From April 1, integrated care boards (ICBs) will assume responsibility for dental care along with general ophthalmic and pharmaceutical services. Chair of the British Dental Association, Eddie Crouch, outlines current concerns on World Oral Health Day and on the eve of the Health and Social Care Committee hearing on NHS Dentistry
There couldn’t be a more difficult time to inherit a service which many describe as in crisis. The BBC conducted an extensive survey of dental practices last year, finding only one in 10 practices were taking on new adult patients and it was only slightly better at two in 10 for children.
The pandemic affected dentistry so badly that 50 million appointments have been lost since lockdown, and a service that was in trouble before has now entered freefall. Dentistry has never had such a high political profile, with MPs from all sides of the House taking part in debate after debate. Pledges have come from both former Prime Minister Liz Truss and current Prime Minister Rishi Sunak. It was part of former health secretary Thérèse Coffey’s ‘ABCD strategy’ where the ‘D’ referred to doctors and dentists and the issues have featured twice in one session of Prime Minister’s Questions.
But the historic budget for NHS Dentistry was only ever enough to commission services for just over half the population. And in the last decade, patients have paid more with above inflationary rises in patient charges while the Treasury has paid less, with dentistry being the only area of the health service to see a drop in government contributions – in cash terms – in the decade leading up to the pandemic.
The Government announced £50 million of funding for additional activity and extra appointments in January 2022. The British Dental Association (BDA) told the Minister this would not be utilised due to practices chasing an unrealistic target increase on the core contracts. It was further compounded by staff absences and patient cancellations as it coincided with the Omicron variant of Covid, making it impossible for the money to be used. In the end only 30% was used and the vast bulk of the funding returned to Treasury at year end as underspend. It was the wrong initiative at the wrong time.
We are on our fifth Minister responsible for dentistry since the start of the pandemic in 2020. Each one starts with the mantra that there is no more money to invest. Spending per capita pre pandemic in England stood at £37 compared to £49 in Wales, £56 in Northern Ireland and £59 in Scotland.
The integrated care boards (ICBs) will potentially inherit the largest ‘clawback’ ever experienced. The failed contract that dentists work to, penalises those unable to hit their targets – very often because they are unable to fill vacancies. The contract’s units of dental activity (UDAs) are the epitome of NHS widget counting, baring little to no relation to time spent delivering care, or the health improvements secured.
Those who don’t make the grade on targets hand back funds to NHS England, where it isn’t ringfenced, and instead plugs holes in other budgets. This year – during an access crisis – the clawback is on track to be as high as £400 million, as dentists struggle to hit unachievable targets and many more reduce their commitment.
The UDA was recently described by Jeremy Hunt, when chair of the Health and Social Care Committee (HSCC), as not fit for purpose, indeed he repeated what the HSCC of 2008 had also concluded. The system of UDAs often does not reward the expense and time of delivering the more complicated treatment needs that have become more prevalent post pandemic.
Of course, this clawback does not reflect any lack of demand for dentistry. And there is concern among the profession that these funds will be used to prop up overspend in the integrated care system (ICS) budgets, rather than being used to flexibly commission services that are desperately needed. So called dental deserts are no longer confined to rural and coastal regions. They are almost universal.
The profession has been calling for a radical review of the failing 2006 national contract, and marginal changes that occurred in autumn lacked ambition and came without a penny of new investment.
The HSCC inquiry beginning tomorrow is looked upon as a potential last chance, to spark urgent and radical reform. There is a belief that the solution will be workforce recruitment from outside the UK, or training more dentists, but historically high numbers of dentists exist on the General Dental Council (GDC) register, but the issue is insufficient numbers seeing the NHS as an attractive place to work in.
Recent figures confirm the number one reason for children entering hospital for general anaesthesia (GA) is for tooth extraction. Insufficient emphasis has been placed on the commissioning of services focusing on prevention and health inequalities have widened, with children in the most deprived communities being 3.5 times more likely to need GA. Prevention schemes commissioned in Wales and Scotland had started to reduce the levels of decayed teeth pre pandemic. These schemes have been exported worldwide, but not, as yet, to England.
Urgent and emergency care and the lack of access, leads to dental patients putting pressure on other areas of the health service, on already overstretched GP and A&E colleagues. Some sessional procurement away from the target driven 2006 contract, has started to ease the pressures on 111 and has been popular with the profession, allowing time to stabilise the oral health of those attending. These schemes have not been universal and there is uncertainty of their long-term sustainability.
There have been some examples of poor procurement in the past where multiple key performance indicators (KPIs) have made the contracts unattractive, or where the unit price has been insufficient to ensure business stability, or well-resourced enough to attract workforce. Orthodontic procurement destabilised provision when new providers took time to mobilise and recruit and the contract awards, were often subject to legal challenge. At its worst this caused abandonment in Midlands and East, this outstanding responsibility will now fall to the ICB to redo in these areas.
We participated in the Fuller Stocktake and the Hewitt review and are developing advice and guidance to local dental committees on engaging with the ICBs. It will need the voice of local providers to work alongside the commissioners, to develop services that address the issues facing the local populations.
Dentists have the capacity to be much better integrated into health systems with many of the key issues pertinent to obesity and diabetes intrinsically linked in causation.
In screening terms, dentists may see patients that don’t frequent their GP and can work upstream in earlier detection and preventative strategies. Unfortunately, dealing with the current deluge of dental needs may make this a much longer-term aspiration.
By Eddie Crouch chair of the British Dental Association