DLS0111
Written evidence for the British Society of Paediatric Dentistry
Introduction
The British Society of Paediatric Dentistry (BSPD) is a specialty of 650 members, mainly Specialists and Consultants in Paediatric Dentistry, committed to improving children’s oral health. Our evidence to the Health and Social Care Committee outlines our vision for improving access and care for patients aged 0-16.
Summary points
Q.1 What is the state of the relationship between the NHS and dentistry? How satisfactory are the arrangements for the provision of dental services by the NHS? Are current arrangements contributing to the widening of health inequality?
Equitable access to health care services which are free at the point of delivery is a basic underpinning principle of the NHS. Dental problems are very prevalent in our population and are a common source of pain and infection. Easy and timely access to effective emergency and follow-up management of acute dental problems is therefore an essential component of overall healthcare.
Unfortunately, for patients with acute or chronic pain or infection, accessing either general or specialist level dental care can be very different to accepted standards of access for similar conditions occurring elsewhere in the body. Dental care is the only part of the NHS where acute pain and/or infection will require non-exempt adults to pay to simply be assessed by a clinician. Dental charges can also be a barrier to adults accessing routine dental care, which can discourage families from attending a dentist, thus depriving some children from receiving dental prevention and early treatment for disease. Some families are not aware that NHS treatment is free for children and both pregnant and nursing mothers. Unlike the family doctor service, children and their families are not registered with a family dentist, meaning that only a short while after completing an oral health review (check-up) family dentists have no further obligation to see those patients. All these factors combine to cause dentistry to be considered separated from other NHS health care in both the minds of NHS health professionals and patients. The effect is to create barriers to accessing routine and emergency care, and we are especially concerned about the negative effect this may have on the health and well-being of children.
We believe that current arrangements for the provision of dental services are unsatisfactory and not as effective as many other parts of the NHS in both the prevention or treatment of dental disease in young people. Since dental disease is more prevalent in deprived communities, the current inadequate arrangements are contributing to widening health inequality.
We recommend that there is a thorough analysis of access to dental care, specifically paediatric dental care, with the aim of achieving easy and equitable access wherever you are in the country.
Q.2 How could access to NHS dentistry be improved? Are there inequalities in access to dentistry services? If so, why, and what could be done to address them?
The number of children being referred into hospital for multiple extractions under general anaesthesia is extremely high and results often from delayed recognition of disease and the difficulties front-line family dentists have in treating dental decay in children, especially the young and/or anxious child. Regular visits to the dentist from the age of six months are essential. Not only is a healthy mouth important per se, oral disease has an impact on all aspects of health and well-being. Shockingly, a survey of three year old children (Ref :1) has shown that 1:8 already have easily visible dental decay.
We have initiated the Dental Check by One campaign (Ref :2) to encourage parents to bring children into a dental practice by their first birthday. If the first dental check does not take place until school age it can be too late for many children.
The Units of Dental Activity system in the current GDS contract further discriminates against child patients with high dental needs, since their treatment is dis-incentivised. These patients are often referred on to a Specialist or a Consultant in Paediatric Dentistry which, because of severe pressure in these overstretched services, may mean going onto often long waiting lists for treatment.
The role of Specialists and Consultants should be largely for the treatment of patients with more complex dental needs. This includes increasing numbers of children who now survive complex medical conditions including congenital cardiac disease, cancer and blood malignancy, organ, bone marrow and stem cell transplant, as well as those with significant disability and those with complex developmental problems affecting the mouth and teeth. But in many areas, these specialist services are currently being overwhelmed by high numbers of children with relatively common less complex, but often extensive, dental problems, whose care falls beyond the scope and skill set of the family (general) dentist. Development and commissioning of services aimed at managing children with extensive dental disease, which is not otherwise complex, in the primary care sector could ensure consultant services are utilised more efficiently. Development of practitioners capable of delivering Tier two dental care, and an appropriate commissioning framework to support such care, is a priority.
Q.3 Where does dentistry fit within NHS primary care services? What opportunities are presented by the development of primary care networks?
The Commissioning Standard for Paediatric Dentistry (Ref 3)- published in April 2018 - outlined the steps that should be taken in order for children and young people needing specialist dental treatment to be seen by the right person in the right place at the right time. The Commissioning Standard describes a three tier structure for dental services. Tier one is for general practice, Tier two is for management of relatively common conditions which are above the complexity deliverable by a general family dentist (probably most efficiently delivered either within the Community Dental Service but also in General Dental Services) and Tier three is for complex, specialist services in the CDS (3a) and in hospitals (3b) which would need to be delivered by specialist and consultant-led teams.
Central to the development of paediatric services are Managed Clinical Networks (MCNs) which are designed to manage services in their areas. However, with the exception of one or two networks, these groups are struggling to make an impact. Their work is frequently seriously hampered by an acute shortage of Paediatric Consultants and Specialists as well as services which are inadequately resourced. Many parts of the country still have no Specialist or Consultant-led Paediatric Dentistry services, with care often being provided by dentists with no specialist training in Paediatric Dentistry and no access to specialist advice or guidance. Even where there is provision, there is often a serious under-availability of Specialists and Consultants, not only to 3a and 3b level care provide care, but also to train, support and develop further skilled practitioners to deliver both specialist and Tier Two level care. The acute shortage of suitably qualified paediatric dentists is a problem. Where there is no local paediatric service for GDPs to refer into, the management of patients and the outcomes of treatment may not be optimum.
We would like NHS England Commissioners to enable the provision of specialist paediatric dental services for children with complex or extensive dental disease, as laid out in the NHS Commissioning Standards for Paediatric Dentistry (Ref 3).
Q.4 What issues are affecting the wider dental workforce? What steps need to be taken to address them? Is sufficient data available on the workforce and if not how should it be improved?
Workforce shortages within Paediatric Dentistry are leading to acute access problems in some areas, with long waiting lists for children to be seen by a paediatric dentist. The rise in the need for specialist and consultant-led paediatric dentistry services means need more Specialists and more Consultants. Consultants and Specialists not only provide care for the most complex cases, but are also needed to train, support and develop other practitioners with so they can manage more common conditions which are nonetheless beyond the scope and skill-set of a family dentist (GDS). They are also needed to train future specialists and consultants.
Unfortunately, in spite of growing demand and waiting lists, there has been a long-standing failure to prioritise the training of specialists in Paediatric Dentistry, leading to a critical shortage. In 2000, when the specialist list for paediatric dentistry was established, there were initially about 200 specialists registered in the whole of the UK. In 2008 there were 234 and The number today remains almost unchanged today at 239 (Ref: 4), which is made even worse by uneven distribution around the country. In comparison, there are now around 1400 registered Specialists in Orthodontics, the vast majority of whom only provide orthodontic tooth straightening.
We would like Health Education England, PHE and NHS England commissioners of dental services to work with us to address this now critical deficiency in services for paediatric patients. We recommend that the oral health needs assessments of the child population are completed as is required in by NHS England’s Commissioning Standards. This should lead to the identification of workforce shortfalls and calculation of the number of Specialists and Consultants in Paediatric Dentistry that are required to support the required volume of Tier 2 and Tier 3a/3b care. We would ask that dental disease leading to pain, infection and morbidity in children is given similar importance to comparable child health problems.
Existing resources could also be used more effectively. For instance, we should recognise the potential for the training and development of the future paediatric dental workforce within the Community Dental Service as well as in hospital. Once we know how many specialists and consultants in paediatric dentistry are required we advocate that there is swift action to develop a paediatric workforce and improve access for children suffering from dental disease.
Our vision is for a paediatric workforce composed of differing skill levels. Dentistry should be maximising the skills of Dental Therapists and Extended Duties Dental Nurses while dentists with Tier 2 skills –ie additional paediatric training - could be seeing patients in practice and community settings. Consultants and specialists could then focus on the more complex needs and provide training for the workforce of the future. BSPD is keen to work alongside NHS England and Health Education England to create a blueprint for an NHS paediatric dental service which can address children’s oral health needs and deliver health improvement by effective timely intervention and prevention consistently across the country.
The Commissioning Standard for Paediatric Dentistry is the first NHS document to detail a comprehensive framework for the development of a consistent and integrated model for the delivery of Specialist Paediatric Dentistry services in England. The goal is to ensure equitable access to high quality Paediatric Dentistry services for all children who need such care.
Q.5 What are the issues in commissioning and payment systems for NHS dental services? How can they be improved?
As highlighted above, the necessary steps to improve the commissioning of and payment for Paediatric Dentistry services are described in the NHS England Commissioning Standards for Paediatric Dentistry (Ref 3). Now that we have MCNs we believe services could be optimised if budget-holders and key decision-makers were co-ordinating with the clinicians within the networks. The work of the devolved administration of Greater Manchester Health and Social Care Partnership shows what can be achieved when commissioners, budget-holders and clinicians work together. In Greater Manchester our vision for stratified services with oral health champions working in local communities is being realised and children’s oral health is improving. However, there is still a shortage of Specialists and Consultants in Greater Manchester.
Q.6 What needs to be included in, or removed from, the forthcoming NHS dental contract? ·
BSPD believes that there are cohorts of children who are not well served by the current NHS contract and there should be services which are better designed to effectively and efficiently meet their needs. We would like to see enhanced support for General Dental Practitioners and removal of financial disincentives in the current GDS contract, so that they are enabled and encouraged to undertake care of children with significant dental disease. Vulnerable children with medical co-morbidities, learning difficulties and behavioural problems need to have a focused specialised services delivered by Specialists and Consultants in Paediatric Dentistry.
Prevention in all its forms – advice and treatment – should underpin the dental contract.
Q.7 Is there enough focus on prevention in dentistry and what are the avoidable harms that could be addressed? What more can be done to encourage prevention and what can be learnt from best practice in other parts of the UK and EU?
Prevention is not integral to the current NHS dental contract but should be. We would like to see the commissioning of oral health improvement measures with a known evidence base (Ref:5 ). We would like to see supervised toothbrushing schemes in early years settings and prevention measures targeted towards the area of greatest need. We would like to see our Dental Check by One campaign launched with the support of the Chief Dental Officer for England becoming fully integrated into all aspects of healthcare. Currently there are too many children suffering from
Q.8 What should be done around fluoridation policy and what is the evidence base to support it?
We have produced a position paper on water fluoridation (Ref: 6) which sets out our views as well as the evidence to support fluoridation. In summary we believe in targeted water fluoridation where it is possible.
A vast array of bodies around the world support water fluoridation. Public Health England’s 2018 water monitoring report (Ref:7) said “…water fluoridation is an effective and safe public health measure to reduce the prevalence and severity of dental caries, and reduce dental health inequalities.”
September 2019