Following similar campaigns for medicine and pharmacy, (no I hadn't noticed either), last week NHS England launched the dental call. It was trumpeted with documents with the admirable aim of improving dental care and oral health, but the large caveat is this must be done with a reducing budget and a £30 billion black hole in the NHS funding stream. One wonders if loosing dentistry from the NHS might infill some of the cavity.

We are told that the NHS dental budget is £3.4 billion per year and that private dentistry makes up £2.3 billion in provision, although some may dispute that. £653 million from patient charges is included in the total budget and is an important part of the contribution. In view of what the government is prepared to pay on other issues, one wonders why it is needed at all, but of course patient charges are a controlling factor of the demand.

Much is made of the Dental Local Professional Networks that have recently been established, but no mention of the chronic underfunding of this, which might explain why so few of us will have noticed their existence to date.

The NHS belongs to the people is the strap line, but not sure the way politicians interfere with it, make any of us feel like the owners.

The document attempts to describe many strengths in the current system and improve access. At a recent GDPC meeting I asked Elizabeth Lynam , head of dentistry at the DoH would there be funding for more patients to register if a reformed registration and capitation model attracted more than the 56% currently visiting practices in a 24 month period, no was the answer.

So if access is to increase, that too must happen within the existing budget. Not so much a call to action as a call for charity from the profession.

As a committed LDC official, I am disappointed that there is not a single reference to local representative committees, nor a mention of them being stakeholders. Perhaps with the manipulation of levy collection ongoing by NHS England maybe they won't be for long anyway?

We are asked to respond to the questions by the 16th May 2014 and that our answers will be independently analysed, we are not told by who,( I am lead to believe it may be an American institution, so much for tendering) but it will make a change for independent analysis when we are deprived that within the pilot programme. A strategic framework for commissioning will be published along with a report.

There is pride on the excellent data on disease and activity NHS England hold but those that witnessed the destruction of the Dental Practice Board will believe this information far inferior to what was previously known.

Again there is a plan to best use tax payer’s money and develop a workforce that is appropriate for the future, a bit rich after what graduates are facing in the lottery of FD placement. But world class has been replaced by exemplar commissioner so perhaps reality is dawning at Whitehall. I wonder where the "tools" to enable a consistent care pathway are being kept.

Remarkably the document admits they need to know how to measure excellence and despite telling us how good the data is they have, they admit they lack data to benchmark performance nationally. I know what I believe of these two versions on data.

In its section on health inequalities it talks about a "seldom heard" group, I got quite excited when I thought it might be the many critics of DoH and NHS England but it turns out to be patients facing barriers to accessing care.

There is a clear message they we carry out our care at times convenient to us, and that patients want extended hours after work and at weekends. Not sure what evidence base there is for this, but the direction of travel is clear.

Much is made of the OFT report of 2012 despite massive criticism from the profession and the BDA. So not much notice taken there then, and of course they trumpet this call to action process is being supported by the BDA. Damned if you do and the same if you don't .

There are also indicators to the shape of general practice of the future, they want to move away from working in isolation and support larger teams in the interest of better care, and develop special interest in primary care. The end of single handed practice and tiered delivery of care for those with the badge to do it is just a review away perhaps?

It is followed by a list of questions deliberately moulded to either restrict answers or get the ones they want, but none the less I would encourage all to let them have the "action" by going to

www.england.nhs.uk/ourwork/qual-clin-lead/calltoaction/dental-call-to-action/

Whilst I understand enthusiasm for this is not great and we are being herded along with the medics, we should not under estimate the importance or messages contained.

Eddie Crouch

It may all end in tiers

In his independent review NHS dental services in England, Jimmy Steele placed advanced care at the top of the pyramid he created for prioritisation, and care pathways determined how patients might scale this structure to reach the pinnacle.

When Andrew Lansley drafted his Health and Social Care Bill, being married to a Doctor obviously drew his focus away from other healthcare providers. The structures were all there for GP commissioning and the formation of Clinical Commissioning Groups, even the removal of PCTs and transfer to NHS England and Area Teams. We can argue if any of this amounted to "no more top down reorganisation of the NHS" as promised in the manifesto, or the most challenging time anyone working within NHS management had ever faced.

It is hard to remember when someone at NHS England twigged or tapped Sir David on the shoulder and said what are we doing with dentists? Are they supposed to be part of this clinically lead new NHS? Someone somewhere found the fag packet, and I think it was John Milne's sister Helen Hirst that wrote the first plan for Local Professional Networks on the back of it. Helen had hardly got the ink dry before she passed the empty fag box to Sam Illingworth; before the final details were released both had jumped ship to the CCGs leaving others at NHS England to finalise.

Of course by this stage pilots had been invited to test the model, this too lacked direction with a "get on and see what you can do" mantra. Even the regular teleconferences to see what was happening and share experiences fell apart amongst the maelstrom of the de structuring of PCTs and the reapplying for posts.

By February and with the impending changes just a few weeks away, the NHS Commissioning Board (remember them?) released Securing Excellence in Commissioning in NHS dentistry was published. Within its pages contained the framework for LDNs and some examples of what the pilots had achieved. Some like in Manchester under the stewardship of Colette Bridgman clearly had an effect, albeit she struggled to fund her projects. Others exampled in the document like the reorganisation of Oral Medicine services in Birmingham perhaps needed placing in the fictional section of any library, but highlighted how little many of the pilots achieved in their lifespan.

Well six months in, we have recruitment processes in all the Area Teams and in others they have appointed a Chair. Many of these posts have been taken by LDC people, some have continued to wear both hats, and for me I am not convinced that's possible. As far as I am aware many of these newly appointed Chairs are yet to be paid for their new job, apparently due to a HR issue at NHS England, it seems like LDNs have taken them by surprise!

Of course the challenges for the LDN Chairs is to assist depleted commissioning teams in delivering national strategy and developing structural changes in service delivery locally, all within perhaps one afternoon a week. Not only is that the challenge but the budget given to them is somewhere in the region of £40,000, a share of a pot of £120,000 secured for Local Professional Networks for dentistry, pharmacy and opticians. The CDO describes this as "seed money" to allow the LDN to grow and show its usefulness, perhaps he is providing the fertiliser?

It really shows the importance of dentistry within the NHS when it's funding is pennies per patient population for an LDN compared to the £25 per patient that CCGs get for management costs. Clearly if members of the dental team are to be involved in LDNs, they are to be expected to do this with benevolence and with no remuneration; it's clinical leadership on the cheap.