DLS0086
Written evidence from Healthwatch Kirklees
Executive summary
Over the last 6 years, Healthwatch Kirklees has worked hard to alert NHS providers and commissioners to the significant gaps in dentistry services across West Yorkshire. We have experienced more struggle in achieving change in the way these services are provided than we have with any other NHS service, and the response that we have received to raising quite shocking feedback and statistics has been one of acceptance of the current issues and resistance to trying to address these.
We believe that NHS dentistry services function in a way that is different from every other part of the NHS and they are not subject to the same scrutiny. There is an acceptance that a significant proportion of people won’t be able to access NHS dental care, dentists are allowed to select who they are willing to take on as NHS patients, little consideration appears to be given to disproportionate impacts of poor access on people with protected characteristics, and people are ill informed about what is available to them. If a GP surgery, local hospital, or community provider were to offer their services in the same way, this would be challenged.
At the end of this document there is a timeline summarising all of the work delivered around NHS dentistry by Healthwatch Kirklees and Healthwatch Calderdale, in which you can see that we have repeatedly raised our concerns to a variety of partners involved in the delivery and commissioning of NHS dental services. Our most significant successes have been working with the MP for Dewsbury and Batley to increase the number of Units of Dental Activity commissioned in that area on a temporary basis. We also worked with the Chief Dental Officer to deliver a project increasing recall intervals for people with healthy teeth; although this didn’t have the full impact that we hoped, it did result in greater variation in length of recall across the area, meaning that it’s likely more people were talking to the dentist about how frequently they need to be recalled.
We are hoping that the scrutiny of this issue through the Health and Social Care Committee will achieve a significant change in the approach that includes:
If any further information is needed to clarify elements of this submission, or details about Healthwatch in Kirklees and Calderdale, please do not hesitate to contact Helen Hunter at Healthwatch Kirklees on 01924 450379. We would be happy to present our findings in person if this were necessary.
Healthwatch Kirklees has been engaging with the public around access to NHS dentistry since it was launched in 2013. One of the first issues that members of the public raised with the organisation was their struggle to find a dentist that would see new NHS patients. National statistics from the British Dental Association state that in June 2017, at the end of 24-month period, only 22.2 million adult patients were seen by an NHS dentist, representing 51.4 per cent of the adult population.
In March 2018, there was only 1 dental practice in 280 across West Yorkshire that was taking on new NHS patients.
In areas of high deprivation in North Kirklees, the charity DentAid has been delivering drop-in clinics for people in need of urgent dental care, who cannot access routine NHS dentistry. This charity delivers dental care in developing countries, in areas where there is no routine access to dental services. It has shocked us that this is necessary in order to meet the gaps in provision in our area, and that this has not resulted in a stronger response from our local dental commissioners.
As is evidenced in the description of work conducted and led by Healthwatch Kirklees in this document, we have invested a huge amount of time in raising issues around dental access with NHS England, the Local Dental Committee, local dentists, the British Dental Association, local councillors, Scrutiny Committees, local MPs, and many more organisations and individuals. We have persisted with a number of different initiatives and approaches, and have gathered feedback from around 2000 people. We have taken the time to understand the widest range of perspectives and present the information in a constructive and competent way.
We have struggled to have any significant impact on access to dentistry in Kirklees, Calderdale or across West Yorkshire more broadly. Our biggest success in increasing the level of access to dental care in Dewsbury was to secure the investment in an additional 13,060 units of dental activity across 3 years to be delivered by dental practices in each area. We worked with the MP for Dewsbury, Rt Hon Paula Sherriff to get this outcome. From the 2017 allocation, all of the available appointments had been used within 6 weeks of the slots being released and there were still significant gaps in delivery.
There has been an unwillingness from NHS England to commit to making any fundamental, sustainable changes. Often the response from this organisation is to reiterate that the current national contract for provision of NHS dentistry services is not up to scratch, and that there is little they can do to address the issues in our area.
Significant numbers of adults and children in Kirklees and Calderdale are unable to access routine NHS dentistry. This puts them at greater risk of developing significant oral health issues and needing urgent and emergency dental treatment. Kirklees is one of the areas in the Yorkshire and Humber with the highest incidence of incisor caries in children aged 5. The percentage of children aged 5 with dental decay is 32.5% in Kirklees, when the percentage in England is 23.3% (statistics from 2017). Without access to a clinician who can offer support, advice and assistance around dental care and hygiene, it is much more challenging to ensure that a child maintains good oral health.
Limited access to routine and preventative dental care means that many people in Kirklees do not see a dentist for several years, and only attempt to access dental care when a critical issue has developed. As there are significant periods of time where it is impossible to visit a dentist based in Kirklees for NHS care, these people often contact the urgent and emergency dental care provision for resolution to their immediate issue. If this isn’t available to them, they sometimes take ill-advised action to manage their pain; we have heard examples of people removing their own teeth with pliers.
Healthwatch Kirklees worked with a patient who needed to access NHS dental care for an extraction, but as she wasn’t a patient of a dental practice in her area, she had to make repeat contact with emergency care services to address her dental health problem. We were able to utilise recording of her calls to NHS 111 to create a short clip telling the story of her experience which can be seen here – Alice’s story. Had Alice been able to access routine NHS dental care, the cost of the extraction for the NHS would have been £53.90. As Alice had to make repeat contact to emergency services due to the pain and distress she was experiencing, the cost of her care was over £500.
Our local health and care system is working toward a preventative, self-care focused, person led model of health and care service delivery, but this strategy seems to omit a focus on dental care. As the service is commissioned on a regional level, local leaders see themselves as powerless to influence dental care provision in their area. This is in spite of the fact that every local strategy articulates that people should be supported to access care that prevents ill health, and keeps people away from unnecessary urgent and emergency care. The biggest cause of 5-9year olds being admitted to hospital is tooth decay, and this is almost always preventable.
We have seen a significant number of examples of people with the poorest dental health experiencing the greatest challenges in accessing dental care. We have spoken with people who are homeless, asylum seekers and refugees, those with substance misuse issues, people with disabilities, many of whom report being turned away from NHS dental clinics.
The current NHS dental contract works in such a way that it is financially advantageous for dental practitioners to see people with healthy teeth and gums, rather than those with more significant oral health issues. As dental activity is placed in to “bands”, and the maximum cost of a course of dental treatment is £269.30, if you have complex treatment that goes above this cost threshold, then the dental practitioner does not necessarily receive commensurate funding. This means that dentists opt to limit the access of complex patients. We have spoken with dentists about this who see this as an acceptable, although not ideal, way of maintaining their business, explaining that people with complex and chaotic lives are more likely to miss appointments, need urgent dental care, and not maintain their dental hygiene as they should.
Below, we explain our involvement in a project (Recall Matters) that aimed to encourage people with healthy teeth and gums to #askyourdentist if you need to attend an appointment every 6months for a regular check-up, as NICE guidance suggests that people with healthy mouths can be seen on a 12-24month basis. This would free up availability of routine appointments for other people without incurring any additional costs for the health system. Whilst we were successful in influencing the behaviour in some practices across West Yorkshire, some dentists were critical of the approach.
Emergency care is in place to address the pressing immediate issue, but is only accessed when the problem becomes critical, and often isn’t a long term solution. We have spoken with a homeless man who sought emergency dental care and had all of his teeth removed, but then was completely unable to find aftercare. This means that he has been left with no possibility of getting dentures, which is having a huge impact on his diet, his self-esteem and his ability to gain meaningful employment.
We have also worked with residential and nursing care homes to understand the picture of provision of dentistry for those living in that type of facility. We were told about significant waits for dentists to visit care homes to offer dental checks, and that when dentists did visit, they could only check a person’s teeth; they could not do any dental work. In some instances, individuals had ill-fitting or missing dentures, and waited over 12months to have this rectified. This impacts what the person is able to eat, whether or not they are getting the right nutrients, leads to weight loss, creates an increased falls risk, and fundamentally changes the person’s quality of life.
When Healthwatch Kirklees first began researching the issue around access to NHS dentistry services, we received many calls to our information and signposting service asking us which NHS dentists in Kirklees were taking on new NHS patients. We weren’t able to answer as we did not maintain a list of dentists in this way, but in 2013/14, there was a Dental Advice Line for West Yorkshire which could provide information about available dentists.
Funding for this service was withdrawn in 2014, and we were told to direct people to the NHS Choices website where each practice and its availability would be listed. It quickly became apparent to us that this information was not kept up to date, so was normally inaccurate.
It was later brought to our attention that some dental clinics were listing that they had availability for NHS patients on NHS Choices, but when people were calling up, this was no longer available, and they were asked if they would like to register as a private patient of the clinic. We felt that this was false advertising and reported this to the Advertising Standards Agency. They agreed with us, but the result of this was not that accurate information was logged on NHS Choices; it was that dental practices did not submit any information about their availability to NHS Choices.
Now, if patients call NHS 111 but are not in need of emergency care, they are told to look on NHS Choices to check for available dental services, but the practices do not state whether they are taking on patients. The option available to them is to call all the dental practices to see which are taking on patients. For those people on low incomes, with language and communication challenges and who are unwell, this can be too time consuming, too difficult, or who expensive to do.
We have heard feedback from people who do not speak English as a first language, who have struggled to get their dental practice to make arrangements for an interpreter to be present at their dental appointment. In some circumstances, patients have been told that it is not the responsibility of the practice to arrange an interpreter; others have been asked to arrange for family members to be present. We have taken up this issue with the Local Dental Committee in Calderdale directly, who are examining the situation and trying to resolve it.
Healthwatch Kirklees and Calderdale have also completed some extensive work around fines being administered to people who had misrepresented their eligibility for free dental care. Often, the people we were speaking to had made an error in the process, and faced challenges in understanding the claim form, for example people with learning disabilities, and those who don’t have English as a first language. Some dental practices are not displaying clear information about this and often staff are not able to support people to understand the information about eligibility. In this case, reasonable adjustments are not being made.
The Public Accounts Committee recently reviewed this issue and pressed for change in the way that the fining policy was being implemented, which is fantastic progress, but there is still work to do to enhance the information provided by dentists around eligibility for free dental care.
Healthwatch Kirklees and Calderdale feel that the people who face the biggest challenges as a result of the existing contract for NHS dentistry services provision are patients. The contract is set up in such a way that dentists can be selective about the patients that they take on, they can remove people from their patient list when they see fit, and despite many reporting that they want to increase the amount of preventative dental work that they are doing, they do not have to focus on this in any way.
Many patients believe themselves to be “registered” with a dentist, in the same way that they are registered with a GP. What they do not understand is that an NHS dentist’s obligation to you as a patient is only for as long as the period of treatment that you need. The “registration” is simply the person’s name and NHS details being held on their system, which is why the practices can set thresholds for missed appointments, and say that you can no longer be a patient of the service. A clear example of this came from a customer of Healthwatch in Calderdale who said:
“They refused emergency dental work which is required after the crown which they mounted on pins failed. Claiming I missed two appointments for dental hygiene, so now they can refuse dental treatment. Appalled at the response.”
We have concerns that the limited availability of NHS dental care in our area means that more and more people who can afford are registering as private patients of dental clinics. This means an increased revenue for individual practices, and means that the limited budget available for dentistry in West Yorkshire can continue to diminish. However, this creates an even bigger gap for those people who cannot afford private dental care.
It is difficult not to feel like there is a move towards the privatization of dental care, when dental practitioners are encouraging people to register as private patients, NHS England cannot find more money for dentistry, and we are seeing an increasing picture of dentists handing back NHS contracts to focus on delivering private practice, which is more lucrative.
Below is a timeline which indicates the time frames for delivery of our work around NHS dentistry services across the last 6 years.
Why can’t I find an NHS dentist in Kirklees?
Healthwatch Kirklees took a range of approaches to gathering people’s views on access to dentistry across Kirklees, including a survey, focus groups with seldom heard groups, research with professionals, etc… Through this, we gained a clear understanding of how the current NHS dental contract works and how that can disadvantage certain people within our communities. The issues were raised with NHS England.
Oral Health Care in Residential Care Homes
Healthwatch Kirklees and Healthwatch Bolton worked with residential care homes across their respective areas to understand what dental provision looked like for residents. Staff reported huge challenges in getting access to domiciliary dental visits, and significant gaps in the provision of dentures.
Subsequently to this, we are assured that there has been an increase in the availability of dental care in care homes through community dental provision, but we are aware that there are still significant gaps.
Unplanned dental care survey
Healthwatch organisations across West Yorkshire undertook a survey to find out how many people in West Yorkshire have access to a regular dentist and to understand their experiences of looking for an NHS dentist. They were particularly interested in Out of Hours emergency dentists and why people use them.
Interestingly, whilst spending time in out of hours and emergency clinics, we found that nearly 50% of the patients surveyed who consider themselves to have an NHS dentist have not seen a dentist for over 2 years.
Accessing NHS Dental Services in Kirklees
Healthwatch Kirklees distributed a survey that was completed by 778 people asking about their access to dental services in Kirklees. Emerging themes were similar to those in the 2014 work, with people struggling to know how to find an NHS dentist, and those who had access being regularly recalled for routine check-ups.
Community Dentistry in West Yorkshire
Healthwatch across West Yorkshire attended Community Dental clinics, which are used by people facing barriers to receiving routine dentistry, such as physical disabilities, phobias and learning disabilities, to gather feedback about people’s experience of those services. Feedback received in Kirklees and Calderdale about this care was very positive. People really appreciated the adjusted environment, having longer appointments and the compassion shown by the professionals.
NHS Choices and the Advertising Standards Agency
When Healthwatch Kirklees established that NHS Choices was being used as a directory for dental availability, but it was updated by each individual dental practice, and that there was misinformation listed, we raised this with the Advertising Standards Agency. We had concerns that NHS Choices signposted people to dentists who claimed to have availability when they didn’t, who would then be encouraged to register as private patients.
The ASA agreed and contacted some of the practices, but this simply resulted in the dental practices no longer putting their availability on NHS Choices, which does not assist the public in finding available NHS dentists.
NHS Charges and Fines – Are patients exempt?
Healthwatch Kirklees and Healthwatch Calderdale received reports from members of the public who had mistakenly stated that they were eligible for free dental care, and had subsequently received fines. Whilst they were happy to pay for the treatment, they could not afford the fine. We worked with local dental practices to ensure that they were displaying information about eligibility and spoke to the NHS Business Services Authority about a change to their approach but struggled to influence.
In May 2019, we made a submission to the Public Accounts Committee Inquiry in to Dental and Prescription Charges and Fines, and were pleased with the outcome of that process.
Recall Matters
Healthwatch across West Yorkshire worked partnership with the office of the Chief Dental Officer at NHS England to review and adjust the dental recall rate for NHS patients with healthy teeth and gums. The project was supported by the British Dental Association, NHS Business Services Authority, Public Health England and the Care Quality Commission. The average recall interval following Band 1 dental care in West Yorkshire is around 8months. We aimed to increase this interval by 1month to release capacity for dentists to see other patients. We sent recall interval data to each dental practice on a monthly, then quarterly basis; ran a public awareness campaign around dental care; surveyed dentists for their views on recall and led a multi-agency board including the above partners.
We were not able to change the average recall rate, but we now see greater variance in the length of time for recall, suggesting that more patients and dentists are thinking about how often they need to attend for a check-up.
Oral Health Action Group
Healthwatch Kirklees now sit on the Oral Health Action Group led by Public Health in Kirklees, through which we hope to raise people's awareness of the importance of good dental care.
NHS contractual changes
We are aware that NHS England are trialling new approaches to routine dental contracting in West Yorkshire, which we welcome.
DentAid
DentAid still deliver urgent sessions of dental access in the most deprived parts of North Kirklees and are busy with patients constantly through those sessions.
There are 3 key adjustments that we would like to see in the delivery of NHS dentistry services.