HOSC members to receive an update on recent developments in NHS Dentistry Services in Gloucestershire and to note work to progress the delegation of dental commissioning to ICBs in April 2023.
At the Full Council meeting on 9 November 2022, members considered a motion relating to NHS Dentistry, where members expressed concern about the quality and cost of dentistry in Gloucestershire.
At the meeting, councillors resolved to:
1. Write to the new Health and Social Care Secretary as well as Gloucestershire’s six MPs to express our concern for dentistry provision in Gloucestershire.
2. Call on Cabinet to ensure that council services work with schools, care homes and the NHS to coordinate dental visits to the people who need it most.
3. Ask the Health and Wellbeing Board and the Director of Public Health to bring a report to HOSC to explain what they are doing to promote good oral hygiene, specifically in children and young people and our vulnerable residents.
In response to the above motion, members to receive a report on oral health promotion initiatives.
Responding to the request for a further update to be presented to the committee in response to concerns about access to dental services in Gloucestershire and on the work to progress the delegation of dental services to the Gloucestershire Integrated Care Board in April 2023, members were reminded that at the Full Council meeting on 9 November 2022, members had considered a motion in response to concerns about the quality and cost of dentistry in Gloucestershire.
At the council meeting in November, councillors had resolved to:
In response to the council motion, it was agreed the members of this committee, (as part of a planned update to the committee on access to dentistry), would receive a report on oral health promotional initiatives at this meeting.
Beth Smout from the Prevention, Wellbeing and Communities Hub (PWC) at Gloucestershire County Council (GCC) informed members that the County Council was statutorily responsible for improving the oral health of its local population. On this platform, there was an expectation for the Council to provide, (or commission), appropriate oral health programmes for the County and to carry out oral health surveys to assess outcomes, (oral health surveys are carried out as part of the Office for Health Improvement and Disparities (OHID) National Dental Epidemiology Programme).
The following information was noted at the meeting: -
1. Since the establishment of the dental reform programme by NHS England (SW), there had been a slight increase in the number of patients in Gloucestershire who had been able to access an NHS dentist for routine care/treatment.
2. The total number of adults seeing an NHS dentist in Gloucestershire had slightly increased from 28.6% in December 2021 to 29.2% in June 2022. However, the access rate for the adult population of Gloucestershire at 29.2% was less than the national access rate (England) at 36.9%.
3. Similarly, the number of children who had seen a dentist in Gloucestershire in the last 12 months had increased from 43.9% in December 2021 to 45.8% in June 2022. However, the proportion of children in Gloucestershire accessing a dentist overall (45.8%) was still slightly lower than the access rate for children across the whole of England (46.2%).
4. 19.5% of 5-year-old children in Gloucestershire had experienced dental decay. This was lower than the average for both the South West (20.4%) and England (23.4%). However, rates of dental decay varied across the county. 26.5% of 5-year-old children in the Forest of Dean and 24.7% of 5-year-old children in Gloucestershire were reported as having experienced dental decay, compared to 12.8% of 5-year-old children in Stroud.
5. Dental decay was strongly associated with deprivation. It was confirmed that 5-year-olds living in the ‘most deprived areas’ of the county were more likely to experience dental decay than those living in the ‘least deprived areas’.
6. Current activities to prevent dental decay in children included distributing tooth brushing packs for children aged 9-12 months via health visiting teams.
7. Oral health advice was also being provided to young children and their families, for which discussions were taking place on delivering a countywide rollout scheme, following successful pilots at particular local authorities
8. In terms of developing oral health care training programmes for care workers, a pilot scheme was being planned for delivery throughout Gloucestershire care homes in 2023, with a wider rollout planned for later in the year/2024, depending on the success of the pilot.
9. Post-Covid, orthodontic services had returned to normal levels of activity more rapidly than high street dentistry. An additional initiative was being rolled out for non-recurrent orthodontic activity from 1 November 2022 to the 31 March 2023. This additional non-recurrent activity/funding was being used to reduce waiting times for those patients on the practice waiting list eligible and ready to receive orthodontic treatment. To date three orthodontic practices in Gloucestershire had signed up to the initiative, which equated to an additional 585 patients gaining access in 22/23.
10.Gloucestershire Health and Care NHS Foundation Trust provided/managed in-hour appointments for patients with an urgent dental need who did not have access to an NHS dentist. The service was for patients in need of relief from acute dental pain; infection; bleeding or trauma. Out of Hours patients should contact NHS 111. It was noted that, only people with a significant dental emergency, such as rapid facial swelling, uncontrolled bleeding, or facial trauma, would be expected to be treated at accident and emergency departments.
11.Gloucestershire Health and Care NHS Trust also managed out of hour appointments for the whole of Gloucestershire, with appointments at the weekends and bank holidays in clinics across the county.
A key factor impacting on accessing NHS dentist services related to workforce issues. A lack of dental practitioners in the area was significantly impacting on the ability of high street dental practices being able to meet their contracts. As NHS England did not employ dentists directly, it was difficult to assess the exact shortfall. However, based on the underperformance in UDA’s, (units of dental activity, and projected capacity, it was concluded that Gloucestershire was currently experiencing a shortfall of about 31 whole-time equivalent dentists. It was confirmed that, within the NHS England SW dental transformation programme was a wide range of initiatives from which to address the workforce gap and associated access issues. Full details of the initiatives are set out in the report presented to the committee.
Members were asked to consider the underlying causes of the difficulties the people of Gloucestershire were experiencing in accessing dental services, in line with the ongoing work being provided by the NHS England South West Dental Reform Programme Board in the attempt to address current issues and improve the oral health of the population. The committee was asked to work in partnership with the NHSE South West Dental Reform Team and to consider ways to market Gloucestershire as attractive place to work for dental and other clinical workforce members, and to encourage more young people in Gloucestershire schools and colleges to consider a career in healthcare.
During the second half of the presentation, Stephen Sylvester, Director of Specialised Commissioning at NHS England, expanded on how current workforce issues were impacting on dental services, including the issue of dentists withdrawing from NHS contracts because of unfavourable terms and conditions. It was noted that the current position reflected issues on a national level. Another limiting factor cited at the meeting was the reluctance by some dentists to take on the business requirements of running a practice.
To try to overcome some of the issues, dental students and recent graduates were being targeted to encourage retention within the area. Salaried positions were also being funded, and leadership and learning opportunities were being offered to make Gloucestershire a more competitive professional environment.
Members asked a series of in-depth questions, including questions highlighting concerns on the levels of child interaction with dental services. In response, it was suggested that schools might be considered as a potential avenue to guarantee engagement with a large proportion of children. The supervised ‘teeth brushing pilot’ was being put forward as a potential candidate for intervention in trying to resolve and improve the issue of child engagement with dental health. The pilot was currently being piloted in Devon, with an assessment of the success of the roll-out of the programme due to be evaluated in February/March. It was also noted that efforts relating to child dental health were focussing on more preventative measures, (such as learning modules stressing the importance of brushing teeth, in addition to minimising fear of dental practices), rather than oral examinations.
It was clarified that treatment in schools was under the remit of NHS England, and not the County Council. NHS England to consider the possibility of exploring school collaboration in forthcoming meetings with the ICB.
In response to other questions, collaboration work and efforts to work with the charity DentAid were discussed, where it was confirmed efforts were being made to boost the partnership arrangement.
Several members reiterated earlier concerns about the lack of NHS dentists, particularly in the more rural areas of Gloucestershire. It was noted that a lack of dentists taking on new NHS patients was one of the core driving forces for requesting a report to the committee. It was confirmed that efforts to approach dentists and encourage the adoption of NHS contracts had led to one practice taking up 3000 UDAs. Members commented on how this was lower than expected and informed that the target relating to access to dental healthcare services had been set as a return to ‘pre-pandemic levels’, though specific numbers were currently unavailable from which to make comparisons on. Members were also informed that there was no specific target set to reduce 5-year old decay rates.
A member referred to reports that, in the UK, there had been a 55% drop in tooth extractions for under 19s in 2022, in comparison to the previous year. Unable to comment on how Gloucestershire compared with the rest of the country, NHS England said it would investigate the reports and feedback to the committee after the meeting. Action by: NHS England
In response to questions on whether the worst affected regions were being targeted in a tailored manner, it was clarified that, whilst some interventions were being applied in a generalised countywide manner, the Forest of Dean, (as an example of a lower performing region), would receive a higher number of toothbrush packs to distribute to the communities within the district. Supervised tooth-brushing resources would focus on areas of greater need. Further updates/details of how the county intended to use tailored approaches would be made available in the New Year.
Another concern raised at the meeting was the large number of EU medics no longer working for the NHS. One member asked how long it would take to introduce a new initiative from which to attract overseas dentists. It was reported that, whilst this was a key area of focus for NHS England, no exact timescales could be given.
Another particular concern was the state of dental hygiene, with a number of questions asked on why interventions, including supervised teeth brushing, were not being implemented at a much quicker pace. It was explained that, whilst the material demands of introducing supervised brushing were not necessarily that high, the human resource demand of employing supervision was a key factor in slowing down the programme, in addition to difficulties accessing funds from the County’s Public Health Fund, which were already stretched. It was explained that, whilst many initiatives had been planned and in the process of being rolled out, it would take time for all interventions to be fully implemented. The Gloucestershire Dental Strategy Group would only commence setting long-term plans in January 2023.
In response to a request for clarification on what the Family Hubs Programme constituted, members were advised that the programme was a national model, taking a new approach to considering how to commission local services. The hub was in the process of being developed. National guidance on the Family Hubs Programme would be circulated after the meeting. Action by – Director of Public Health
Referring to financial issues, it was reported that the overall budget underspend was currently estimated at around £5million, but that the figure was constantly changing. Exact predictions on expenditure anticipated by the end of the financial year were difficult to predict but it was unlikely that the entire budget/funding would be spent by March 2023. It was clarified that the full budget would be transferred from NHS England to the ICB at the point of transfer, (on 1 April 2023), rather than the full amount, less any underspend.
At the time of the meeting, the full budget figure was set at £18.7 million, though this was reported to be flexible and that the amount may change. It was confirmed that, following transfer of responsibility to the ICB, the use of national contracts would be applied. Efforts would be made to build in flexibility to allow local commissioning.
Commending examples of good work referred to at the meeting, the report was noted, with a request that a further update be made to the committee post the transfer of responsibility from NHS England to the ICB on 1 April 2023.