Written evidence submitted by the LDC Confederation (DEL0248)
The LDC Confederation welcomes the House of Commons Health and Social Care Committee Inquiry into Delivering Core NHS and Care Services during the Pandemic. We direct you to our submission to the aborted Health and Social Care Committee Inquiry into Dental Services from September 2019 for further recommendations on dental services. We are very happy to expand on any point mentioned in this response or our previous response either over video link or in writing. Our additional policy statements and consultation responses are available on request.
Local Dental Committees (LDCs) exist throughout the UK. They are the elected representative bodies for primary care NHS dentists at the local level. They exist to support and represent primary care dentists working under NHS contracts, and to help plan, coordinate and manage services in local areas. There are 15 LDCs in London. Ten of the LDCs have joined together to create the LDC Confederation and together represent approximately 3,000 primary care NHS dentists. The Local Dental Committees and the LDC Confederation are committed to working with local partners to ensure that dental services are in the best position to meet the needs of local populations. In this document where we refer to LDCs or LDCs in London we mean this to apply only to those 10 LDCs which are part of the LDC Confederation.
- We are sure that dental practitioners will want to play their part in helping a return to normality and would be keen to act as testing hubs and provide vaccinations when they become available. Dentists are, after all, used to providing injections and all premises are regulated by the CQC including for the safe storage of medicine.
- Our key recommendation is that a full strategy for what a return to full routine dental practice would look like with a proper timescale be developed. Short term plans should be published by the end of May and cover access to dental services for vulnerable and shielded patients, and services generally while movement is restricted. The second section, covering the reopening of primary care dental practices before a return to usual movement will need to be addressed with a view to contractual payments and PPE supplies as well as the impact on the government's advice on social distancing and travel. The third section, on the full return to routine dental practice should consider what contractual changes and improvements to integrating dentistry with the rest of primary care are needed in light of the current crisis to put dentistry on a firm footing for the future.
- The LDC Confederation is keen to work with the Chief Dental Officer and other stakeholders on developing this strategy and distributing it to dentists to give them confidence at this uncertain time.
- The LDCs in London are committed to providing the best dental care to patients possible during this difficult time and continue to work closely with the NHS England and NHS Improvement (London Region) dental commissioning team, consultants in dental public health, Local Dental Network, local Healthwatch and other stakeholders.
- Communication from NHS England and NHS Improvement, and from the Chief Dental Officer to primary care dentists has been very slow and, when correspondence did arrive, ambiguous. Many of the ambiguities suggest a lack of understanding of how primary dental care services operate, causing immense distress and concern among the profession.
- The Chief Dental Officer has held two webinars. Neither has been informative or done anything to improve the morale of the profession. Guidance for dentists in England lagged significantly behind that provided in the devolved nations. Given the circumstances this may have resulted in dentists, their teams and patients, not to mention the families of all of these, being at risk of contracting COVID-19.
- There has been a lack of communication about dental services to the public and other stakeholders. London has finally approved communications to be sent out to all Sustainability and Transformation Partnerships, Clinical Commissioning Groups, Local Councils and Local Healthwatch.
Current provision of services
- There has been a lack of coordination for dentists and their teams to volunteer for redeployment, with very few dentists being called upon and little use being made of their specific skills when called upon. Dentists and their teams are more than willing to play their part in supporting the health and social care system at this time but many will want to use the skills they have spent years developing and which people value. The LDC Confederation has made repeated offers to help redeploy practitioners to their local UDCC, but so far this offer has not been taken up.
- London established 30 urgent dental care hubs (UDCHs), with an additional one being set up independently of central commissioning. An additional two sites are due to go live from Saturday 09 May. Access to these UDCHs is through the dental nurse triage (DNT) service only, not through direct referral from a triaging dental practice as in other parts of the country. The London dental commissioning team has also been setting up prescription hubs to help manage this aspect of care.
- At present there is no specific service for vulnerable or shielded patients. There is a limited amount of dental care that can be provided in a domiciliary setting under normal circumstances. It may, however, make sense to permit primary care dentists with appropriate PPE to provide domiciliary visits to households with no symptoms after appropriate time frames etc. to provide more robust advice and some minor non-aerosol generating procedures. How this would operate in practice, however, would require clear protocols. Some Trusts which have been designated as UDCCs are providing a shuttle service for vulnerable and shielded patients, but it will be important that the environments they are taken to for treatment are appropriate and there are no dedicated vulnerable or shielded UDCHs.
- London represents specific issues that are different from other areas of the country. Chief among these is the reliance on public transport over private transport which in the current circumstances many people will try to avoid. This makes accessing the limited number of UDCHs more difficult for everyone.
- The UDCHs are suffering from the same issues with lack of personal protective equipment as other parts of the NHS, with the issues for patients exacerbated because of the aerosol generated by most dental procedures. We understand that the existing UDCHs have 300 face to face treatment slots. It is not clear, however, how many of these slots are available to provide aerosol generating procedures (AGPs) which is what many patients referred will need, as opposed to simply face to face advice and whether any restrictions are due to a lack of PPE, surgery space or staffing issues.
- The DNT often receives over 1000 calls a day. These calls may be from patients who have spoken to a dentist and who has been advised by the dentist to call the DNT to get an appointment at an UDCH. Others will be direct calls from patients. The procedure set out by the Chief Dental Officer for dental practices, and also applied by the DNT in London, is that the dentist should offer advice, analgesia or antibiotics. These have limited effect. The longer that access to dental services is suspended the worse many dental problems will get. We are already hearing reports of patients who have been given multiple courses of antibiotics and who are in need of face to face dental treatment but who are struggling to get it, and who should not have had to wait so long in order to be seen.
- The UDCHs are able to offer limited treatment for patients and it seems that many will opt for extracting a tooth rather than restoring it. As the patients are told this there are many who may be refusing treatment as they want to save the tooth rather than lose it. Depending on the original issue this can result in people being left in avoidable pain and developing much more severe conditions.
Issues that need to be addressed
- While there are many financial and contractual issues that still require resolution we will not address these here but leave the British Dental Association to cover these points as they relate to national guidance and discussions which they are involved in.
- While government guidance was quickly issued around sick pay for people self-isolating there has to date been no change to the statement of financial entitlement (SFE) for general dental practitioners. Despite dentists being frontline staff and exposed to aerosols prior to the suspension of services, the SFE requirements for a dentist to be off work for two weeks and have a doctor's note remain in place before any sick pay can be claimed. In addition, pregnant dentists who either followed government guidance to isolate, or followed specific advice from their GP, are left only with the option of applying for maternity pay early (thereby sacrificing it later) despite being forced to stop work. The fact that the SFE has still not been amended months into this crisis leaving frontline staff exposed is unacceptable.
- How regular, non-UDCH, dental practices will be able to reopen and what procedures they will be able to provide needs to be carefully considered with representatives of the profession. Dentists provide surgical interventions in their practices. Many of the treatments a dentist provides generate aerosol (Aerosol Generating Procedures - AGPs), which cannot be provided at the present time without full PPE (FFP3 masks etc.) and without the surgery being decontaminated between patients. If these requirements are to continue for the foreseeable future then the rate of dental care will be significantly reduced. When decisions about a return to practice are being considered then it is imperative that active primary care dentists are involved in the discussions and decision making. Many practices may require new equipment such as specific extractors and ventilators to assist with decontaminating surgeries, and there will be a cost for new more expensive PPE than is normally used in primary care. These factors will need to be taken into account.
- Care and provision for vulnerable and shielded patients needs to be addressed as a matter of urgency. All domiciliary visits, of which there were far too few anyway, are suspended leaving these groups at particular risk of dental deterioration.
- The current crisis has shown several weaknesses in the current arrangements of dental services. We hope that some positive steps may be taken to integrate dentistry properly with the rest of the NHS rather than keeping it at arms length.
- Firstly, as the profession has long been arguing, a move to a capitation based contract rather than activity would make the funding arrangements for dentistry much more simple. It would however require an honest conversation about what government is prepared to fund. NHS Digital statistics show that over 60 million people in England are registered with a GP, compared to access levels of 22 million for dental services.
- Private dentists and dentists with a mixed income from NHS services and private dental services have felt under immense financial pressure as they are mostly exempt from the support for the self employed. Those working under an NHS contract are supposedly in receipt of their usual income from that NHS contract but that may represent a small proportion of their usual income. Yet it is clear from the figures above that many dentists have no choice but to provide dental care privately as access to NHS services has never reached over 60 per cent of the population. These dentists are now being penalised because the NHS has not considered dental services on a par with general medical services. Hopefully a frank and honest conversation about what government is actually willing to fund for dental services will take place.
- The LDC Confederation has long been championing the integration of primary care services, working hard to promote strong local links and good relationships with the intention of dental practices being key partners in Primary Care Networks. Hopefully a capitation model and an honest conversation about access levels will support improvements and integration at the local level.
- To support local integration, and a real flaw in the system that has been exposed by the current crisis, is the issues dentists have in accessing the NHS Spine and summary care records. This would make prescribing faster and more accurate as well as speed up communication between different parts of the health sector.
- Access to electronic prescribing and relaxing the rules for pharmacists about the requirements for paper prescriptions within 72 hours would also increase efficiency.
- The LDC Confederation has long been working with stakeholders and arguing for improvements to oral health for those in care homes and for older adults in general. Indeed even during this time we continue to encourage our partnership working by pairing care homes with dental practices to provide telephone advice. We hope that out of this crisis the NHS will look again at the restrictions in the GDS contract that needlessly prevent NHS primary care dentists from providing domiciliary care.
- Finally, the NHS has decided to continue funding dental practices month by month at 1/12th of their contract until further notice. Figures suggest that around 30 per cent of the funding allocated to primary care dental services in England is derived from patient charges. The NHS is willing at this time to absorb the full cost of primary care dental services. We think that this situation should continue and that patient charges for NHS primary care dental services should be abolished. We have provided evidence to the Mayor of London and to the Health and Social Care Select Committee's aborted Inquiry into Dental Services on this and recommend that these submissions be looked at to consider the evidence base for this recommendation.
Statement from Dr Lalit Patel, Chair Hillingdon Local Dental Committee redeployed to support Dental Triage in London.
I have been deployed to work at the NHS 111 call handling team to triage patients using Advice, Analgesia and Antibiotics and divert them to the necessary UDCHs.
I work night shifts from 12pm to 6am and have noticed that there are a large volume of calls during the night. These calls are mainly patients who are not registered with a dentist, occasional attenders, homeless, and nervous patients. Many have had dentistry done overseas which has failed.
It is a huge demand on the service as the scale of the problem ranges from toothache to abscess to broken fillings.
There are patients crying on the phone with toothache who need interventions and cannot wait until the morning despite taking the strongest pain killers. The scale of the problem is increasing daily as the demands outweigh the number of UDHCs.
We need more surgeries to open as UDCHs (with PPE) in specific areas to meet the need of patients.
Certain patients are frightened to travel to UDCHs as well for fear of catching the virus. Setting up prescribing hubs in different areas is proving very effective, but this is a short term solution as lock down continues
As noted in our submission NHS England and Improvement (London Region) has set up 30 dedicated Urgent Dental Care Hubs which are accessed only through the dental nurse triage system. Independently of this process a 31st Urgent Dental Care Hub was set up on the initiative of local clinicians at Queen Mary's Hospital in Sidcup. This service is not accessed through the Dental Nurse Triage but by direct referral from dentists in Bromley, Bexley and Greenwich. In the first month of operation the service has received 518 referral and has seen:
Failed to attend
 Available on request.
 Details of this extra UDCH are in annex 2.
 The experience of Dr Lalit Patel, Chair of Hillingdon LDC, is described in annex 1.
 Please contact us or the NHS England and Improvement (London Region) dental commissioning team for more information about how the prescription hubs operate.
 As we outline in an article in the Integrated Care Journal: https://integratedcarejournal.com/newsdit-article/fe51ba35e73623dbde1add36430c5992/ last accessed 06.05.20
https://app.powerbi.com/view?r=eyJrIjoiNjQxMTI5NTEtYzlkNi00MzljLWE0OGItNGVjM2QwNjAzZGQ0IiwidCI6IjUwZjYwNzFmLWJiZmUtNDAxYS04ODAzLTY3Mzc0OGU2MjllMiIsImMiOjh9 last accessed 04.05.20
 Figures from NHS Digital https://files.digital.nhs.uk/4F/B3B6FE/nhs-dent-stat-eng-17-18-rep.pdf last accessed 28.08.19