Written evidence submitted by the Association of Dentist Groups (DEL0276)
- This submission from the Association of Dental Groups (ADG) responds to the Health and Social Care Committee’s call for written evidence on delivering Core NHS and Care Services during the Pandemic and Beyond opened 22 April 2020.
- The Association of Dental Groups (ADG) is the trade association for large dental providers in the UK. Our members include 19 of the largest groups of dental practices in the country, representing over 10,000 clinicians delivering NHS and private dentistry to more than 10 million patients every year. Many of our members staff are either engaged in providing urgent dental treatment centres or have volunteered for wider NHS redeployment.
NHS Dentistry before the Pandemic
- Much of the evidence concerning the parlous state of NHS dentistry before the pandemic is available to the Committee from their call for written evidence on dental services dated 31 July 2019.
- To summarise, over the last 10 years, ADG members have seen government net spend on NHS dentistry remain stagnant with no increase with inflation, which in real terms represents a cut to NHS dentistry in the UK. There have been significant challenges recruiting dental professionals to deliver NHS treatment in many areas of the country, adding to reduced access for patients.
- ADG members report significant concern with the current NHS General Dental Services (GDS) contract and its inability to deliver a comprehensive NHS dental service, especially as it does not allow for prevention to be delivered adequately. Our members have experienced significant challenges with the current GDS contract where the use of Units of Dental Activity (UDA) has led to clinicians looking to leave NHS practice for private practice or looking to considerably reduce the number of hours they practice in the NHS. This has been confirmed by the NHS Confidence Monitor Survey. As current contractual arrangements require patients to pay a contribution towards the cost of their care, we note that this has led to some individuals having difficulties accessing affordable dentistry and therefore resulting in health inequalities.
- Access to NHS dentistry could be improved by addressing the causes of recruitment challenges in remote, rural, coastal and areas of higher deprivation. ADG members have faced significant recruitment challenges which have resulted in practice closures along the Yorkshire coast, Lincolnshire coast, South coast, around Portsmouth and in Cornwall, among others. There are inequalities in access for certain groups, including homeless people and care home residents. A recent report by the Care Quality Commission (CQC) confirmed it was difficult for residents to access dental care and 73% of care plan reviews only partly covered or did not cover oral health at all. Tooth decay is a leading cause of hospital admission in children. Almost 9 out of 10 hospital tooth extractions among children aged 0 to 5 years are due to preventable tooth decay and tooth extraction has been the most common hospital procedure in 6 to 10-year olds.
Dental provision during the Pandemic
- All routine dentistry treatment in England was ceased in the Chief Dental Officer (CDO) letter to the dental profession on 25th March 2020 for the safety of patients and of dentists and their teams during the COVID-19 pandemic. Individual practices were instructed, that unless they have been identified by area commissioners as part of the urgent dental system in a/their regions they should not see patients face to face.
- The urgent dental system can be best described as a “work in progress”. Dental practices, as part of receiving ongoing NHSE contractual payments are required to provide telephone, or more ideally, video triage at their surgeries for patients seeking treatment during the pandemic. Only the most urgent/emergency cases will then be referred to their nearest urgent dental centre for face to face care. Many patients will be prescribed antibiotics for their treatment remotely. All the ADG members practices and staff are involved in the triage system and the delivery of the urgent dental centres.
- Aerosol generating procedures are required in most dental work and have been ceased during the pandemic due to the risks of Covid-19 transmission. Urgent dental centres can undertake aerosol generating procedures where necessary using FFP3 masks, gowns and accompanying PPE for emergency dental work.
- The range of conditions outlined by the CDO to be provided for by local UDC systems include but are not limited to
- Life threatening emergencies, e.g. airway restriction or breathing/swallowing difficulties due to facial swelling
- Trauma including facial/oral laceration and/or dentoalveolar injuries, for example avulsion of a permanent tooth
- Oro-facial swelling that is significant and worsening
- Post-extraction bleeding that the patient is not able to control with local measures
- Dental conditions that have resulted in acute and severe systemic illness
- Severe dental and facial pain: that is, pain that cannot be controlled by the patient following self-help advice
- Fractured teeth or tooth with pulpal exposure
- Dental and soft tissue infections without a systemic effect
- Oro-dental conditions that are likely to exacerbate systemic medical conditions
Referral to an urgent dental centre is often recommended as a last resort. Most routine dental care members of the public would recognise is no longer available for face to face treatment. If you have toothache you will be remotely prescribed a painkiller.
- There are estimated to be approximately 308 urgent dental centres in England and some are designated “hot” sites specifically for Covid-19 symptomatic patients. However, information is not currently fully available on regional coverage (for example it was the case initially that there was only one urgent dental centre for Cornwall but more are now being provided). It is understood that there are parts of the country where it is difficult for patients to access a centre and ongoing efforts are being made to expand the number of centres.
- Members of the committee will have had complaints from constituents unable to access the urgent dental centre for emergency treatment. As reported by the BBC and confirmed in a recent answer to a parliamentary question given by the Public Health Minister access to appropriate PPE has been a factor in site opening:
“Dentistry does not usually require FFP3 masks or other higher-level PPE. However, the heightened risks presented by COVID-19 mean that this is required for any aerosol generating procedures. We are aware that there have been delays for a number of urgent care dental hubs in getting all the PPE now required and that this is still an issue for some hubs. The Department and NHS England and NHS Improvement are working urgently to resolve this. As an immediate measure emergency dentistry has been placed on the list of priorities areas to receive supplies from Local Resilience Forums.”
The availability of appropriate PPE, for the safety of the dental team and the patient alike remains an ongoing issue which has constrained some urgent dental centres from opening.
- Due to the PPE and social distancing requirements the number of patients that an urgent dental centre can see in one day is limited to approx. 8. Before the pandemic, a dentist might be expected to undertake 30 appointments a day.
Dental provision beyond the Pandemic
- Our overriding priority is to ensure patients can continue to be able to access emergency NHS dental care and that continuity of high-quality treatment is preserved at this difficult time. However, in the interest of the public good of sustaining access to oral health provision we would urge policy makers to consider how to provide support for the dental profession to ensure we can achieve this goal once the threat from pandemic recedes. It has already been observed that patients remotely prescribed with antibiotics are returning with pain or further swelling as the cause of the problem has not been able to be treated during the period of the pandemic, contributing to an overhang of oral healthcare. Even before the Covid-19 outbreak almost half the adult population had not seen an NHS dentist in the last two years.
- The Office of the CDO England is currently establishing several workstreams to provide clinical and operational guidance as to how more comprehensive oral healthcare may be resumed in England. Policy makers should not underestimate the scale of this challenge. Even with the easing of some of the current restrictions it is likely that the dental profession will have to accustom itself to different ways of working in how treatment is undertaken for a considerable period of time as part of the wider efforts to restrain the risks of a second wave.
- Recovering the overhang of oral healthcare arising from the pandemic will be limited by any ongoing social distancing measures, patient confidence and the associated PPE requirements for most dental treatments. The current additional PPE requirements have already been outlined above and further guidelines should be considered by Public Health England (PHE) for dental settings on reopening, although the evidence base is limited. The global shortage of PPE will have a significant impact on practice costs. A study undertaken by Dental Directory (DD Group) indicates the cost of PPE for AGPs could rise from £0.33 per patient pre pandemic to £38.60 per patient post any lockdown on current pricing information. Such costs are unlikely to abate soon.
- Prior to the pandemic the government had introduced Starting Well: A Smile4Life Initiative and Dental Check by One to help children access dental services. Both initiatives had been positively received and must not be lost. ADG members would like to see a school tooth-brushing scheme in more pre-school settings and primary schools in England implemented as circumstances allow to prevent a potential rise in hospital admissions, as outlined in the Prevention Green Paper.
- These additional challenges overlay on the pre-existing problems facing dentistry. We already know that there has been a particularly acute access issue in remote and deprived communities. In areas such as Cornwall, parts of Wales and Yorkshire where there have been so few clinicians that practices have had to close. Some ADG members have been forced to close significant numbers of practices due to recruitment issues. Practice closures lead to further accessibility issues which further increase health inequalities as outlined above. This may be a time to consider again how more efficient and cost-effective preventative dentistry can be when the full dental team’s skills are used.
- Dental care in the UK is a mixed economy with nearly half of spend on private dentistry which meets much of the population need that is not met by the NHS. Both the ADG and BDA (British Dental Association) have raised with Ministers that private practices currently have no revenue and are ineligible for several HM Treasury support schemes. Policy makers need to ensure fair and equitable support to the private sector over the months ahead to ensure that it can reopen to meet demand that will otherwise add further pressure to NHS budgets.
- The current UDA contract system has been shown to inhibit innovation due to its inflexibility and inability to effectively use the dental team. It will certainly not allow dentistry to address the post Covid-19 challenges when the current restrictions on routine treatment begin to be eased.
Specifically, the UDA system will not allow the profession to:
- Address the significant inequalities of access which have been exacerbated by the Covid-19 shutdown.
- Treat the significant patient need which has built up over the shutdown period.
- Provide a service which addresses the expected anxiety in the population about many treatments – including face to face dental work.
- Adequately address the expected increase in time to deliver face to face treatment.
- Use the full dental team to deliver dental services to address pent up patient need.
- Treat large volumes of patients with capacity reduced by the additional infection control requirements.
- Remunerate for the increased use of PPE.
- Delivery of contracted levels of activity due to the inflexibility of the UDA measure will not be possible to be met.
For these reasons, a different contracting solution is needed now for the provision of dentistry post Covid-19. NHSE should be giving consideration to a capitation model for the rest of the contract year.
- The dental profession is looking to retain positive changes that have taken place in working practice post Covid-19. These include utilising technology for more remote consultation and prescribing. There are opportunities over the months ahead to develop more effective oral health messaging.
- Given the urgency of the issues this submission is a high-level summary for members. The dental profession will face a wave of unmet and rising demand for care once restrictions are eased which due to the nature of oral healthcare is going to be difficult to meet over the next 12 months. The NHS will have to take a fresh approach to its model of provision to ensure that providers can try and meet the population’s needs. We would welcome the opportunity to give further written or oral evidence to the committee as this inquiry continues.