Agenda item

To scrutinise the provision of NHS Dentistry Services in the Dover District.

 

Representatives of NHS Kent and Medway will be present at the meeting to respond to questions from the members of the Overview and Scrutiny Committee.

Sukh Singh (Director of Primary and Community (Out of Hospital) Care – NHS Kent and Medway), Louise Matthews (Deputy Director Primary Care Commissioning – NHS Kent and Medway) and Cheryl Wood (Chair of Kent Local Dentistry Committee) were present at the meeting to provide answers to the Key Questions submitted by Members.

 

The Director of Primary and Community (Out of Hospital) Care informed Members that the ICB was keen to learn from dentists, particularly given the national challenges around dentistry provision. He emphasised the importance of preventative care for patients to prevent future problems.

 

A report containing statistical information had been circulated to Members in advance of the meeting.

Q1.      What proportion of the 1) adult, and 2) child population of the district is registered with a dentist as an NHS patient?

 

Patients were not registered with a dentist in the same way that they were with a GP because dental patients were not bound to a catchment area, nor could the ICB allocate a patient to a dentist in the same way they could a GP. The onus was on the patient to find an NHS dentist and they were not restricted by locality.

Patients were aligned to a dental practice for their course of treatment only and NICE guidance recommended an adjustable recall interval for adults ranging from a minimum of three months to a maximum of 24 months between recall appointments (dental check-ups). For children, the recommended recall interval was between 3 and 12 months.

From the NHS perspective, dental access was measured by the number of individual patients seen by a NHS dentist, at least once in the most recent 24-month period. Between April 2018 and April 2020 slightly less than half of the Kent and Medway population accessed NHS Dental Services.

 

For children this was around 65% and for adults around 43%. In February 2022 this dipped to 33.5% of the Kent and Medway population accessing NHS Dental Services. For children this fell to 49.3% and for adults 29%.

 

In response to a question from a Member it was stated that it was possible for patients to drop off the books of dentists once their work had been undertaken. Additionally, if a dentist had fulfilled there contract they could refuse to undertake additional work.

Q2.    How has the number of dentists (and dental surgeries) in the district changed over the past 5 or more years?

 

Currently there was limited workforce data available.  A national workforce data collection was introduced in October 2023, and NHS Kent and Medway were waiting on the publication of the results. They did not hold district level workforce data.

The Annual National Dental Statistics provided information at a Kent and Medway level on the number of dentists undertaking NHS dentistry.

Between 2012-13 and 2022-23 the total number of dentists undertaking NHS dentistry in Kent and Medway rose from by 9.4% from 801 to 876, an increase of 75 dentists.

Between 2021-22 and 2022-23, the total number of dentists undertaking NHS dentistry in Kent and Medway fell by 2.1% from 895 to 876, a decrease of 19 dentists.

Members were advised by Cheryl Wood that work force issues had seen dentist practices close down across the country. This led patients to struggle to find alternative NHS provision. In her view, the national contract needed to be changed.

 

Q3.    What proportion of the dental surgeries in the district are currently accepting new NHS patients?

 

As of 10 April 2024, there were three general dental practices accepting new patients, which represented 30% of dental surgeries in the dover district. These were:

 

·         AF Dental, 1-2 Biggin Street, Dover, Kent, CT16 1BD

·         Dumbledore Dental Care Ltd, 27 BIGGIN STREET, Dover, Kent, CT16 1BU

·         Mydentist, 9 Stanhope Road, Deal, Kent, CT14 6AB

 

When availability allows, these dentists accepted new patients if they were:

 

·         Children aged 17 or under

·         Adults 18 or over

·         Adults entitled to free dental care

 

Information on NHS dental surgeries accepting new patients is available on the NHS.uk website (https://www.nhs.uk/service-search/find-a-dentist). Dental Providers were required to update their information on the NHS.uk website every quarter.

Q4.    Are there any areas of the district particularly well served, or under served by NHS dentistry?

 

A map of the general dental practices in the Dover area from the Shape Place tool had been provided to Members as part of the report from NHS Kent and Medway.

Q5.    How does oral/dental health in the Dover district compare to the rest of Kent, and the rest of the country?

 

Local Authorities remained responsible for commissioning oral health promotion services. The Health and Social Care Act (2012) made upper tier and unitary authorities responsible for improving the health, including the oral health, of their populations from April 2013. 

From 1 October 2015 the commissioning responsibility for the Healthy Child Programme for zero to five-year-olds transferred from NHS England to local government. This included the commissioning of health visitors, who lead and support delivery of preventive programmes for infants and children, including providing advice on oral health and on breastfeeding, reducing the risk of tooth decay.  Local authorities were also required to provide or commission oral health surveys to facilitate:

•        assessment and monitoring of oral health needs

•        planning and evaluation of oral health promotion programmes

•        planning and evaluation of the arrangements for the provision of dental services

•        reporting and monitoring of the effects of any local water fluoridation schemes covering their area

•        the dental data required for the single data list and the public health and NHS outcome frameworks.

Q6(i) How will the government's NHS dentistry recovery plan affect residents, and be delivered in the Dover district?

 

On 7 February 2024, the Secretary of State for Health and Social Care announced the dental recovery plan “Faster, simpler and fairer: our plan to recover and reform NHS dentistry”. Although, nationally a £200 million investment fund was supporting the dental recovery plan only minimal new investment has been signalled and the expectation was that ICBs ensure dental budgets were ringfenced for 2024/25 to meet these commitments and improve dental access more broadly.

The plan sets out several approaches to improve dental access and was supported by a number of local authority led prevention initiatives as well as NHS led initiatives.

Public Health Promotion and Oral Health Initiatives for Children (Local Authority Led)

•        Promotion of prevention initiatives to improve the oral health of pregnant mums, and guidance for parents about how to protect baby gums and milk teeth from decay.

•        Promotion of Smile for Life good oral hygiene into the daily routines of infants and toddlers so that, by the time they reach primary school, every child saw daily toothbrushing as a part of their normal routine.

•        Deploy mobile dental teams into schools in under-served areas to provide advice and deliver preventative fluoride varnish treatments to children, strengthening their teeth and preventing tooth decay.

•        Consultation on expanding water fluoridation aimed at reducing the number of tooth extraction due to decay in most deprived areas.

 

NHS Led Initiatives

1)      New National Minimum £28 UDA rate

•        This announcement introduces a new national minimum UDA rate of £28 from 1 April 2024 for all dental providers.

•        The ICB had 31 dental practices that currently received a UDA rate below £28 and was expected to cover this financial uplift from within existing dental budgets.

•        Two Dover dental practices had a UDA rate of £27.19. This had now been uplifted to £28 in line with the national minimum UDA rate.

 

2)      New Patient Premium (NPP)

•        The ICB had received an additional allocation of £199,000 for 2023/24 to support the role out of the NPP.

•        This will be claimable for new patients who have not accessed NHS dentistry treatment over the last 2 years and would run for a 13-month period from 1 March 2024 to 31 March 2025.

•        The NPP will be transacted as a Unit of Dental Activity (UDA) credit on completion of a course of treatment (£15 for a band 1 dental treatment, and £50 for band 2 and 3 treatments).

•        The issuing of UDA credits was likely to mean that providers will deliver their contracted UDA activity more quickly and may require providers to “pace” their activity over the course of the financial year.

•        As new patients would attract the NPP providers were likely to push existing patient recall intervals in line with NICE guidelines (up to 24 months for adults and up to 12 months for children). This might generate patient queries and complaints.

•        The ICB will need to reach an early decision on whether to pay for overperformance of up to 10% contracted activity (allowable under the contract) during 2024/25. It had been signalled that NHS England would work with ICBs over the course of 2024 to 2025 to identify opportunities to support contractors to deliver additional capacity beyond their existing contractual requirements (up to 110%).

•        All General Dental Practices operating in the Dover were signed up to the NPP.

 

3)      Mobile Dental Vans

•        The launch of a new dental van service to take dentists and surgeries to the most isolated under-served rural and coastal communities nationally where there are no dental practices.

•        No identified areas are in Kent and Medway or the Southeast

 

4)      ‘Golden Hello’ for Dentists

•        Targeted funding to encourage dentists to work in areas which had historically been difficult to recruit to.

•        Offer of a £20,000 support package over a three-year period (payable instalments of £10K year 1, £5K year 2 and £5K year 3) requiring a commitment from the dentist to stay in that area delivering NHS work for at least 3 years.

•        It was estimated this would support 240 dentists nationally during the first year. It is unclear how this element of the plan will be funded, and further detail was awaited.

 

5)      Streamlining and tackling bureaucracy, with a wider set of workforce reforms

•        Reaffirms commitments to increase workforce capacity as set out in the NHS Long Term Workforce Plan,

•        As part of the NHS Long Term Workforce Plan, build a pipeline of new dentists for the future by expanding dental undergraduate training places by 40% to more than 1,100 per year by 2031 to 2032, with an initial 24% increase to 1,000 places by 2028 to 2029.

•        Consultation this spring on ‘tie-ins’ to NHS for dentist graduates.

•        Increase the number of dental therapists and other dental care professionals, through a 40% increase to more than 500 training places per year by 2031 to 2032.

•        Promote therapist led models of care.

•        Make it easier for NHS practices to recruit overseas dentists who meet the UK’s highest regulatory standards.

•        Consultation during 2024 with the dental profession on reforming the contract with any changes phased in from 2025 onwards.

•        Implement regulations to allow ICBs to rebase contracts where providers consistently underperform over three consecutive non-covid years enabling commissioners to reinvest in services.  The same regulations were expected to include further detail on the supervision of Therapists and allow for Therapists to open a course of treatment.

 

Q6(ii)   Are any 'dental vans' planned to be introduced in the Dover district?

 

No dental vans were to be introduced in the Dover district.  They were being introduced nationally where there was no dental provision currently.

Q7.      How many NHS patients have been removed from dentistry lists since 2020 and how many new registrations have there been since then?

 

Members were advised that this had been partly covered in response to question 1.

New NHS Dental patients seen was defined as the number of patients who had not received NHS dental care in the previous 24 months.

Between April 2022 and March 2024

• The total number of New NHS dental patients seen per 100,000 population in Kent and Medway continued to exceed the Southeast position.
• The total numbers of new NHS dental patients seen increased from 270 per 100,000 population to 897 per 100,000.
• The total number of new NHS patients seen had risen from 5071 to 16,831 new patients seen.

Approximately 60% of new patients seen are adults and 40% are children.

Q8.    How many people present at hospitals with dental emergencies? Of these, what % are children?

 

Members were advised that the ICB did not currently have access to data on the number of people presenting at hospitals with dental emergencies.

Q9.    How do you measure the number of NHS dentists in an area, given that some dentists have all NHS patients, some have some NHS plus some private, and some have only private patients?

 

The Annual National Dental Statistics provides information at a Kent and Medway level on the number of dentists undertaking NHS dentistry. This information had been provided above as an answer to Q2.

Dentists could hold both private and NHS dental contracts at the same time. In a survey of Kent and Medway Dental Practitioners undertaken jointly by NHS Kent and Medway and the Kent Local Dental Committee in 2023, 8 out of 10 respondents said they offered private dental practice alongside their NHS dental contract and half of respondents said that 70% or more of their dental service they provided was private dentistry offered alongside NHS dentistry.

When asked why private dental practice was a more attractive option 30% of respondents said if offered better pay and benefits, 26% said it offered more opportunities to develop skills, 20% said it offered better opportunities for career progression and 9% said it gave opportunities for on-the-job coaching and mentoring.  A further 14% gave other answers that included ‘the UDA system means treating some patients at a financial loss’, “the current NHS contract is not fit for purpose’, private dentistry gave the opportunity to offer treatments not available on the NHS, being able to spend more time with patients and delivering tailored care.

Q10.    Given the size of the population in Dover District (in 2022, a bit over 117,000). How many NHS dentists should there be?  So, what is the shortfall?

There was no national benchmark on the number of dentists per head of population. 

Q11.    How does the number of NHS dentists in Dover District compare with the UK average, and other districts in the South-East?

Q12.  How does the average no of patients per NHS dentist in Dover District, compare to other England districts? 

Dentists per 100,000 population

 

As at 2022-23 the number of dentists per 100,000 population undertaking NHS dentistry in Kent and Medway was 47. This was marginally less than the position for the southeast but higher than for England.  This had remained static since 2011/12.

Q13.    Can you tell us about local children’s dental services? (that is preschool, primary aged and secondary aged).

·         What preventative services do you run for children? Is there a school dental service?

·         If a child is found to need the attention of a dentist what happens if they don’t have an NHS dentist?

·         How many NHS dentists are regularly treating and checking children’s teeth locally?

·         What %age of children in Dover District get seen regularly by a dentist?

 

Local Authorities remained responsible for commissioning oral health promotion services. The Health and Social Care Act (2012) made upper tier and unitary authorities responsible for improving the health, including the oral health, of their populations from April 2013. 

 

From 1 October 2015 the commissioning responsibility for the Healthy Child Programme for zero to five-year-olds transferred from NHS England to local government. This included the commissioning of health visitors, who lead and support delivery of preventive programmes for infants and children, including providing advice on oral health and on breastfeeding, reducing the risk of tooth decay.  Local authorities were also required to provide or commission oral health surveys.

 

The Dental Recovery Plan set out proposals for Public Health Promotion and Oral Health Initiatives for Children. This was covered in the answer to Q6(i) and the report submitted to the Overview and Scrutiny Committee.

 

If a patient needed a dentist, those dentists accepting NHS patients could be found by searching https://www.nhs.uk/service-search/find-a-dentist. Further information was provided in the answer to Q3.

 

There were 10 NHS Mandatory Dental Service (MDS) contracts across Dover, some contracts cover multiple sites.

Children Attending a Dentist 0–10-year olds

Across Kent and Medway, the proportion of 0-10-year-olds attending a NHS Dentist was 59.3% in 2018/19 falling to 21.8% in 2020/21 and rising back up to 51.6% in 2022/23. For Dover local authority area, the position was slightly lower at 57.6% in 2018/19 falling to 19.8% in 2020/21 and raising back up to 43.7% in 2022/23.

 

Children Attending a Dentist 11- 19 Year Olds

Across Kent and Medway, the proportion of 11-19-year olds attending a NHS Dentist was 57.6% in 2018/19 falling to 22.9% in 2020/21 and rising back up to 56.3% in 2022/23. For Dover local authority area, the position was slightly lower at 58.6% in 2018/19 falling to 21.1% in 2020/21 and raising back up to 48.8% in 2022/23.

Q14.    Do you have figures on children seen by local hospitals for emergency dental treatment? I believe it is the highest reason for children attending A&E, is this correct?

 

The ICB did not currently have access to data on the number of people presenting at hospitals with dental emergencies. However, dental claim forms provided information concerning how many children received urgent treatment.

 

In 2022/23, across Kent and Medway, just over 10% of claim forms were for band 1 urgent treatment in 0-10-year olds and 8% of claim forms were for band 1 urgent treatment in 11-19-year olds. For Dover this was 8% for both age groups.

Q15.    My concern as a DDC councillor, is the long-term consequences of the number of children with poor teeth, and what this is storing up for the future of their dental health, and also the impact on hospitals.  Please will you comment on this.

 

Local Authorities remained responsible for the promotion of oral health. The ICB had recently engaged with the Kent Public Health Team to explore the possibilities of undertaking some joint work aligning oral health profiles and dental needs assessments and were keen to see more information on dental health included in the joint strategic needs assessment.

Q16.    Why are so many dentists leaving the NHS to do private work?... I watched Countryfile on BBC1 TV on Sunday 16 March. They quoted the British Dental Association, that there is a crisis in dental care and 1 in 4 people have unmet dental care needs.   

 

The two main reasons given by dental providers that choose to hand back their dental contract was (1) that the national general dental contract was not fit for purpose and (2) the lack of available suitability skilled workforce.

Q17.    In 2005/6 a new Dental Contract was introduced with Units of Dental Activity (Bands 1, 2 and 3).  Many dentists did not renew their NHS contract which I believe has led us to the current position of poor dental health in the UK.  Are there any plans to change the contract to a fee per procedure? or other changes e.g. to what it was before 2005? 

 

As part of the dental recovery plan announcement the government had indicated that during 2024 they would undertake consultation with the dental profession on reforming the contract with any changes phased in from 2025 onwards.

Q18.    On 1st April 2024 the costs to patients went up 8.5%, Band One being £26.80.( In April 2014 that figure was £18.50, so a 45% increase)  If everything on that band was completed it would take an hour to complete and, therefore, dentists do not have the time.  Some tasks will be put off requiring the patient to attend again, therefore, delaying treatment and an additional £26.80.  Is the Dental Service monitoring all NHS dentists to ensure this does not happen?

 

With effect from 1 April 2024, a band 1 course of treatment cost £26.80. This could include an examination, diagnosis (including X-rays), advice on how to prevent future problems, a scale and polish if clinically needed, and preventative care such as the application of fluoride varnish or fissure sealant if appropriate. Not everything that is listed as a band 1 treatment would be carried out at every appointment, what is necessary is a clinical decision in line with National Institute for Health and Clinical Excellence (NICE) guidelines on dental recall intervals.  For adults this ranged from a minimum of three months to a maximum of 24 months between recall appointments (dental check-ups). For children, the recommended recall interval was between 3 and 12 months. The ICB did not routinely monitor clinical decisions to treat and recall intervals decided upon.  It did respond to any patient complaint raised.

 

Q19.    From April 2024 Band 2, costs £73.50, and includes Band One treatment plus up to three fillings, root canals, extractions. ( in April 2014 this was £50.50, a 45% increase). There is no incentive to preserve teeth.   It is less time consuming for the dentist to do an extraction, thus affecting patients’ long term dental health. Is the Dental Service monitoring all NHS dentists to ensure this does not happen?

 

With effect from 1 April 2024, a band 2 course of treatment costs £73.50. This could include band 1 treatment plus any further treatment such as fillings, root canal work or removal of teeth but not more complex items covered by Band 3.

Since November 2022, as a result of dental contract reform band 2 treatment had been split into a number of subcategories attracting differing UDA rates

·         Permanent fillings and the number of affected teeth in a course of treatment

• Extractions and the number of affected teeth in a course of treatment
• Endodontics - molar on permanent teeth 
• Endodontics - non-molar on permanent teeth

Not everything that was listed as a band 2 treatment would be carried out at every appointment. Instead, what was necessary was a clinical decision in line with National Institute for Health and Clinical Excellence (NICE) guidelines on dental recall intervals.  For adults this ranges from a minimum of three months to a maximum of 24 months between recall appointments (dental check-ups). For children, the recommended recall interval was between 3 and 12 months.

 

Q20.    For a dental emergency, people are referred to a hospital A&E by 111.  How many dentists are employed at our local hospitals? Is there an out-of-hours emergency service?  Can you explain please. 

 

The ICB did not have access to data on the number of people referred to hospitals by dental emergencies.  They did not have details of how many dentists were employed by local hospitals.

 

The ICB commissioned an out of hours emergency dental service. The Out of Hours service was dental emergencies and urgent symptoms – haemorrhaging/bleeding from the mouth; trauma - following a recent accident or injury; severe facial swelling - affecting the airway or eye; and sudden onset of acute pain not relieved by over-the counter pain killers.

 

This is accessed by contacting Dentaline on 01634 890300 on Monday to Saturday 6 -10.55 pm and Sundays and Bank holidays 8.30am to 1.25 pm.  An assessment, or advice would be offered, and an appointment arranged for that session if necessary.

 

Q21.    In Feb this year a dental recovery plan was announced by the government. How do you see this affecting Dover District residents? What can you do about increasing the number of local dentists? Can we request a mobile service?

The answers to this question had been provided above at Q6(i) and Q6(ii)

The ICB recognised that further work was needed to continue to address the challenges in accessing NHS dental services and were committed to working with key stakeholders and system partners to make the best use of existing provision and bring forward innovative solutions.

 

Members discussed the following points:

 

·         To question how the Dover District could be made more attractive to new dentists. The ICB advised that it was looking at what could be done to increase NHS dentist provision.

·         The preventative work being undertaken in schools. Members were advised that Kent Public Health was separate from the ICB. However, discussions had been held as to what could be done together.

·         The importance of having local training schools. The closest training was based in London and accordingly a lot of newly qualified dentists tended to stay in London.

·         To recognise that the current contract did not attract new dentists into the NHS. In some cases dentists would lose money on NHS patients.

 

The Chairman thanked the representatives from NHS Kent and Medway and the Chair of Kent Local Dentistry Committee for attending the meeting and answering the committees questions.