Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 65 - 79)




  65. Can I welcome our witnesses to the second part of our session this morning. We do appreciate your willingness to come before the Committee. Can I briefly ask each of you to introduce yourselves, starting with Mr Tyas?

  (Mr Tyas) Thank you. I am Adrian Tyas. I am Manager of Operational Services, Cornwall and Isles of Scilly Health Authority, so I have responsibility for all primary care services. I have been involved with dentistry for the last ten years because we have had a dental access problem in Cornwall for ten years. We set up a dental help line ten years ago and we had been planning a PDS pilot for a merger of CDS and GDS salaried dental services in Cornwall. When PDS came along we took advantage of it. That scheme commenced in 1998 and I have been heavily involved in it right from its inception.
  (Ms Holland) Thelma Holland, Chief Executive of Cornwall and the Isles of Scilly Health Authority. I am relatively recently in post and I have had about the most rapid learning curve in NHS Dentistry. I went to Cornwall eight months ago.
  (Mr Scaife) I am Geoff Scaife, I am Chief Executive of Birmingham Health Authority. I started in October last year.
  (Mrs Hamburger) Ros Hamburger, I am the Consultant in Dental Public Health for Birmingham Health Authority. I have been a Consultant in Dental Public Health since 1993 working in Birmingham.

  66. Perhaps I could start with you and your background to ask you more or less the question I put at the start of the previous session, if you were in. What are your thoughts on why we have got the current problems? Do you more or less concur with the points that were made by the previous witnesses as to the background of the current difficulties?
  (Mrs Hamburger) Yes, I would concur, although I would put more emphasis on some of the problems that we had prior to the 1990 contract and the 1992 dispute because within Birmingham we have had inequalities in oral health that predate that and those difficulties have not been affected particularly by those contractual difficulties. My interest is in oral health, not just the provision of dentistry, and it concerns me greatly that in some parts of our inner cities, and my inner city in particular, we have still nearly half of the children arriving at school at the age of five with active dental decay and in some parts of the outer city only ten per cent are arriving with dental decay. We do quite well in Birmingham, we have fluoride in our water, we are better than the North of the country—

  67. Us Northerners are having a tough morning.
  (Mrs Hamburger) The North of the country is absolutely lovely, and it is where I was born, however, unfortunately, there is a gradient which is outside of socio-economic deprivation, outside of anything else, whereby oral health gets worse as you go North. I am afraid that is a fact. Yes, I think the problem was exacerbated by those difficulties and, as I speak to General Dental Practitioners, my experience is the same as Mr Renshaw's, they all mention the 1992 dispute and I can remember them all working very hard to increase their registrations.

  68. Can I put a question to Mr Scaife. Obviously the Government's strategy on dentistry which came in in September identified health authorities as the bodies that will "take the lead in delivering the changes that patients expect". Clearly in doing that you have got a major task because you are dealing with a group of individuals who are in private practice, semi-private practice, scattered all over the place, moving from the North to the South. Do you feel that this is a role that can be reasonably expected of you when effectively we have got a market that perhaps you have only a limited ability to control?
  (Mr Scaife) I think you are right in terms of General Dental Practitioners but, of course, in a city like Birmingham we have more resource on the ground than self-employed, independent General Dental Practitioners. We have got a sizeable Community Dental Service and we are fortunate in that we have a dental hospital and that also enables us to provide a service. As far as the General Dental Practitioners are concerned, they are self-employed, they are independent, many of the rules, if you like, the policies, are nationally determined, Government decides how many places there will be on under-graduate dental courses, Government decides the system for paying dentists both in terms of the operating of fee scales and, of course, the make-up of those scales as well. We do not control all of that. Given that we have a strategy and given that it is entirely right that the Government pays attention to the need to improve access and to improve services, I think all of us would say that this is a beginning rather than an end in itself. Health Authorities are the appropriate agencies because, of course, they are concerned not only with the provision of service and with access but they are also concerned with improving dental health in the round and connecting the two together. I think it is right that Health Authorities should have been given this overall responsibility.

  69. Can I put to our witnesses from Cornwall and the Isles of Scilly this general point that we picked up in the previous session about how we may draw dental provision into primary care. I think you will probably agree with me that we are now attempting more and more to bring into primary care a range of provisions that have been scattered around in Social Services or wherever, in new Care Trusts etc. Do you see a role for your authority in that process? Do you see the prospect of bringing dental provision within the mainstream in a practical sense as well as just in the National Health Service and, if so, how would you go about achieving that locally? Particularly, what does that mean for national policy to assist you in moving in that direction?
  (Ms Holland) If I can take the last bit first in terms of national policy. It is about taking the strategy we have got now a stage further. It is about picking up those issues about workforce, about distribution, about remuneration, so that we have got more than the short-term, we have got the medium to long-term strategy. Within that, as far as the health authorities are concerned, not only across dentistry, we are now trying to ensure that our advisory structures and our relationships with staff on the ground can be mapped to take account of the emerging structures in Primary Care Groups and Trusts. We have got a very good advisory system, we have got very good relationships with the local dental practitioners. Phase 1 of our pilot project was about dealing with some of the emergency things, getting the access. What we are now moving on to is to work more closely with family dental practitioners and to develop plans for a Phase 4 project involving family dental practitioners. What we are doing is trying to coalesce them around the patches that will be the Primary Care Trusts. One example would be the way we are handling out of hours services where we have got projects and arrangements that match the Primary Care Trust structure. That is emerging, it is not there yet, because it is a completely different set-up. That is what we need to work on over the next few years.

Siobhain McDonagh

  70. How will you ensure that the important functions the Community Dental Service presently undertakes can be protected? Indeed, where unmet need is demonstrated, how can you develop the CDS further, given the new requirements being placed on this service? I am particularly concerned about the dental care of elderly people in nursing and residential homes and, of the elderly people, particularly concerned about those who are demented.
  (Mr Tyas) This is an objective that we have set ourselves in setting up the PDS pilot, that the CDS will not be diminished in any way through the need to provide general dentistry to the public of Cornwall. We have been monitoring the activity of the CDS and monitoring the number of dentists who are employed on CDS activities. The question that you raise about the elderly population is a big problem in Cornwall, as you can imagine. Fortunately the service has grown up around it in Cornwall in that we have three practices that do mostly domiciliary work in nursing and residential homes. The CDS part of the PDS does provide that service where it is required but so far it has not really needed to do it to any great extent. Our pilot is continuing to complete what are called KC 64 returns, which are the national returns about community dentistry, even though with the PDS pilot we do not need to complete those. In relation to the unmet need we are working with learning disabilities people to provide a whole service whole county review, including dentistry.
  (Mrs Hamburger) In Birmingham the picture is much the same. We have undertaken to provide the current level of service to people with disabilities and the frail and elderly, and in fact we have plans to develop that service and we want to put in some outreach specialist services which will not only support the current Community Dental Service but also general dental practitioners, so we have plans for a consultant community paediatric dentist and a consultant community restorative dentist to be established in the future. I think that will be an important change. It will help both primary care sets of practitioners in dealing with the very complex work we heard about earlier, which I do believe to be a challenge to the profession now.

  71. It is a personal hobby horse, Chairman, if you will just give me a bit of space on this. It seems to me from personal experience that Community Dental Service provision for people in residential homes is much better than the dental service provided for elderly patients in hospital. Certainly in a hospital not very many yards from here I was shocked at seeing the number of elderly people in wards where they had been for months and months desperately needing dental treatment as well but simply not getting it.
  (Mrs Hamburger) We try not to keep elderly people in hospital for months and months and months in Birmingham. If they are in hospital for months and months and months which, as I say, we hope they are not, we have provision within the Community Dental Service to treat those people which comes out of the auspices of one of the consultant services. In the old days when we used to have wards that were full of elderly people, we had an all-singing all-dancing Dental Service. Fortunately, we have fewer of those long-stay patients now.

Mrs Gordon

  72. Listening to what both groups of people have been saying so far I wondered within the primary care work that you are doing how you manage to get the dentists on board on this, given that it is a financial disincentive for them to treat NHS patients, given that they lose money if they take this holistic approach, which obviously we are all trying to adopt. How did you get them working with you?
  (Ms Holland) There are a number of things that persuade people to change, are there not, and I think one is the push of desperation with the current situation. The plans in Cornwall were laid on the basis of phased implementation. Our immediate need was to provide access to a service for people who needed treatment within the next 24 hours and, by and large, that we have done and we have managed to recruit people into the county so we have not pulled people away from the General Dental Service in Cornwall. We obviously recruited them from somewhere but we have now got 17 out of 19 in post, new appointments into the county, so we have increased the level of dentistry. That has had an impact on everybody. The next phases for us are around beginning to pull into the pilot project the more routine, the maintenance services and beginning to address the oral health issues and to involve the family dental practitioners. We were reflecting coming up yesterday why it was that we had such a huge turn-out at the meeting to discuss this and why there was this tremendous interest from the existing general dental practitioners. There is not one reason. In many cases it is because it might offer a better alternative to the treadmill we have heard about earlier this morning. The other issue is that the perception of the dentists locally is that the first-wave pilots have been well-run and well-led and they have been fully consulted and fully involved. Therefore, if that model is followed then they can see that there are advantages for them.

Mr Gunnell

  73. I would like to ask a question about the plans you have got in each authority for developing the Personal Dental Service and what sort of liaison arrangements you have got with the various groups involved and whether you feel that that is a cost-effective way of using dental resources and whether the costs of treating patients through that sort of system have increased in comparison with operating the General Dental Service. One wonders whether each of you have developed Dental Access Centres and how far you feel that the costs of developing them and the revenue costs of running them offset their value and the likely development of them. You have heard what was said in the last session about Dental Access Centres.
  (Mr Scaife) I will start with Dental Access Centres and then move into costs and ask Ros to pick up the large Personal Dental Service pilot which is about to start in Birmingham. We do not have and do not propose to have at this point one of the 60 or so new Dental Access Centres that are proposed for England. Frankly, we do not think at this point that we need one. We are fortunate in that we have a dental hospital and that provides a service. We are also fortunate in that we have in Birmingham (probably because of socio-economic reasons) still a very fair coverage of general dental practitioners providing a service to NHS patients. Our registration rate is about 48 per cent currently so we do not propose to have a Dental Access Centre. The point you make about relative cost is interesting because what we have heard earlier this morning is a very clear explanation that the service that is provided by general dental practitioners is paid for as piece rate, is looking after patients who probably take an interest in their oral health, and obviously is based upon what they do, and you have also heard this morning that the Community Dental Service exists primarily to provide a service to particular groups, vulnerable groups, whether they are the elderly in hospital, or children, or children in care, or whatever, often people with poor dental health and often people who need extended service, and the pressures are not the same. So I think in terms of cost there is a danger here of comparing apples and pears. The Community Dental Service is providing a service to a different constituency and it is providing a different kind of service to the General Dental Service, although I accept that the payments system does impose a pressure upon general dental practitioners to work quickly and therefore to be less expensive. But I will ask Ros to pick up the point about the Personal Dental Service pilot.
  (Mrs Hamburger) We intend that the Personal Dental Service pilot extends in the way I have already described in that we get some more specialist services out there as an outreach. We also hope that the development of information and management technology will be a pilot, perhaps for General Dental Practice in Birmingham, because we see we may be able to improve the effectiveness of both services if we can get better patient administration systems at the very least for our general dental practitioners and we hope that the PDS will act as a focus for that. Our PDS will have to work—and we are very encouraged by the reaction of our local dental practitioners—very closely with the GDS. My vision for the future would be that the PDS outlets would form a focus for primary dental care in the future which will be part of a primary care network, a locality network, which perhaps will fit in better with present Primary Care Trusts and Primary Care Groups to allow dentistry to be a fuller part of the NHS.

  74. Thank you. Cornwall?
  (Mr Tyas) Our position is that we have got a network of 20 clinics which are all Dental Access Clinics around the county. Our first objective was to be able to provide emergency treatment at the least for anyone who required it and the figures show that we are doing that within 24 hours for 94 per cent of patients. We set ourselves a target of people not having to travel further than 20 miles to access a dentist and the statistics show that 70 per cent travel less than ten miles. We have available advice or triage every day 24-hours a day, either through the Dental Health Line or NHS Direct. We are trying to achieve an end to inequalities in access to dental care in Cornwall. Not everyone wishes to be registered, therefore the kind of service that the PDS 1 in Cornwall is providing will supplement what the GDS can provide and what we aspire to for a fourth wave of practice based PDS schemes. The costings, as we have already heard, are not directly comparable. We have looked at them very closely. The figures that we have got show that in the PDS in Cornwall the cost is £65.50 per patient which relates to 1,010 claims per dentist, but they all involve intervention. PDS includes general anaesthetics, special needs and orthodontic treatment. The GDS, on the other hand, is less cost, £42.10 per patient, an average of 1,786 claims per dentist, 916 of those are for no intervention, 870 therefore with an intervention. Looking at the statistics in GDS in Cornwall, there is relatively little complex dentistry being carried out in the General Dental Service.
  (Ms Holland) I think the other thing that we have found over the years that we have had the Personal Dental Service pilot is that there is an economy of scale. In the first year it was more expensive, it came down in the second year, and as we have expanded and developed it it is going to come down again in this year.

  Chairman: Any further questions?

  Mr Gunnell: No, I think that was adequately covered. When I look back at the statistics you have given us it is obvious that you have got tabs on it all.

Dr Brand

  75. Do you think there is a paradox that you are supplying emergency one-off care in Dental Access Centres where you have an employed service so people do not work on piece rate for doing piecework, and you are trying to develop a wider public health agenda through your General Dental Service, which is on piecework?
  (Ms Holland) The short answer is yes. The health authority has responsibility to try to make sure that we can provide a long-term objective of oral health and, at the other end, we can deal with those people in immediate need.

  76. But your means of influencing events, oral health, are largely restricted to what monies you can give out direct and national contracts. As health authorities, and Dr Hamburger especially as a Consultant in Dental Public Health, do you get frustrated about the structure that we currently have which, to me, does not seem to encourage either team work between dentists and other professionals within oral health and a bit of a long-term commitment to dental health?
  (Mrs Hamburger) I have been frustrated because General Dental Practitioners are independent and there have been very few levers that the Health Authority has been able to use to—

  77. There are lots of levers but you cannot use them. The levers are with Central Government through their contract.
  (Mrs Hamburger) That is right. The strategy, which does have its weaknesses , does signal that the Health Authority has more levers than it has had in the past. For instance, we can take out—

  78. Does that include NHS contracts?
  (Mrs Hamburger) Yes.


  79. What levers should there be? You have got this enhanced role and I am worried that your ability to address these concerns has not been enhanced in any way by the plan. What are the levers that you need? We need to be looking ahead at the strategy that we will suggest from this inquiry, the proposals that we make. What do you feel would help you to bring about what you obviously desire to achieve and establish in Birmingham?
  (Mrs Hamburger) Some of the levers are coming and we know that the Modernisation Fund is there waiting to be used and the Dental Care Development Fund is there. I would like to be able to pursue that further. I think dentists, particularly in socio-economically deprived areas, have considerable difficulty in making adequate investment into their practices, there are a lot of disincentives to those investments. I would like to be able to redress those disincentives locally. The other options which are really open to us now, which I think we could pursue with the current strategy, are some of the softer options of working more closely with the profession, looking at some of those things that cause them stress outside of the treadmill, how to cope with the treadmill, helping with their patient administration, bringing them up to date with IM&T, which sadly they are behind on because there has been a lack of investment there. It is accepting that dentists are there, not thinking that they are some other place on Mars, and working with the group, asking locally what would help them and being able to provide some of that.

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