Written evidence submitted by NHS Confederation (DTY0087)
The NHS Confederation is the membership organisation that brings together, supports, and speaks for the whole healthcare system in England, Wales, and Northern Ireland. The members we represent employ 1.5 million staff, care for more than 1 million patients a day and control £150 billion of public expenditure. We promote collaboration and partnership working as the key to improving population health, delivering high-quality care, and reducing health inequalities.
As the committee will be aware, from April 2023, all integrated care boards (ICBs) take on the commissioning of NHS dentistry from NHS England. The NHS Confederation’s ICS Network has all 42 ICSs in membership and this submission has been written reflecting their insights as they approach taking over this statutory responsibility. Also, it concorporates insight from our Acute and Primary Care Networks which are also involved in the delivery of NHS dental services.
All Integrated Care Boards (ICBs) will have taken on responsibility for the commissioning of NHS dentistry from NHS England by 1 April 2023. As the NHS Confederation has all 42 integrated care systems (ICSs) in membership, the majority of our submission focuses on this part of the inquiry’s scope.
This upcoming change in commissioning arrangements offers the ability to do things differently. ICBs will be responsible for commissioning right across oral health patient pathways and have more autonomy to commission services that meet the particular needs of a local population. There is a real opportunity ahead: ICS leaders are enthusiastic to apply a system-lens to the problems in NHS dentistry and see a focus on prevention and upstream work – keeping patients out of hospital – as a key way for health services to stem the tide of the most severe dental cases which are becoming all too common in the current context.
There is also an opportunity to reduce inequalities in access to services and in oral health outcomes. With reducing health inequalities as one of ICS four founding purposes, we know ICS leaders are committed to this and a number of ICS are already undertaking good work.
That said, ICS leaders are anxious about what they are inheriting and they know that it is unlikely that we are going to see drastic improvements to patient outcomes nationwide in year one of the new commissioning arrangements without further national support. Seven ‘early adopter’ ICSs took on dental commissioning from 1 July 2022. During this time, they have mainly been focused on the transition of commissioning function and most of the opportunity to do things differently lies ahead - they are surviving but not yet thriving.
Both commissioners and providers of dental services have concerns about the existing dental contract, which often disincentivises dentists from taking on more NHS patients. ICS leaders want to be empowered with greater flexibility in the contract so they can develop new models of care and ensure the NHS can provide care for those patients who need it.
In order to make the most of this opportunity, there are a number of things ICS leaders want to see from government and NHS England, in common with wider NHS Confederation members.
The first is a clear strategy for commissioning support and the transfer of expertise from NHSE (or elsewhere) into systems.
The payments made to providers of primary dentistry services – Units of Dental Activity (UDA) – often do not provide sufficient payment to incentivise dental surgeries from taking on more NHS patients. This must be addressed if we are to incentivise dentists to take on a higher amount of NHS work.
On funding, the NHS Confederation wants to see dental underspend – that is the money that dentistry providers turn down as the payment isn’t competitive – remain with ICBs rather than being ‘clawed back’ by NHSE. This will allow systems to reinvest dental funding back into transformative dental services, from new UEC centres to preventative programmes, rather than being used to plug gaps elsewhere in the national budget.
Finally, it is critical that workforce shortages in dentistry are included in the government’s long-term NHS workforce plan, which must be fully funded by Treasury.
What role should ICSs play in improving dental services in their local area?
- With all 42 Integrated Care Systems (ICS) in membership, our ICS Network has spent time over the previous months working closely with ICS leaders ahead of ICBs taking on responsibility for the commissioning of NHS dentistry services from NHS England.
- ICS leaders are enthusiastic to apply a system lens to the problems in NHS dentistry. A focus on prevention and upstream work, for instance, could help to stem the tide of the most severe dental cases in future and it is hoped ICSs’ commitment to health equity will improve access to services as well as oral health outcomes. For the first time, dentistry will be commissioned alongside wider primary and secondary care services, incentivising financial efficiency, services tailored to the needs of local communities and signposting and better integrated pathways.
- One such example is that where money allocated with a ring-fence for specific conditions, such as diabetes, it could be used for improving dentistry services because of the links between diabetes and poor oral health.
- ICS are built on foundations of partnership, and their four core purposes include reducing health inequalities and delivering value for money and efficiency. ICS leaders know there is an opportunity to demonstrate that these new partnerships can foster real change and provide dentistry services in a way that best meets the specific needs of the population they serve.
- For example, some ICSs will look to set up an urgent dental care system that connects individuals from NHS 111 to a clinical triage and a designated urgent care provider. In some areas, improved community dental services are needed with capacity to meet the expanding needs and volume of patients who cannot be cared for in a high street setting. In others, domiciliary care is considered essential in residential settings and for vulnerable groups.
- ICS – particularly the Integrated Care Partnerships – provide an opportunity to work more closely with other public and community services to deliver oral health care, such as schools, early years settings and residential care settings. This has the potential to help tackle health inequalities by reaching demographic groups that are more likely to have poor oral health such as those living in deprivation.
- Seven ICS have been early adopters for the new dentistry commissioning powers since 1 July 2022, while all ICS are due to take on dentistry commissioning by 1 April 2023 (along with pharmacy and optometry – the three collectively known as POD).
- In addition to commissioning powers, ICS also have the ability to work with partners more innovatively to create more capacity. In Suffolk an innovative partnership between the University of Suffolk and the Suffolk & North Essex Integrated Care Board is seeking to create capacity through the set-up of a community interest company (CIC) specifically to provide NHS dentistry.
- In the Midlands, NHS leaders are looking to place a new urgent dental care service alongside an A&E department, reflecting that if that’s where patients are presenting, then that is the best place to locate it.
- Some ICS have been able to move work forward already –for example Greater Manchester has had POD commissioning powers including for dentistry for some time under their devolution deal, which enabled it to invest in dentistry during the peak of the COVID-19 pandemic.
- The NHS Confederation’s ICS Network is developing a ‘lessons learnt’ report involving reflections from the early adopter ICBs for pharmacy, optometry and dentistry (POD) commissioning. This will be published prior to wider delegation in April 2023.
- Whilst there is much to be optimistic about there are some considerable challenges facing ICS as they move to take on the commissioning of NHS dental services.
- Members tell us a key concern is the lack of access ICSs currently have to dental datasets to best understand current demand for services and the needs of the local population.
- ICBs require the commissioning infrastructure for dentistry – with skills and staff moving from NHS regional teams, who have carried out dentistry commissioning on behalf of NHS, into systems to reflect the delegation of responsibility.
How should inequalities in accessing NHS dental services be addressed?
- As noted above, with reducing health inequalities as one of their four core purposes, ICS leaders are committed to commissioning services in a way that best tackles local inequalities in access to NHS dental services, along with inequalities in oral health outcomes.
- NHS data reported an increase in general dental service activity being higher in adults than in children following the reopening of dental services after closure due to COVID-19, with clear inequalities in the uptake particularly amongst children and older adults; 10% more children and older adults in the least deprived areas of England utilised services in October 2020, compared to those in the most deprived areas.
- Hospital admissions for tooth extractions are strongly socially patterned with children living in more deprived areas being more likely to receive this care and have more teeth removed during an episode. There are also there are marked inequalities in rates of oral cancers, with higher incidence rates in more deprived and vulnerable groups.
- When local access to NHS dental care is poor, the expectation is often that patients will travel to a neighbouring area, such as a large urban area, to get dental care. Even if a patient is eligible for free dental treatment due to their financial situation, many cannot afford the cost of travel to get to an appointment when it is not local.
- Over time, ICSs will be able to achieve more equitable access to NHS dental services and they can also help to address some of the most acute access inequalities now through partnership of NHS and local authority to provide services in accessible spaces through health on the high street schemes, for example.
Does the NHS dental contract need further reform?
- The NHS dental contract is what ICS leaders are most concerned about in taking on commissioning NHS dental services.
- The contracting mechanism varies across community, acute and independent providers and this risks undermining some of the progress commissioning services across a system will bring.
- In July 2022, the then-Parliamentary Under-Secretary of State for Health and Social Care described current dental contracts as “a perverse disincentive for dentists to do NHS work.” 2020/21 saw a 4 per cent reduction in the number of dentists with NHS activity and a British Dental Association survey found that 75 per cent of dentists responding said they were likely to reduce their NHS commitment in the next year.
- The current contract also incentivises the treatment of people with healthy teeth – the income from delivering simple dental interventions for the NHS is far greater than the income from delivering complex interventions. This is often why people with healthy teeth and gums are encouraged to return to their dentist once every 6 months (when according to NICE guidelines, many patients only need a check-up once every 2 years).
- This results in dental capacity being taken up by with patients without clinical need, and there is less capacity for those who might struggle to attend appointments in work time, who have additional health needs or other challenges in their life. This exacerbates inequalities in accessing NHS dentistry services.
- Some of the people with the most complex dental needs are those who are unlikely to have seen a dentist for many years due to their personal circumstances – for example, people experiencing homelessness. Under the current contract, it’s unlikely that they will be taken on by an NHS dentist as the extent of their dental work will far surpass the contracted value for delivering the care.
- Given low Unit of Dental Activity (UDA) rates in the national contract dentists are reluctant to take on NHS patients and are instead prioritising private patients.
- Therefore, national funding pots allocated by NHSE to improve dentistry access are being made available but are in many parts of the country not being spent and thus returned to NHS England.
- Proposed reforms to the dental contract that reflect the NICE guidelines and incentivise NHS dentists to take on more complex cases must be implemented as soon as possible. The reforms must be accompanied and informed by a full health equalities impact assessment.
What incentives should be offered by the NHS to recruit and retain dental professionals, and what is the role of training in this context?
- NHS Employers is part of the NHS Confederation and works closely with employers of those dentists directly employed by the NHS, such as dentists working in acute settings employed by NHS trusts. They also have a salaried dentists negotiation group which negotiates on pay and conditions. They also work with employers across the NHS on training for community dentists.
- We know from the British Dental Association (BDA) that there is not enough of a skill mix amongst the dental workforce. Health Education England (HEE) are working an Advancing Dental Care Training review and NHS Employers are working closely with them on this.
- HEE have reported that the geographical distribution of the dental workforce ‘does not match the need or demand for dentists and specialists.’ The uneven distribution of dental training schools has resulted gaps in remote areas such as Cumbria, Lincolnshire, East Anglia and some parts of the South West.
- Whilst there are overall gaps in the dentistry workforce there is scope for ICS to help to address inequalities in access to NHS dental services through system-wide workforce planning. Without more national action to bolster recruitment and retention however this will be difficult.
- HEE’s Advancing Dental Care review, published in September 2021, recognised that the composition and skill-mix dental workforce must be aligned with patient need and future training provision must be patient-centred. Its recommendations included exploring the creation of centres for dental development in areas with unmet need.
- Plans to implement HEE’s recommendations must be agreed and initiated as soon as possible, ideally before all ICSs assume formal responsibility for dental services by April 2023.
What steps should the Government and NHS England take to improve access to NHS dentistry?
- Our broader membership across the NHS system is concerned about the increasing pressure issues with access to dental care are placing on the wider NHS – particularly on A&E. Pressures also exist in primary care, placing the workforce under pressure around clinical competency and indemnity. One senior dentist recently told us that 11% of NHS 111 calls in his integrated care system (ICS) were dentistry related.
- In the current context of a waiting list of over 7 million people waiting for elective treatment, serious problems with flow through the system driven in part by the lack of available social care packages and wider structural pressures on the health service including over 130,000 workforce vacancies and a lack of investment in capital, this increase in patient need for acute dental care only adds to the pressure we’re seeing on services. Additionally, despite a record number of GP appointments taking place in October (the latest published data available) – patient need still outstrips capacity.
- The NHS Confederation believe it’s critical that NHS England commits to further national support in dentistry. This would have ideally started with a full review of the existing dental contract and overall funding levels before all ICSs assume formal responsibility for dental services by April 2023. NHSE should seek to learn from the early ICS adopters for dentistry commissioning to help systems identify effective interventions.
- But shifting power away from the centre and to ICSs, as Professor Sir Chris Ham proposed in our report earlier this year, requires a shift of resource. NHSE must encourage those with dental expertise into local systems, including by supporting ICSs with recruitment, so that the institutional commissioning knowledge and experience is not lost with the transfer of commissioning responsibilities.
- The NHS Confederation also believes that national funding made available for dentistry should stay with ICBs so they are able to reinvest in dentistry. Often when NHS England has provided funding it has been made available until the end of the financial year and any underspend has not been carried forward, instead being ‘clawed back’ to plug gaps in other areas of national NHS spending. This figure could rise this year to around 20% of the national allocation.
- In addition, the issues with the UDA mean that dentists across England will hand back £300m at end of year of under-delivered work. Again, the NHS Confederation wants to see this money remain with ICBs so they are able to invest back into oral healthcare to address the significant problems we see in NHS dental service provision.
- The long-term workforce plan for the NHS that the government committed to at the Autumn Statement must reverse the decline in the number of NHS dentists – the number of which fell from 23,733 at the end of 2020 to 21,544 at the end of January this 2022. As the NHS Confederation has said before, it’s critical this plan is fully funded by the Treasury.
- Despite the best efforts of ICS leaders, it is unlikely that we are going to see drastic improvements to patient outcomes nationwide in year one of them taking over dentistry commissioning powers from NHS England without further support. Indeed, seven ‘early adopter’ ICSs have taken on dental commissioning already and much of the first 6 months has been focused on the transition of dentistry commissioning, not yet transformation in dentistry care. Fixing a failed model of NHS dentistry will take some years for ICS to achieve without the three key changes highlighted in this submission.