Witnesses:
Mark Nuti, Cabinet Member for
Adults and Health
Liz Bruce, Joint
Executive Director, Adult Social Care and Integrated
Commissioning
Hugh
O’Keeffe, Senior Commissioning Manager
Dental
Lillian
Nigrelli, Senior Delegated Commissioning Transition Manager, Dental
Contracts Surrey Heartlands Integrated Care Systems
(ICS)
Rachael Graham,
Director of Non Acute and Primary Care Contracts, Surrey Heartlands
Integrated Care Systems (ICS)
Nicola Airey,
Director of Commissioning and Assurance, SRO Delegated
Commissioning, Frimley Integrated Care Board
(ICB)
Rachel Thompson, Associate Director Primary Care
Transformation, Lead Commissioner Dentistry Frimley Integrated Care
Board (ICB)
Key
points raised during the discussion:
- The
Chairman asked what could be done to record information about
residents who had tried and failed to access dental services.
The Director of
Commissioning and Assurance (SRO) explained that a consultation
and engagement process with local communities had not yet taken
place, however it was expected that the implementation of methods
similar to those underway in other areas in addition to
collaboration with partners with established links into communities
would take place. The Director of Commissioning and Assurance (SRO)
added that the link between deprivation and access to dental
services required a commitment to engage with communities and
welcomed any suggestions from Members regarding this.
- The
Chairman said that understanding the number of people that had
failed to access dentistry was essential to recognise the size of
the issue and asked why dentists were not required to record the
number of people being turned away. The Chairman also suggested
that the current opening hours of dental surgeries could result in
some people not being able to access treatment. The Director of
Commissioning and Assurance (SRO) explained that what could be
mandated of dentists was influenced by the national dental
contract. The Senior Commissioning Manager, Dental said that
dentists were mandated to collect the data of patients treated to
record the activities being delivered with no requirement to
collect the data of those turned away, however the NHS contact
centre did record and report on people that had made contact
because of difficulties in accessing dentistry. Following a request
from the Chairman, The Senior Commissioning Manager, Dental agreed
to provide this data to the Select Committee including surveys of
work being undertaken by partners in this area. Action – Senior Commissioning Manager,
Dental/ Director of Commissioning and Assurance
(SRO)
- A Member, in
referring to the new commissioning arrangements for dentistry
outlined in the report, asked how effective the delegation
agreement between NHS England and the Integrated Care Boards (ICB)
was expected to be. The Director of Non Acute and Primary Care
Contracts, Surrey Heartlands Integrated Care System (ICS) explained
that the agreement would define the roles and responsibilities of
the ICB’s with NHS teams continuing to deliver services,
impart experience to the ICB’s and afford the opportunity to
bring commissioning closer to the patient, focusing on the
provision and improvement of services for those in greatest
need.
- A
Member asked how long it could be expected for NHS England
officials to work with the ICB’s as referenced in the report.
The Director of Non Acute and Primary Care Contracts, Surrey
Heartlands ICS confirmed that the delegation agreement would be
amended by July 2023 to reflect a single ICB host from the NHS team
which would come down to the ICB at a local level. These
ICB’s would continue to work together to continue to provide
consistency.
- A
Member noted concerns about the NHS previously stamping on local
initiatives and asked what extent the ICB’s would take charge
with local initiatives. The Director of Non Acute and Primary Care
Contracts, Surrey Heartlands ICS noted that immediate changes would
not be possible, however, national contract boundaries in
particular those with a level of inflexibility were being
challenged.
- A
Member queried how the effectiveness of the new commissioning
arrangements for dentistry would be assessed to allow improvements
to be made accordingly. The Director of Commissioning and
Assurance, SRO Delegated Commissioning, Frimley ICB said that
information measures currently in place had proven useful and were
being developed adding that ICB and local authority data sources
would expand on the information that could be used to measure
improvements.
- The
Non-executive Director, Healthwatch Surrey asked if there were
intentions to improve the complaints process. The Senior
Commissioning Manager Dental said that dental practices were
required to follow complaints standards as part of their contracts
and asked Members to provide further details if that was not
happening. The Chairman suggested that all relevant information
documentation include Healthwatch details and clear guidance about
the complaints process. The Director of Commissioning and
Assurance, SRO Delegated Commissioning, Frimley ICB agreed to
follow up on the availability and provision of clear information
regarding the complaints process. Action - Director of Commissioning and Assurance (SRO) Delegated
Commissioning, Frimley Integrated Care Board (ICB)
- A
Member asked to what extent residents were made aware of the dental
services available to them. The Associate Director Primary Care
Transformation, Lead Commissioner Dentistry Frimley ICB explained
that in addition to some practices having their own websites, a
dental services section was available on the national NHS website
where residents could find information about oral health services
and how to access their local NHS dental practice. Under the dental
contract reforms, practices had a contractual obligation to keep
their information updated and state whether they were accepting new
patients.
- A
Member queried the likelihood of residents being able to access
dental services. The Associate Director Primary Care
Transformation, Lead Commissioner Dentistry Frimley ICB explained
that funding was based on 50 per cent of the population attending
an NHS dental practice on a regular basis however the current
figure was 40 per cent following a significant fall during the
pandemic with challenges remaining in the short term. For patients
finding it difficult to access dental services, additional access
slots were provided at some practices via NHS 111 or through the
practices directly. Access to dental services was under review and
remained high on the agenda.
- A Member queried the
measures taken to ensure patients understanding of the appropriate
charging exemptions for which they may qualify. The Director of Non
Acute and Primary Care Contracts, Surrey Heartlands ICS said that
the national NHS website dental services section included
information about patient charges and eligibility relating to those
charges. Another Member emphasised that
patients should receive more guidance and advice on charging
exemptions.
- A
Member queried how could residents find information regarding their
nearest local dental practice and asked how digitally excluded
patients could find information on dental services. The Chairman
added that the 120,000 digitally excluded residents was in line
with deprivation and queried what programmes would help in reaching
these communities. The Associate Director Primary Care
Transformation, Lead Commissioner Dentistry Frimley ICB said that
an online search to find an NHS dentist would bring up the national
website where residents could enter their postcode to show all
local dentists, with the distance from that postcode and whether
they were accepting NHS patients. Information was available from
the Citizens Advice Bureau (CAB) and local libraries; however work
was required to make the information available to the digitally
excluded. The Senior Commissioning Manager Dental said that the
information that organisations such as Healthwatch provided could
be considered in the non-digital space and committed to follow this
up. Action – Senior
Commissioning Manager Dental
- The
Chairman asked if mobile dentistry had been considered to provide
dental services in areas of need. The Senior Commissioning Manager
Dental said that most NHS dental practices were in the most
economically diverse and deprived areas to ensure the maximum NHS
footfall.
- The
Chairman queried the success and process of identifying the need of
dental services through annual health checks conducted on adults
and people with learning disabilities.
- The
Chairman, in referencing report item 5.5 and the use of the 0-17
age group to obtain data as they would be more likely to use NHS
dental services rather than private care, suggested that parents
with private dentistry would include their children on their
private policy and queried using this group to obtain the
data.
- The
Chairman, in referring the mention of six lost NHS contracts in
Surrey, said it would be useful to know their
locations.
- The
Cabinet Member for Adults and Health said that prevention was key
to avoid expensive treatment in the future and asked if there was
scope for dental check-ups and oral health education in schools.
The Director of Non Acute and Primary Care Contracts, Surrey
Heartlands ICS explained that Surrey County Council (SCC) Public
Health was responsible for oral health promotion and surveillance.
Surrey Heartlands had reached out to SCC Public Health to ascertain
what was happening in this area with the aim to work with teams to
focus on initiatives and interventions. The Chairman requested an
indication of timelines for rolling out
prevention strategies and measures. The
Director of Non Acute and Primary Care Contracts, Surrey Heartlands
ICS said that there was no aligned budget and further formal work
was required to understand the position and support local team
initiatives. The Chairman asked if large companies could be
approached to donate toothbrushes and related resources to
foodbanks. The Director of Non Acute and Primary Care Contracts,
Surrey Heartlands ICS agreed that that this was a good starting
point in respect of sponsorship.
- A
Member asked what was being implemented to improving the diets of
children living in poverty. The Director of Commissioning and
Assurance, SRO Delegated Commissioning, Frimley ICB said that this
area would benefit from the dental commissioning coming to the ICS
as dental care could be considered on a whole systems
level.
- The Vice Chair asked
what measures were being taken to ensure that patients understood
the appropriate charging exemptions that they may qualify for and
how would this help to reduce fines for patients who have
misunderstood their eligibility. The Senior Delegated Commissioning
Transition Manager, Dental Contracts Surrey Heartlands ICS
explained that dental charges were available on the NHS website
which also included dental services and links to an advice tool on
how to get help with the cost of dental treatment. Inquiries to
better understand process of charges have been made to the NHS
Business Services Authority (BSA), who manage NHS charges and a
commitment was made to clarify this to Members if required. Work
was required to ensure practices were aware that leaflets could be
provided in specifically requested languages if required and that a
translation service for patients was available.
- A
Member noted that Surrey Heartlands had been considering the
accessibility of information since it began and the law said that
people should have access to information in the format that they
choose which was not the case with NHS England. The Director of
Commissioning and Assurance, SRO Delegated Commissioning, Frimley
ICB agreed to take away an action to ensure the accessibility of
dental services information and other elements were in
consideration. Action
- Director of Commissioning
and Assurance, SRO Delegated Commissioning, Frimley
ICB
- A
Member, in reference to homeless communities noted in paragraph
2.10, page 41 of the report, asked what support would be provided
to homeless people to help them access dental care and long-term
treatments. The Director of Non Acute and Primary Care Contracts,
Surrey Heartlands ICS said that whilst there were no specific
services commissioned for homeless people, they were eligible to
receive treatment through High Street dental services and homeless
people with additional needs could also access community services
and self-refer or be referred by support groups on their behalf.
The Member asked if data regarding the number of people accessing
these services was being collected. Director of Non Acute and
Primary Care Contracts, Surrey Heartlands ICS advised that resident
data was not routinely collected through general
practice.
- A Member asked if the
need to see and treat patients was being balanced with the steps
being taken to maintain infection control procedures within dental
practices, as referred to in paragraph 5.1, page 49 of the report.
The Associate Director Primary Care Transformation, Lead
Commissioner Dentistry Frimley ICB said that infection control
measures had become part of normal operations, resulting in a
reduction of the impact on the time required to treat
patients.
- A
Member asked what reassurances could be provided that backlogs
because of the pandemic could be reduced, how would future backlogs
be avoided and were there higher levels of acuity because of these
backlogs. The Director of Commissioning and Assurance, SRO
Delegated Commissioning, Frimley ICB confirmed that these backlogs
were being reduced because of the recent contract changes, however,
dentists had reported higher levels of acuity because of the
pandemic backlogs. Further contract changes would be expected to
ease any future backlogs with the pace of the backlog reduction
dependant on the workforce and ensuring that the offer for NHS
dentists was attractive.
- A
Member asked if the acuity data was available to Members. Senior
Commissioning Manager Dental said that the increase in acuity had
been evidenced by contract delivery.
- The Chairman, in
referring to item 5.12, page 53 of the report, and dentists
preferring to work fewer days for the NHS queried the possibility
of making contract changes to include a minimum number of days for
NHS provision. The Director of Non Acute and Primary Care
Contracts, Surrey Heartlands ICS explained that the national
contracts limited any changes to incorporate a minimum number of
NHS working days. The Director of Commissioning and Assurance, SRO
Delegated Commissioning, Frimley ICB added that in addition to
exploring the extent to which services were commissioned locally
within the national framework and pushing the boundaries of these,
there were opportunities to feedback to the national contracts
process and committed to consider a way of collecting these
views. Action - Director of
Commissioning and Assurance, SRO Delegated Commissioning, Frimley
ICB
- The
Chairman, in noting the previously mentioned workforce issues,
asked if more could be done to promote dental nursing and related
roles as desirable careers and asked if there were apprenticeships
or on the job training available. The Senior Delegated
Commissioning Transition Manager, Dental Contracts Surrey
Heartlands ICS confirmed that conversations regarding the promotion
of dental nursing as a career had begun with Health Education
England and any support they could provide to sign off competencies
as part of apprenticeship training. The Senior Delegated
Commissioning Transition Manager, Dental Contracts Surrey
Heartlands ICS added that there were also issues around pay not
being comparable to the responsibilities of the role.
- A Member asked if
patient satisfaction data was collected and if so, what were the
causes of any dissatisfaction. The Associate Director Primary Care
Transformation, Lead Commissioner Dentistry Frimley ICB said that
information about levels of satisfaction had been obtained from
letters to MPs and complaints and confirmed there was evidence of
significant levels of patient dissatisfaction around access to NHS
dental services were evident, adding that it was clear that that
the level of satisfaction remained high when patients were
successful in accessing services.
- A Member questioned
if exit interviews took place for dentists leaving NHS contracts.
The Senior Commissioning Manager Dental confirmed that dentists
were asked their reasons for leaving with the most common issues
cited being delivering a contract with greater patient needs and
difficulties in appointing staff to fulfil the
contract.
- The Chairman in
referencing item 5.13 and the loss of six contracts, queried their
locations and what had been done to try and replace them. The
Senior Commissioning Manager Dental confirmed a total of nine
closures at Addlestone, Banstead, Caterham, Cranleigh, Dorking,
Epson, Guildford, Horley and Woking. The Senior Commissioning
Manager Dental explained that closures were happening nationally
and a national action on contract flexibility was required.
Temporary activity to mitigate these closures in the short term
included approaching a neighbouring practice to take on extra
patients followed by the service replacing the activity lost
through a procurement programme.
- A Member asked of it
was becoming more costly to run dental practices and if so, would
NHS contracts take this into account. The Senior Commissioning
Manager Dental confirmed that it had become significantly more
expensive and although phase one of the contract would help the
situation, phase two was urgently required.
- The Deputy Cabinet
Member for Children and Families questioned why residents were not
being made aware of the reasons for the issues being raised.
Director of Commissioning and Assurance (SRO) Delegated
Commissioning, Frimley ICB agreed in the need for partners to
collectively explain to residents the issues and solutions
regarding dental access.
- A
Member suggested the consideration of people from overseas to take
roles within the dental profession. The Senior Commissioning
Manager Dental confirmed that many practices were already routinely
recruiting from overseas.
Recommendations:
Dentistry
Leads at Surrey Heartlands & Frimley ICSs
- To
improve access to dental care for vulnerable individuals; including
the homeless, deprived communities, Domestic Abuse Victims, those
suffering ill Mental Health, and residents with Learning
Disabilities and Autism.
- To
reduce existing and future backlogs in dental care.
- To
improve communications, vehicles for communications, and work
better with partners, to ensure that residents are aware of dental
services available to them.
- To
urgently campaign for improvements to NHS Dental Contracts to
maximise potential for patient access and to retain and attract
dentists to perform NHS treatments.
- To
identify and implement strategies to work with schools to improve
dental health.
- In
order to understand supply vs demand for appointments, it is
recommended that a log is created, at all entry points into the
system, of individuals denied dental appointments at NHS registered
practices; and for this information to be centrally
collated.
Actions/
requests for further information:
- Dentistry Leads at Surrey Heartlands & Frimley Integrated
Care Systems to look into developing mobile solutions for the
provision of dental services in geographical areas underprovided
for.
- Dentistry Leads at Surrey Heartlands & Frimley Integrated
Care Systems to look into receiving Corporate donations for
toothbrushes and toothpastes for deprived communities.
- Dentistry Leads at Surrey Heartlands & Frimley Integrated
Care Systems to provide further details on the support available
for homeless individuals on an area by area basis.
- The
Director of Commissioning and Assurance, SRO Delegated
Commissioning, Frimley ICB, to feedback to the national contracts
process and commit to consider a way of collecting these
views.
- The Senior
Commissioning Manager-Dental to provide the monthly reported NHS
contact centre data regarding contact made by residents unable to
access dentistry, including the survey work being undertaken by
partners in this area.
- The Director of
Commissioning and Assurance, SRO Delegated Commissioning, Frimley
ICB, to follow up on the availability and provision of clear
information regarding the complaints process, including collation
and analysis of Issues Of Concern.
- The Senior
Commissioning Manager-Dental to follow up and update the committee
on resident’s ability to find information regarding their
nearest dentist, including the digitally excluded.