NHS England (NHSE) must encourage those with dental expertise to join local systems, including by assisting ICSs with recruitment, so that institutional commissioning knowledge and experience are not lost when commissioning responsibilities are transferred, writes Matthew Taylor.
Ask any MP or local Healthwatch what health issue sits at the top of their inbox, and there is a good chance it will be the public’s access to NHS dentists. The launch of a Health and Social Care Committee inquiry into dentistry is therefore welcome news.
The inquiry is well timed, coming after a recent BBC investigation showing that 90 per cent of practices across England were not accepting new adult NHS patients.
The severe access problems stem from several factors. Longstanding issues relating to the dental contract not offering high enough rates for dentists to provide NHS care, for example, have contributed to a decline in the availability of NHS dentistry. This has led to thousands of people across the country going private or, very concerningly, turning to self-care. Where we do spend money, we do so on an inverse care gradient that means we spend less per head of population in the areas with the highest levels of deprivation.
Two thirds of practices say they have unfilled vacancies for dentists
Accident and emergency departments are over-flowing with people in severe dental distress, with tooth decay being the most common reason for hospital admission among children aged five to nine in recent years. One senior dentist recently told us that 11 per cent of NHS 111 calls in his integrated care system were dentistry related.
The British Dental Association, the body representing the dental workforce, describe barriers to working in the NHS and two thirds of practices say they have unfilled vacancies for dentists.
ICSs will take on the commissioning of NHS dentistry from NHSE in April. While no one should under-estimate the scale of the challenge involved in improving dentistry services, this an opportunity to do things.
ICS leaders have told us they are keen to apply a system lens to the problems in dentistry. A focus on prevention, for instance, could help to stem the tide of the most severe dental cases in future and it is hoped ICSs’ commitment to health equity will improve access for the most urgent cases. For the first time, dentistry will be commissioned alongside wider primary and secondary care services, incentivising financial efficiency, signposting and better integrated pathways.
ICS leaders have told us they are keen to apply a system lens to the problems in dentistry
A priority will be to set up an urgent dental care system that connects individuals from NHS 111 to a clinical triage and designated urgent care provider. In some areas, improved community dental services are needed with capacity to meet the expanding needs and volume of patients who cannot be cared for in a high street setting. In others, domiciliary dental care is considered essential in residential settings and for vulnerable groups.
We are already seeing encouraging innovation in pockets of the country. In Suffolk an innovative partnership between the University of Suffolk and the Suffolk and North Essex Integrated Care Board is seeking to create capacity through the set-up of a community interest company specifically to provide NHS dentistry. In the Midlands, leaders are looking to place a new urgent dental care service alongside an accident and emergency department.
However, despite the best efforts of ICS leaders it is unlikely that we are going to see drastic improvements to patient outcomes nationwide in year one without further support. Indeed, seven 'early adopter' ICSs have taken on dental commissioning already and feel they are surviving but not yet thriving. Fixing a failed model of NHS dentistry will take some years for ICS to achieve.
There are steps the government and NHSE can be taking now to best prepare ICSs to hit the ground running from April
Over the coming months, we will be working with local and national stakeholders to establish what long-term action is needed to improve access across the country.
First and foremost, a clear strategy is needed to reverse the decline in the number of NHS dentists - a figure which has fallen from 23,733 at the end of 2020 to 21,544 at the end of January this year. ICSs cannot solve this problem; national action is needed.
However, there are steps the government and NHSE can be taking now to best prepare ICSs to hit the ground running from April.
We need a clear plan for commissioning support and the transfer of expertise from NHSE into systems. We are supportive of giving ICSs more autonomy to deliver on local priorities, one of the aims of the recently announced Hewitt Review. But shifting power away from the centre and to ICSs requires a shift of resource.
NHSE must encourage those with dental expertise into local systems, including by supporting ICSs with recruitment, so that the institutional commissioning knowledge and experience is not lost with the transfer of commissioning responsibilities.
We also believe that national funding made available for dentistry should stay within dentistry. Often when NHSE has provided funding it has been made available until the end of the financial year and any underspend has not been carried forward, instead being “clawed back” to plug gaps in other areas of spending. We must address this and invest now in dentistry infrastructure ahead of April. We will be setting out our views in more detail through the committee’s inquiry.
ICSs are built on foundations of partnership, value for money and a strong focus on equality. There is an opportunity to demonstrate that these new partnerships can foster real change and tackle thorny issues like dentistry. Yet at a time of significant pressure for the new emergent partnerships, they will need robust support from the centre to do so.
Matthew Taylor is chief executive of the NHS Confederation. You can follow Matthew on Twitter @FRSAMatthew
This first appeared in the HSJ.