Oral Evidence To Commons Health Committee Pulls No Punches – Part One
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- Published: Thursday, 23 March 2023 07:55
- Written by Guy Tuggle
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‘The can cannot be kicked down the line any further, or could it?’
The first session of Westminster’s Health and Social Care Committee’s inquiry into NHS dental access and, by implication, contract reform, took place on Tuesday in Committee Room 5 of the House of Commons.
Set up in response to the deluge of complaints MPs have received from constituents unable to access much needed care, the Inquiry is examining why there is such a problem and what can be done to improve recruitment and retention of clinical professionals within the NHS.
The inquiry, by virtue of its very existence, is the most tangible evidence to date that at last the country’s politicians are alarmed and seeking change. People with toothache have votes, after all.
Having collected written submissions, today’s hearing saw the Committee hear oral evidence from the first pool of contributors invited to appear and face questioning from MPs eager to learn more. Many of the themes will be familiar to GDPUK readers. What’s impressive is how forceful the witnesses were and how wide ranging their contributions were.
First off was a trio of witnesses that consisted of Professor Nick Barker, GDP and Professor of Oral Health Science at the University of Essex, Shawn Charlwood, Chair at the BDA General Practice Committee, and Dr Sandra White, Clinical Director at Association of Dental Groups (‘ADG’).
Committee Chair Steve Brine MP opened by asking Prof Barker to quantify the extent to which the changes to the contract announced last year constituted ‘tweaks’ or ‘something worthwhile’. ‘Tweaks’ was his reply, because the contract continues to mark on activity that ‘scores points’ and how prevention scores ‘low points’.
Shawn Charlwood for the BDA – with Eddie Crouch seated behind him - was scathing: “the recent changes are not reform: I want to make that very clear .. they will not stop the exodus of dentists and their teams from the NHS. The fundamental perversity of this system is unchanged … we have a higher reward for treating three or more teeth, but many of the new patients presenting to dentists and their teams now have far more disease than that. People haven’t been able to present, are presenting much later, have far more disease, and the disease if often more complex to treat.
…The perversity of this UDA system remains baked into the system: less complicated work will be rewarded, more complex work will not. And there is no new money: none of these changes have new money attached”.
Mr Charlwood likened the marginal changes as akin to rearranging the deckchairs on the Titanic “ while the service slowly slips into the sea”.
A Capitation system, where prevention is rewarded, is what was needed Charlwood said.
Dr White from ADG which represents twenty of the biggest groups most committed to still offering NHS dentistry, engaging ten thousand dentists and seeing some ten million patients said “there’s no holistic individual care. Our dentists have been waiting a decade for real reform and they’re losing hope”.
Chair Stephen Brine MP said it “was a huge wrench to leave NHS” suggesting that it would be very hard for dentists to return to it even if all Dr White’s wishes were granted next week. Dr White said that preventative messages like giving advice on tobacco, alcohol, diet, and breastfeeding “needs time you don’t have in the NHS” and that those that are left in the NHS are having to pick up the pieces because a lot of their colleagues are leaving. “We’ve got a demotivated, unhappy workforce” she added.
One MP talked of the varying UDA rates, claiming he had two practices within 100 yards of one another one on around £20 a UDA and one on around £35 “based on historical data based on 17 years ago”.
The committee then turned to the projected underspend of £400m that will be lost to NHS dentistry where constituents would be left scratching their heads that they can’t get access when the budget that is available isn’t even being spent.
Mr Charlwood pointed out that the barriers to change are many. Blaming the Treasury for dragging its feet, he reminded the room that the government only funds enough dentistry for 50% of population adding that if that applied to medical provision in general “there would be rioting”.
But the problem ran deeper than funding said Professor Barker. When East of England reached out with an enhanced UDA rate package ‘to mop-up’ some of the missing UDAs “nobody offered to do them: if you’re working with something that isn’t workable nobody wants to do it” he said. Reform needs to start with a blank canvass.
Asked how capitation would change the system Professor Barker said that having been a prototype practice under blend B he thought it worked because it incentivised whole team rather than just dentist which is what the UDA system does, leading to integrated care or ‘patient centred care’ as he preferred to call it.
Shawn Charlwood also argued for a prevention based capitation system “which could include weighting for need…. and that may be based on a postcode, weighting for new patients much as you do in general practice because typically they need more time than patients who’ve been attending on a regular basis... Just as GP those who need us most would be able to gain access and new patients would be weighted which would start to address some of the problems we have at the moment. So capitation, weighting a national tariff to get rid of discrepancies which would help recruitment”.
Mr Charlwood illustrated the difficulties UDA discrepancies have on recruitment, specifically a practice’s ability to bid for a clinician’s services. And in a fierce critique of the constraints the NHS contract places on clinical practice, Mr Charlwood said the NHS way of working is not the way dental graduates wish to deliver dentistry with scant regard being placed on prevention.
Professor Barker picked up the prevention theme adding that undergraduate training is about preventative care so we need to put a preventative model in place. Patient demographics change as they age so the system needs to take patients in and then “keep them on a maintenance road. The current contract just treats disease”.
Workforce head counts were identified as being in need of urgent review. Whilst they counted the numbers on a register they did not measure how many were full time or part time or even not active at all. Dr White said a dentist “could be seeing a friend once a year” and confessed that she is on the register but “hasn’t worked clinically for twenty years”.
White added that that dentists operate in a global market and that we “need to keep door open to EU colleagues and look to attract more overseas dentists” This is not easy when placing our NHS contract alongside working models from Canada, the USA and Australia.
Turning to workforce flexibility Professor Barker suggested other dental professionals could do more of the tasks the dentists perform and identified a need to change training to address wider skills mix. Reference was made to GP practices where nurses given enhanced roles but in dentistry even therapist had little scope or freedom to treat or prescribe without referral to a dentist.
The committee next addressed the imminent involvement of ICBs in dental commissioning, admitting many were inexperienced at this complex task. Their local focus was acknowledged as a force for good but Shawn Charlwood lamented that “local innovation will not overcome a flawed national contract.”
As ‘half time’ approached, the first three witnesses were able to put forward some positive steps that could be taken including ‘payments for audits, for peer reviews, touch feely things that make being a dentist rewarding’ said Dr White.
The BDA’s Charlwood seized on this and proposed bringing back NHS commitment payments so that dentists were rewarded for doing more NHS work. “Late career retention payments” to reward those who mentored teams were another incentive that would be easy to restore having been removed.
‘How about occupational health service for dentists and teams? Protective learning time, clinical audit….when you can see all the good things of a system have been removed are you surprised dentists are leaving the system? It’s not rocket science - improve the terms and conditions, increase the commitment to NHS dentistry through proper sustainable funding and you’ll have NHS dentistry again’ Mr Charlwood said.
With regard to prevention – Charlwood suggested paying dental teams a sessional rate for going into schools and communities to teach tooth brushing, diets, oral cancer education but the UDA system does not cover this. Dr White added that there was evidence for the effective impact of toothbrushing in schools and also for water fluoridation.
Closing the first half, Stephen Brine thanked the witnesses adding that the inquiry was looking for brutally honest answers and had not been disappointed by the opening contributions.
GDPUK’s next report will review the evidence of the next three witnesses who appeared on Tuesday - Ian Brack of the GDC, Dr Abhi Pal, President of the College of Dentistry and Malcolm Smith of the HEE.
A Health & Social Care Committee spokesperson told GDPUK that there would very likely be at least another session of oral evidence before which the committee will discuss the problem and make recommendations to government.
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