Written evidence submitted by The LDC Confederation (FND0014)

1. The LDC Confederation is a membership body for Local Dental Committees (LDCs). We currently represent four LDCs covering 22 London Boroughs, representing about 3,500 primary care dentists who provide NHS dental care under a GDS contract.

2. As the largest representative body of primary care dentists with a sole focus on NHS primary care dentistry, the LDC Confederation is submitting evidence on behalf of its members. The LDC Confederation and member LDCs are committed to strengthening and growing NHS primary care dentistry, working with stakeholders at the local, regional and national level to ensure value for money and a sustainable NHS dental service. The LDC Confederation recently outlined our main issues and concerns from 2024 in an article in early 2025[1].

3. We will not be providing any data in our submission as the Committee has access to sufficient data from the same sources we would use, e.g. the NHS BSA, and through the National Audit Office. Our response will, as a result, focus on our perspective on the value for money that NHS primary care dental services can and should provide, and what is needed for it to be able to do so.

4. The LDC Confederation has argued that NHS dental services are being failed due to a lack of coherence and planning about what NHS dentistry is meant to provide for the population[2]. In order for NHS dentistry to provide value for money to the taxpayer, by which we mean being able to play its role in Integrated Care Boards' (ICBs) responsibilities to reduce health inequalities and improve health outcomes, a coherent vision for NHS dental services is required.

5. What is not value for money is a system driven by arbitrary activity measures influenced by perverse incentives. The lack of clear and robust flexible commissioning guidance for ICBs which could result in meaningful improvements to services means that in the areas represented by our member LDCs there is currently no flexible commissioning. Instead if there is an anticipated underspend the funding is simply allocated to practices which are expected to exceed their contracted target. This is untargeted and does nothing to support a reduction in health inequalities or improve health outcomes. It simply ensures that a budget that has been allocated has been spent, with no consideration given to why it has been allocated in the first place.

6. In our view, there is a significant misalignment between the responsibilities of ICBs to reduce health inequalities and improve health outcomes for their populations and the current structure of the national dental contract. The contract's lack of targeted focus and coherent strategy creates challenges in delivering equitable and effective care.

7. The dental contracting arrangement has perversity built into it from the outset. For instance, even if flexible commissioning guidance was improved and contracts could be targeted to a specific location (e.g. Core 20 areas) or people with specific conditions (e.g. diabetes) there would be an incentive on ICBs to not use dentistry in this way. Access for children could be universal (to the exclusion of everyone else unless the overall budget increased), but this would result in a significant drop in patient charge revenue as well as overall access. Integrated Care Boards thus have a perverse incentive to not focus solely on reducing health inequalities as they require a significant proportion of their budget to be recouped by patient charges. Unless this system is changed and the reliance on patient charges removed, the move to full integration and allowing dentistry to play its part in reducing health inequalities will not be possible. This leaves dentistry not providing as much value for money as it otherwise could[3].

8. There is a clear move to greater integrated ways of working, which the LDC Confederation and our member LDCs welcome[4]. Having dentistry as part of Integrated Neighbourhood Teams would represent a significant step forward in improving health outcomes, reducing health inequalities, increasing patient satisfaction and, we believe, boosting the morale and motivation of the dental profession[5].

9. The ICBs that our members are engaged with, North West London, South West London, South East London and North Central London have all started discussions about how dentistry can be part of an integrated way of working and place based leads are especially keen to see this way of working develop[6]. There is a clear evidence base of the relationship of oral health to overall health, making it clear that involving dental services would improve health outcomes[7]. Yet progress is hampered by an outdated and purposeless contract which actively prevents the targeting of care while pretending that it is a universal service when it is no such thing. Indeed all discussions about dentistry, including the Dental Recovery Plan, continue to address dentistry in a silo and as separate from the rest of the NHS.

10. In the short term, to support the integration of NHS dentistry with the rest of health and social care we need improved guidance on flexible commissioning which widens its application to the targeting of mandatory services in line with local priorities (Core 20+5). Current guidance allows new or existing funds to be used only for advanced or further services, provided that no drop in access or activity would be recorded. This severely restricts innovation. In the long term we need a reformed contract to be developed in discussion with the BDA which takes into account the need to support integrated services. As well as these factors several other things are required, including improved digital connectivity for NHS dental practices, far better data on dentistry to be made publicly available to support planning of services and investment in the dental profession to ensure that by the time the contract is reformed there is a dental profession left to work on it.

11. To date there has been no movement on contract reform. This is, despite reform being recommended as long ago as 2008, and despite there being several administrations since then, each pledging to reform the contract. Instead with the Dental Recovery Plan and with the current administration there is once again only a focus on uncoordinated action, primarily focused on urgent care. This is despite the evidence that a continuing care relationship is both better for outcomes and something that patients want[8]. To date there has been no movement to explain how NHS dentistry fits with the rest of the NHS. The NHS is routinely described as free at the point of service, but it is not for dentistry. The NHS Constitution says: "the NHS provides a comprehensive service, available to all”. But not when it comes to dental services. Nor indeed is dentistry usually included in documents which discuss "primary care", even though in others it is referred to as one of the four pillars of primary care. There is simply no parity for dentistry at the moment. What this indicates most strongly, however, is the lack of ambition that goes into planning for NHS dentistry. With a national contract which says anybody can access care anywhere, there is no planning required. As a result it is easy for successive governments to claim that there is sufficient investment in the global sum because someone in the south of England could in theory access an available appointment in the north of England.

12. We draw the Committee's attention to the report from the London Assembly Health Committee which recently investigated NHS dental services in the capital. Its report was balanced and made clear and actionable recommendations. One of the key points it makes is that despite almost all contracted activity being delivered, only about half the population of London had accessed an NHS dentist, clearly showing that there is a lack of supply[9].

13. The Dental Recovery Plan set out various ambitions as noted in the call for evidence. The ambitions, however, such as an increase in courses of treatment and appointments for "new patients" were untargeted and incoherent. As the National Audit Office has shown, the plan did not deliver. Further, the application of the New Patient Premium prevented ICBs from running any flexible commissioning models in addition to the New Patient Premium. This undermined the potential for progress in local decision making[10].

14. The New Patient Premium used existing money to pay dentists more for seeing a patient they had not seen before or at least for two years, though they may have been seen at a different practice in that time. It represented no new investment and so could only realistically reduce access overall[11].

15. The Committee has already noted in its call for evidence the reduction in the number of dentists providing NHS care and also the general access rates. As noted above we will not be providing data which is publicly available, or available to the Committee from other organisations which are the data controllers such as the NHS BSA. However, in September 2024 we asked the NHSBSA for the number of providers of NHS Dental care by local authority in 2019 and in 2024 to see what change there had been during the pandemic. In April 2019 the NHS BSA told us there were 7,041 providers and that this had reduced to 6,553 by April 2024. This is a reduction of 488 providers or a loss of almost seven per cent[12].

16. If practices continue to hand back NHS dental contracts there will be several repercussions. A survey of 237 people carried out by the LDC Confederation confirmed that the vast majority of respondents were in favour of dentistry being available on the NHS and that cost was a barrier, with private dental fees being unaffordable for many[13]. If there was no NHS dental service a significant cohort of patients would be left with no access, and as seen over the general election period this can lead people to take drastic action. Not only would this result in a severe drop in access to dental care, it would also result in a fragmented health system just at the point where integration is being promoted as the future way of working. If the most vulnerable in society are unable to access dental care the impact on health would be severe as would the overall impact on the economy[14]. The Secretary of State for Health has made it clear that the NHS must help drive economic growth by enabling people to work. Dental care is a vital element of this. If someone cannot eat, speak or socialise with confidence they will be unable to get any job. Furthermore, there has been a long held intention for the NHS to move away from being a sickness service towards a prevention, wellness service. Dentistry represents the main prevention focused primary care service. The message that people go to the dentist to prevent oral disease is very strong. Rather than jettison that we recommend that the NHS capitalises on that message and makes it clear that the dental practice represents a fantastic opportunity for first contact with the health system. For that to be meaningful dentistry needs to be a full part of the NHS, with investment in IT infrastructure and a contract that supports integration with the rest of health and social care.

17. For further information we direct the Committee to our response to the Change NHS consultation which is with colleagues at the Department for Health and Social Care.

18. As ever the LDC Confederation would be happy to provide any clarification necessary to the Committee on points made in this submission.

Recommendations

1. A clear vision for NHS dentistry must be articulated in conjunction with stakeholders so that all parties know how the service is intended to operate. This is the only way to achieve meaningful accountability.

2. The contract must be reformed taking into account how dental services can and should integrate with the rest of health and social care. This must be done in association with the British Dental Association and be informed by local models and plans from Integrated Care Boards about how they see dentistry working as part of integrated teams.   

3. In the meantime improved guidance on flexible commissioning must be issued, giving ICBs the ability to flexibly commission as much of a dental contract as they see fit (in consultation with the LDC and other local stakeholders) for the purpose of reducing health inequalities and improving health outcomes.

4. Flexible commissioning standard variations should be created to ensure that models operate in a consistent fashion nationally, but with a focus relevant to local needs. This will reduce the burden on overstretched commissioning teams and mean that there are simple standard templates to choose from.

5. Patient charges need to be reviewed to make sure they do not represent a perverse incentive for commissioners or barriers to care for patients.

6. Dental data needs to be published on a par with GP data to support integration of services. Ideally dental data would map onto and be reported in the same way as GP data so that it can be of use in planning services and evaluating outcomes.

January 2025

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