needs,’ he says.

Already, the ICB has invested £3.8 million to support dentistry during the 2023/24 financial year, with a focus on improving access for patients with the greatest clinical need. This includes offering additional funding to dental practices, to create up to 27,000 extra appointments across the North East and North Cumbria, as well as increase capacity within dedicated urgent care treatment services.

The funding has also been used to increase the NHS 111 dental clinical triage workforce capacity to meet increased demand and better support patients with urgent dental care needs into the most appropriate dental service, says Dr O’Brien.

NHS Cheshire and Merseyside ICB: Collaborating with clinicians to share ideas and good practice

NHS providers are struggling to recruit dentists, says a spokesperson from NHS Cheshire and Merseyside ICB. ‘Anecdotally, approximately 80% of Cheshire and Merseyside providers are advertising for NHS performers.

‘We are also finding that areas of need – the more deprived – find it more difficult to recruit, so no targeting of projects can be undertaken as these practices have no capacity to be involved,’ the spokesperson says.

Robust urgent care provision, extended pathways following provision of urgent care – reducing the need for urgent care appointments – and access with a focus on vulnerable groups, are priorities, the spokesperson says.

The ICB offers patients on urgent care pathway appointments a full examination and completion of any treatment requirements. Providers are paid a sessional fee or have a deduction of UDAs. ‘Feedback from providers and performers delivering these sessions is excellent with some reporting “it’s made them enjoy dentistry again”,’ the spokesperson says.

The ICB has also been collaborating with clinicians and local stakeholders and has developed a multi stakeholder oral health steering group, to share ideas and examples of good practice, as well as ensure a population approach to delivery of oral health improvement programmes.

While the recent announcement of the national dental recovery plan is ‘welcomed’, ‘what is required is fundamental reform of the dental contract and funding model for NHS dentistry,’ the spokesperson says. 

Future for ICBs and NHS dentistry

Ms Walter says ICBs will be ‘looking at what the opportunities are in the context of the current dentistry contract, and what flexibility might exist under current arrangements, and are keen to transform pathways and look at how they can do things differently’. ‘However, as part of that transformation they need high quality data and the capability to analyse it,’ she says.

On Mr Crouch’s wish list for ICBs and dentistry is for ‘ring-fencing to really mean ring-fencing – and to not allow the dental budget to be swallowed up by overspends in other areas of the health service’.

For any ICB ‘balancing the books is a really challenging issue’, says Ms Stein, ‘but I would urge all ICBs to hold their nerve and understand the importance of investing in dental services.’

Mr Martin wants ICBs to ‘talk to their LDCs’. ‘They’re in the front line, and will tell you what works and what won’t work.’

What is also needed from ICBs is ‘a comprehensive, combined plan for dentistry’, says Mr Bason. ‘I would like ICBs to get together to learn from each other.’  

Mr Bason’s rescue plan for dentistry, includes, ‘recognising that primary care dental practices are a core part of dentistry’. ‘If they are functioning healthily, then all other aspects of dental care will also function. So, we need to invest in those practices, increasing the UDA value to £40, reducing UDA targets, and recognising that practices need more time to deliver quality care.’

He says that with all practices there should be ‘an element of flexible commissioning as part of their NHS contract’.

‘I believe the ICBs can make these changes. They’re the ones that can bring NHS dentistry back from the brink. But they need to be bolder. And the changes need to happen now,’ he says.

For ICB commissioners, and for dentistry as a whole, all roads to recovery seems to point to some form of contract reform. Ms Stein points out that while the government says it will consult on measures to improve the contract, it is ‘reluctant to pursue the kind of full-scale contract reform that many agree is needed’.

Mr Crouch wants to see contract reform, and says it is ‘extremely disappointing’ that the Health and Social Care Committee’s report on dentistry’s recommendation for a fundamental move away from the current contract and UDAs, has not been accepted by the government.

However, the move to ICBs commissioning services, and their innovative approaches to addressing the dental crisis, means there’s still cause for some optimism.

‘I believe that by working collectively with the local profession, ICBs will see some significant improvements – that’s been evidenced by those areas where this has happened already,’ says Mr Crouch. ‘ICBs should be encouraged by the small progress that has been made in some of those areas, and not think that they can’t do anything about the problems facing dentistry.’

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