Written evidence submitted by the British Dental Association (HSC0955)
About the British Dental Association
The BDA is the professional association and trade union for dentists practising in the UK. BDA members are engaged in all aspects of dentistry including general practice, community dental services, hospitals, academia and research, and our membership also includes dental students.
Good oral healthcare is essential to general health and wellbeing and it is critical that there is dental input to Integrated Care Systems. Dentists have much to contribute to population health, but place-based care needs to be founded on a sustainable footing to really deliver change.
Our key points on the integration proposals are that:
- There is a risk that dentistry and its impact on system health is overlooked in the integrated care proposals. The direction of travel from the NHS Long Term Plan is not as clear for dentistry as it is for other sectors and there is a concern that the opportunity for a holistic approach which will greatly benefit patients will be lost if the profession is not involved in shaping models of collaboration.
- Systems should look to include dentistry and oral care within their programmes of work and governance structures. There should be a mandated position for dentistry on each ICS Board to ensure that knowledge and experience from across the profession is shared at system level.
- The implementation and funding plans mentioned in the White Paper will be central to the success of the NHS integration proposals – as will be meaningful collaboration and consultation in their development.
- Prevention is a key ICS responsibility which must be supported and enabled across organisational boundaries. Perverse incentives need to be removed from the system if the true benefits of integration and achieving oral health outcomes are to be realised.
• To protect provision for patients there must be safeguards in place to mitigate against the risk of fragmentation and variation if dental commissioning is to be transferred over to local systems. Dental funding streams across primary and secondary care dentistry must be protected, and indeed enhanced, if we are to meet oral health needs.
• We strongly welcome the commitment in the White Paper to maintaining patient choice. There is a need to ensure that services are delivered locally wherever possible across primary and secondary care. Primary care dentistry is not always accessed close to home by patients, and patients must be free to seek treatment across ICS and Primary Care Network boundaries.
- The commitment to reducing competition and bureaucracy in the NHS is welcomed but cultural change will only come through advice, guidance and training for commissioners.
- Given the scope of the work that has been and is yet to be carried out we understand that the proposals cannot be comprehensive. We have commented on the implications of these proposals as far as we can and await the opportunity to engage in discussions on the other reforms and the implementation plan.
- We cannot overstate how important the implementation and funding plans will be nor the importance of meaningful collaboration and consultation in their development.
- We welcome the general direction of travel which this White Paper underpins. Our health service works through collaboration and goodwill and it is important that the underpinning structures facilitate this. We are pleased to see steps being taken to remove some of the barriers we have highlighted many times: the application of procurement legislation has been (and continues to be) a barrier to the provision of quality dental care.
- We welcome the commitment to shift away from systems centred on activity payments to more collaborative systems dedicated to tackling shared problems. This is the approach we have taken in our work on a prevention focused reformed national dental contract - it is important that transformational commissioning is facilitated as that will do much to underpin dental involvement in integrated care.
- We have focused here on the integrated care and workforce proposals (rather than the additional measures). In looking at these we have highlighted areas where the rationale for change is unclear or where there are risks of unintended consequences.
Establishing Integrated Care Systems
- Whilst we welcome this as a direction of travel, we share the concerns voiced by other stakeholders about the timing of these changes to the structure of the NHS when health care staff (clinical and non-clinical) are still dealing with a pandemic and its aftermath.
- Prevention is one of the key drivers for integration and one of the key ICS responsibilities – it must be supported and enabled across organisational boundaries. Currently, local authorities are responsible for oral health improvement programmes, but any potential cost savings are realised by NHSE/I and not local authorities, deterring them from long-term investment. These perverse incentives need to be removed from the system if the true benefits of integration and achieving oral health outcomes are to be realised.
ICS NHS Body role
- The White Paper states that the ICS NHS Body may take on some of NHS England’s commissioning functions.
Maintaining dental commissioning expertise
- The commissioning functions of CCGs currently do not include responsibility for commissioning primary care dentistry. NHSE/I commissions all dental services (primary, community and secondary care including dental hospitals and out-of-hours services) with the aim of achieving greater efficiency, and better integration between general and specialist dental care.
- The dental profession is different to other professions in terms of the breadth of the training and career pathways, the way in which care is delivered in different settings, and the way professionals work in the NHS as well as on a private basis. The business arrangements and costs to the end user in primary care and the mixing of NHS and private treatment is unique to primary dental care provision. An understanding of these issues is important so that the commissioners are aware of how decisions they take will affect the profession, and thus the delivery of oral health care.
- ‘Securing excellence in commissioning NHS dental services’ published by NHS England in 2013 stated that: ‘Commissioning the totality of dental care gives us the opportunity to better integrate primary and secondary services to provide better care and outcomes for patients’. The care pathway approach was designed to ensure consistency in the delivery of dental services, the ‘journey’ that patients’ experience, and to ensure a focus on patient outcomes. This has proved to be the case and we must be assured that we build on this - not go backwards.
- In terms of primary dental care, we are aware that much of the discussion about involvement in ICSs and PCNs to date has been in terms of primary medical care. This is understandable but there is a risk that primary dental services are seen by ICS commissioners as a smaller part of this provision – and an assumption made that the same approaches can be applied and will work across primary care. This is not the case. The differences are significant and are both contractual and structural.
- NHS dental services should be commissioned by dedicated dental commissioners who understand how NHS dentistry should work. This position has been reinforced by the problems we have experienced with dental services provided in secure estates – where the subcontracting or use of inappropriate NHS contracts has led many practitioners to lose pension, maternity and paternity rights - an issue which it has taken us many years to resolve with NHS England Health and Justice
- In terms of hospital and community dental services, there is much to gain from collaborative care, and clear linkages with other professions and areas of work. For community dental services in particular there may be opportunities brought about by greater integration within an ICS. Better integration may better enable shared care which the CDS excels at because of the nature of the patient base, and we are looking to explore where there might be those opportunities. However, each ICS is constituted differently so one approach for CDS might not be appropriate.
- We note and welcome the statements about limiting employment changes for NHS staff but the structural changes proposed are significant and there will surely be impacts. Even where experienced commissioners are retained within the new arrangements there will need to be a period of transition and learning whilst new work cultures are built - in some areas it will take time to embed these across the board. We would wish to be reassured that uncertainty is minimised for dental providers and no new burdens added.
- In addressing one set of problems/barriers we would not want to add new ones in the form of increased complexity and cost.
Maintaining equity of access for patients
- We welcome the affirmation in NHS England’s legislative recommendations of its continued commitment to national contractual arrangements across the primary care contractor professions. Also, the commitment to the primary and community services funding guarantee in the NHS Long Term Plan.
- It must however be noted that NHS general dental practice remain the only part of the NHS in England operating on a lower budget, in cash terms, than it received in 2010. In real terms, net Government spend on general dental practice in England has been cut by 42% in real terms since 2005/06.
- The unmet need for dental care is a significant public health problem - amounting to 1 in 10 of the adult population pre COVID – this is certain to rise and will likely to be felt most by those in most deprived communities.
- To protect provision for patients there must be safeguards in place to mitigate against the risk of fragmentation and variation if dental commissioning is to be transferred over to the local systems. The national dental contract for general dental practice must have primacy. Dental funding streams across primary and secondary care dentistry must be protected and spent on NHS dental services. Any pooling of resources among already under-resourced branches of primary care is likely to determine the fate of any plans at the outset. Oral health funding needs to be enhanced if we are to meet oral health needs.
- Whilst the national contractual arrangements protect against the risk of a postcode lottery, there is also much scope for involvement in targeted local initiatives. There are many examples of dental involvement in PCNs and ICSs (including the Healthy Living Dentistry framework used in Greater Manchester where a toolkit and pathways have been developed). Funding from the Better Care Fund or an Extended Services Contract would facilitate the significant contribution which could be made in other areas.
Maintaining patient choice
- We strongly welcome the commitment in the White Paper to maintaining patient choice. There is a need to ensure that services are delivered locally wherever possible across primary and secondary care.
- It should also be noted, however, that primary care dentistry is not always accessed locally by patients. Most practices are located in local communities, often close to schools and on the high street where they are easily accessed by patients. We would be concerned if patient choice was in any way constrained and if longstanding patients could not attend their regular practice. Many patients suffer dental phobias and being able to choose and continue to see a dentist they trust is paramount to ensuring their well-being. Many patients choose to travel substantial distances crossing multiple PCNs and localities to attend their practice of choice.
Dental input on ICS management or governance bodies
- Given the importance of oral health to overall health and wellbeing there should be a mandated position for dentistry on each ICS Board to ensure that knowledge and experience from across the profession is shared. If the ICSs are to take on commissioning for general dental practice, the input of dental clinicians on the frontline is needed.
- In addition to dental representation from services, the input of dental public health must be safeguarded in ICS governance and function to ensure a population view of oral health is maintained and ICSs are able to benefit from the expertise and knowledge of the speciality. There is a risk that oral health data and intelligence will only be available and reported at ICS level, a great concern at a time when oral health inequalities are widening. This may harm efforts to identify local commissioning priorities.
- As stated, arrangements for medical care are not easily mirrored for dentistry. This is not often widely understood even by those involved in healthcare. It even applies in respect of funded participation in important non-clinical activity such as attendance at PCN meetings – for which provision is made in GP contracts but not GDP contracts. Any ICS management or governance bodies should have appropriate funded dental representation and dental staff should have access to leadership training.
- Managed clinical networks (MCNs), including representatives from primary care, public health, general dental practitioners and the Community Dental Service where relevant, should feed into ICSs.
- ICS links with Local Dental Committees should also be strengthened and formalised in ICS governance. These statutory bodies have a key role in helping contractors deal with the local commissioning landscape – which will become even more important in the transition ahead.
- We strongly welcome the proposals and have long argued for dental access to summary care records and e-prescribing. Whilst this could be of massive benefit across all parts of dentistry, financing this could be an issue for independent contractors (including community dental services) as dental practices source and buy their own equipment. Funding would therefore need to follow any legislative mandate for data sharing.
- We welcome the plan to reform procurement of healthcare services and create a bespoke regime and will be contributing to the NHS consultation on this issue.
- We have long called for an end to the use of competitive procurement in dentistry and have supported proposals by NHS England to legislate for this. For general dental practice and particularly community dental services, going through a procurement process can cause services to be destabilised – impacting on the most vulnerable patients.
- It will however take time for a more collaborative way of working to embed – it is important that support is provided (in terms of learning and development) so that commissioners are able - as well as ‘allowed’ - to work in new ways. It is important that new commissioners are given time to work collaboratively with all contractors – large or small. It is often the smaller providers who are providing care in the right place and at the right time for patients, particularly in more rural environments.
- We would welcome a provision for a light touch independent appeals process in terms of the procurement process as there is currently no external recourse should issues arise other than legal action by individuals.
- We welcome the proposal to introduce a Secretary of State duty to publish a report every Parliament to support workforce planning responsibilities. Information about the workforce - including the numbers of NHS whole-time equivalent dentists working in the UK - in each area of dentistry should be assessed in the light of current and future needs.
- Whilst we welcomed the vision articulated in the NHS’s People Plan, in dentistry, financial pressures on practices are prevalent, and in a post-Covid situation economic recovery and dealing with the backlog of clinical issues while there may well be continuing NHS workforce shortages are likely to be the significant priorities. In our recent response to the Committee’s inquiry into workforce burnout and resilience across the NHS we explained how burnout in the dental profession is driven principally by systemic factors, which require a wide-ranging response reflecting both duty of care to practitioners and supporting patient access to services.
- Many of the support mechanisms offered to doctors, for example the Return to Practice support scheme, are not available to dentists. We are aware of the work of HEE’s Advancing Dental Care project but, while some of its approaches are welcome, the real situation the profession, the healthcare sector and the general economy find themselves in will not be a positive basis for major change. They will also require appropriate funding if they are moved forward.
- The White Paper contains several proposals about professional regulation. An intention to make the system of regulation more flexible and proportionate is clearly welcome. We are however supportive of the retention of a dental-specific regulator. As outlined elsewhere in this document the provision of services is different across different professions, and an understanding of this at regulatory level is essential for fair and proportionate regulation. Based on overseas experience (in Australia for example) such reforms do not necessarily lead to greater efficiencies, and there is a palpable risk of loss of needed understanding of the clinical context in which registrants operate. A ‘rebranding exercise’ that does not address the fundamental issues in terms of legal framework, administration, process and procedures must be avoided.
Public Health power of direction
- The White Paper makes provision for Power for the Secretary of State to require NHS England to discharge public health functions. It is not yet clear how this fits with the wider changes to Public Health.
- We have supported steps taken by the government to address obesity but continue to stress that the public health impact of such measures can be maximised only by considering the wider context of diet-related ill-health, including oral diseases. Front-of-pack nutrition labelling, HFSS TV advertising restrictions and online advertising bans are all measures we have campaigned for.
- We welcome the plans to re-centralise fluoridation but await the implementation and funding plans. We also need to ensure that this does not come at the expense of other public health programmes or proper investment in services.