Agenda item

To receive a report regarding NHS Dental Services in Wokingham.

The Committee received an update on NHS Dental Services in Wokingham from Hugh O’Keeffe, Senior Commissioning Manager, Dental NHS England (BOB & Frimley, Susan Whiting, Director of Integration & Delegation of Direct Commissioning, BOB ICB, David Chapman, System Clinical Lead for Pharmacy Optometry & Dental Services, and Nilesh Patel, Chair-Thames Valley Local Dental Network.

During the discussion of this item, the following points were made:

·       On 1 July 2022 the programme of delegation of direct commissioned services took place and the ICB had assumed responsibility for community pharmacy, optometry and dental services.  The ICB was working closely with NHS England, with a focus on identifying local solutions to issues such as access to services.

·       Members were informed that local commissioning of NHS dental services had begun in 2006, starting with the Primary Care Trusts.  The Primary Care Trusts had brought in the new dental contracts in 2006, introducing cash limited budgets for dental services.

·       Dental public health services were commissioned by the PCT until 2013 when it then became the responsibility of local authorities.

·       Clinical advice to commissioning was provided via Local Dental Networks (LDNs) and specialty Managed Clinical Networks (MCNs) from 2013.

·       ICB/NHSE officers were working in partnership in 2022 – 2023.  From 2023 NHSE officers would be transferring to the ICBs

·       Hugh O’Keeffe provided an update on oral health.

·       Tooth decay was the most common reason for childhood admission to hospital, with approximately 40,000 per year admitted pre pandemic, nationally.

·       98% people had gum disease of some sort.

·       Oral cancer was an ongoing issue. 

·       Higher risk groups (deprivation; ethnicity; age; people with learning disabilities; prison population) were at greater risk of poor oral health.  Poor oral health had links with other diseases such as cardiovascular disease and diabetes.

·       Hugh O’Keeffe emphasised that patients were not registered with a dental practice and could attend any practice they wished.  Dentists were only responsible for patients during a course of treatment.

·       Dental practices had cash limited contracts with annual activity targets (Units of Dental Activity) which were linked to banded treatments.  A certain amount of activity had to be undertaken each year to ensure funding levels were retained.  If the practice underperformed against these targets the money came back to the NHS.  The following year what was required to be achieved was reset.

·       Investment into dental care was based on the 2006 baseline with additional new investment.  When the new contract came into effect in 2006 a number of practices had chosen not to continue with NHS work and had become private.  Several of these had been based in Wokingham Borough.

·       Referral pathways to specialist services were underpinned by commissioning guides.  About 80% of referrals were to non-hospital services such as primary care orthodontics, community based dental services, and community based oral surgery.

·       It was noted that about 66% of investment was into primary care services.  Wokingham investment was lower than Berkshire West and South-East

·       Contract delivery rates in Thames Valley were highlighted.

·       With regards to access to services, a Dental Access Programme had been in place between 2009-12.  During that period new practices had opened in Winnersh, Finchampstead, Shinfield, Wokingham and Earley.  Up to the pre pandemic period access had increased by 30% in Thames Valley.  Access was counted on the basis of unique patients who had attended a dental practice in the previous two years.

·       Access levels in Wokingham were historically lower than in Reading, the South East and England, and were similar to West Berkshire.  Information provided in the report was from 2018, the last time information had been provided on a local authority level, as opposed to a wider commissioning footprint level.

·       The pandemic had had a massive impact on dental services.  Practices had closed between March and June 2020, and capacity had been reduced between July 2020 and July 2022. 

·       During the pandemic dentists were required to follow the National Standard Operating Procedure which prioritised urgent patients.  The percentage of urgent patients treated had risen from approximately 8% to 30%.  Urgent Dental Care Centres had been established, although none of these were located in the Borough.

·       The Royal College of Surgeons had introduced prioritisation guides for surgical procedures during the pandemic.

·       Primary Care contract delivery had fallen to 29% in 2020-21 and 66% in 2021-22.  This year it was likely to be around 70%. 

·       The pandemic had had a knock-on impact on other urgent care services such as NHS 111 and A&E.

·       Significant concerns had been raised regarding access from a number of sources including MPs, Health Overview and Scrutiny Committees and Healthwatches.

·       There was a backlog of patient treatments in primary, community, and hospital services.  The pandemic had also had an impact on patients’ oral health as they had attended services less frequently.  Later presentation of cancers had become more of a concern.

·       Access to primary care had been improving since February 2022. Primary care capacity had increased back to 100% since July.  Additional Access practices had helped to improve access for those requiring urgent treatment and who were unable to access a dentist.

·       Elective Recovery Fund investment for hospitals was in place to help meet waiting time targets for those patients waiting the longest. 

·       Locally there was restoration and re-set investment in community-based referral services to reduce backlogs in these areas.

·       Hugh O’Keeffe highlighted some of the ongoing challenges.

·       Access for patients remained a concern.  Urgent treatment needs remained high.  In addition, as practices were returning to capacity and calling patients back in for treatment, many of those who had not attended a practice in recent years or had moved geographical location (e.g., new house; armed forces; Looked After Children; asylum seekers/refugees), found it difficult to access a dentist.

·       The increased time required to complete more complex patient treatments had an impact on the rate at which the backlog was cleared.

·       Ongoing Covid and flu pressures impacted on planned care in hospitals.

·       Community Dental Services used hospital theatres for surgery and had experienced difficulties in accessing slots for treatment following the pandemic.

·       Patient concerns around service access remained high.

·       Members were informed that recruitment and retention were difficult, and morale amongst the workforce was an issue.

·       It was noted that some practices were choosing to leave NHS work and to become private.  A practice in the Borough had recently announced its intention to do so.

·       Members were informed of actions being undertaken to address the challenges. 

·       National contract changes late 2022/early 2023 would increase the ‘allowed’ contract delivery to up to 110%. 

·       Guidance recommended a greater use of skill mix within practices.

·       There would be more ‘levers’ for commissioners to target resources to need.  If practices repeatedly under performed on their contract, more powers were given to commissioners to move that resource elsewhere.

·       There was a focus on recall intervals based on need.  It was noted that elder people often tended to need more frequent treatment.

·       More information for patients around access, was being produced.

·       The National Planning and Operational Guidance 2023-24 had been issued which looked at increasing primary care activity, continuing to reduce the number of very long waiters in hospital (with a target of no one waiting more than 65 weeks for hospital treatment by March 2024), and addressing the challenge of children’s access to extractions in hospital.

·       Locally, agreement had been given to ‘flex’ contracts to provide more capacity for patients who had struggled to access treatment and to increase provision for patients with greater oral health needs.

·       A strategy to improve access and oral health would be produced via the Local Dental Network.

·       A Member expressed surprise that there were not official patients lists.  Some residents had been informed that practice lists were full, or they had been removed from lists because of infrequent attendance.  Hugh O’Keeffe re-emphasised that patients were not specifically registered with a practice.  Locally, it was hoped that flexibility in contracts would help to reduce target pressure on surgeries.  Nilesh Patel commented that he understood frustrations.  Prior to 2006, practices had registration lists and the NHS had paid a small amount per patient.  After 2006 there was no longer an official registration process.  However, practices built relationships with patients and tended to run ‘unofficial lists.’  A Member added that this was not helpful to those who were struggling to access a practice.  Nilesh Patel responded that the Local Dental Network was pushing for more flexible contracts to enable practices to take on more patients without disincentive.  At present there were numerous barriers to taking on new patients.

·       There were four additional access practices operating in Thames Valley.

·       A Member referred to patients previously being treated under the NHS being informed that they would have to be treated privately in future. 

·       The Beanoak practice would be going private in the near future and 9000 units of dental work would be reallocated from the practice.  A Member asked about the relocation process and how patients were informed that they would no longer be able to access treatment at NHS rates.  Hugh O’Keeffe indicated that practices were required to give 3 months’ notice of their intention to go private.  In the interim basis, other practices in the area would be approached to take on that activity, and further long term commissioning options would be explored.  It was the responsibility of the practice to communicate the change to patients and the possible options that they could take.  David Chapman emphasised that the NHS had a duty to ensure provision and to make sure that the activity lost was replaced.

·       In response to a Member question, it was confirmed that there were three bands of NHS treatment.  Treatment was £23.80 under Band 1, under Band 2 it was £65.20, and under Band 3 it was £282.80.  Private practices had their own fee structures.  Members commented that many residents were struggling to access treatment under NHS bands.  Practices would make clear to patients whether their treatment was being charged under NHS bands or at private rates.  Nilesh Patel commented that those receiving an NHS examination could be offered both NHS and private treatment.

·       With regards to tooth decay in children, within Berkshire, Wokingham was ranked 4^th out of 6 local authorities with Slough, Reading and Windsor and Maidenhead seeing higher rates of decay, with lower rates in West Berkshire and Bracknell Forest.  Members questioned what Wokingham could do to improve in this area.  Hugh O’Keeffe commented that higher rates of tooth decay were often linked to deprivation.  A Member went on to ask what action was being taken to improve tooth decay rates.  Hugh O’Keeffe stated that a multi-agency approach to oral health was required.  The Community Dental service provided support for children’s needs, and practices tried to encourage people to attend as early as possible.  Susan Whiting added that the health visiting service was also important.

·       Alice Kunjappy-Clifton stated that pregnant women were exempt from paying NHS treatment charges whilst pregnant, but that many were struggling to access dental treatment during their pregnancies.  She went on to ask about how information around available services was being developed.  Susan Whiting indicated that the ICB would be working with system partners to ensure this information was clearly visible.  Work was being undertaken with the Healthwatches in BOB to produce a Frequently Asked Questions which would be included on the ICB website.

·       David Chapman indicated that the ICB had powers to enforce the fluorination of water, which could have an impact on dental wellbeing in children. The preventative agenda and getting messages out around oral health such as spitting out toothpaste and not immediately rinsing your mouth, and not drinking for 30 minutes after brushing your teeth, was important.

·       A Member commented that a lot of new homes were being built in the Borough.  They questioned how new residents could find out where they could access dental services.  Hugh O’Keeffe indicated that five practices had opened in the Borough between 2006 and 2011, partly in response to planned housing developments.  In the short term there was the flexing of contracts.  Strategic work with the Local Dental Network, planning for 5-10 years ahead, was taking place.   Susan Whiting added that a multi-agency approach was important, and that consideration should be given to the forums that discussions took place in.  She questioned how the Council had engaged with NHS England about the development of additional houses and required capacity, prior to July.  The need for joint working and effective collaborative conversations was emphasised.  It was suggested details be provided of relevant Planning officers and Members with responsibility for Planning to help further conversations to improve outcomes for residents.  Susan Whiting indicated that she would also escalate it with the Place Based Director.

·       A Member questioned why the data was not available at a local authority level.  The Committee was informed that the data was based on the commissioning footprints in the NHS.  

·       Members questioned why Wokingham received a lower NHS primary care dental funding per head (£31.04) than other areas.  The Committee was informed that this was partly historic.  In 2004/05 the base work for contractual arrangements had been carried out, looking at the case mix, which generated the price per unit of dental activity.  The amount of provision through the NHS going into 2006, had helped to set a base line for investment.  In addition, areas of greater deprivation often had a heavier case mix and a higher price per unit.   Wokingham would have seen an increase in investment via the Dental Access Programme.

·       In response to a Member question, Hugh O’Keeffe stated that as at 2018 approximately 46% of Borough residents accessed NHS dental services.  This had dropped because of the pandemic but was likely to be on the increase again.  How the recovery progressed was vital.  It was likely that Wokingham had higher levels of private activity than some other areas.

·       With regards to prevention, a Member asked about dental provision for the elderly and those living in care homes, and whether care home staff received guidance on oral health.  Hugh O’Keeffe stated that care homes and access to dentistry, was an area of challenge.  The CQC had issued a report called ‘Smiling Matters’ which looked at the multi-agency responsibility of ensuring that the elderly and those living in care homes’ oral health needs were met.  Whilst community dentistry had a domiciliary service for those unable to go into practices, there were lots of barriers for services going into care homes.  It was hoped that flexing the contracts would help to prioritise priority groups.  In addition, consideration was being given to different ways of delivery and skill mix.

·       Members were informed that one of the Oxfordshire local authorities had retained a dental oral prevention service.  The team was commissioned by the local authority to support the paediatric services and care homes with oral hygiene and prevention.  Members requested information be shared about this service.  Susan Whiting questioned whether the Council commissioned such services.  It was agreed that clarification would be sought from officers. 

·       Members questioned if any dentists in the Borough were currently taking new NHS patients.  Hugh O’Keeffe commented it was unlikely that practices were accepting NHS patients.  Pressure to deliver a certain level of activity within contracts by the end of the year likely incentivised the recall of patients who had previously attended.  The situation may ease with the start of a new financial year.  Susan Whiting referred to the Additional Access service which could inform people of the nearest practice that was accepting new patients.  It was accepted that people might have to travel some distance.

·       A Member commented that the Council provided new resident packs and suggested that information regarding local dental services be included in this.

·       The Committee questioned what impact any additional funding would create and whether there was sufficient workforce to cover additional treatments.  They went on to ask for a view on how dental services were functioning in general.  Nilesh Patel responded that it was becoming harder and harder to operate in the NHS service.  Fees were increasing but under inflation, which made operating services effectively, more difficult.  Many dentists then chose to leave the NHS service and those who remained were under increasing pressure.  If further funding was available, it would be helpful but not necessarily address all problems. 

·       Members questioned whether there were lots of people leaving the service and if there were sufficient number of people joining.  Nilesh Patel commented that there was a difference of views.  Some parts of the profession believed that an insufficient number of dentists were qualifying, whilst others felt that there were sufficient.  However, NHS work was becoming less attractive and those undertaking private work tended to see fewer patients. 

·       Nilesh Patel encouraged Members to continue to put pressure on commissioners and providers to ensure sufficient services for residents.

·       The Committee were of the view that a further update should be sought in 6 months’ time.

RESOLVED: That

1)    the presentation be noted and that Hugh O’Keeffe, Susan Whiting, Nilesh Patel, and David Chapman, be thanked for their presentation.