Health Select Committee, Final Oral Session – GDPUK Report

Health Select Committee, Final Oral Session – GDPUK Report

The second panel of witnesses on the final day of oral evidence to the Health and Social Care Committee enquiry into NHS dentistry, offered an opportunity for those in charge to defend their record. 

The second panel of witnesses on the final day of oral evidence to the Health and Social Care Committee enquiry into NHS dentistry, offered an opportunity for those in charge to defend their record. Neil O’Brien MP, Parliamentary Under-Secretary of State for Primary Care and Public Health at Department of Health and Social Care, frequently handles dental questions for the government.  Sara Hurley, Chief Dental Officer at NHS England and Dr Amanda Doyle, National Director for Primary Care and Community Services at NHS England speak for the organisation ultimately responsible for the service.

Chair Steve Brine declared an interest, he had once been a Junior Health minister and worked with the CDO. “You’ve outlived me”, he observed, with a wistful smile. He began by quoting Tony Blair’s 1999 pledge to his party conference that within two years everyone would be able to access NHS dental care by calling NHS direct. What then, he asked Neil O’Brien, was his ambition was for the service?

The minister responded that, it was to recover to pre pandemic levels, and then improve the service. Levels of activity were recovering he said, omitting to mention the low point that they were recovering from. He spoke of reforms which were about making NHS dentistry more attractive to dentists. This included more UDA bands. Access for those without a “regular” dentist was on his mind. He spoke of improved performance management of those who persistently failed to hit their UDA target. He said that it had until now been “very difficult” to take the UDAs’ back and “redeploy” them. He mentioned prevention. He spoke of a “thorough overhaul” of the contract, “we’re not into small tweaks” he said, which will be news to those who have listened to the CDO over the last couple of years. Pressed by Steve Brine over whether in his “heart of hearts” he believed we could reach a point where everyone who needed to, could access an NHS dentist, the Under Secretary unblinkingly said that he thought it was achievable.

Brine quoted the BDA’s statement about the contract changes to date being “tweaks” that “rearranged the deckchairs on the Titanic.” Neil O’Brien did not directly answer this, but accepted that fundamental reform was needed. Capitation, endorsed by the BDA, did not see enough patients. He articulated what could be described as a “new UDA” arrangement. Brine then spoke of dentists leaving the NHS having made a difficult a final decision, he worried that even with an improved system they would not return. Did this worry the Chief Dental Officer, he asked.

Despite her recent comments at ExCeL anticipating private dentists returning, it turned out that this did now worry Sara Hurley. However the flexibility that ICB’s could offer might be enticing, and perhaps it was time to move from self-employed arrangements so that NHSE set associate’s terms and conditions. Perhaps unsurprisingly, given her personal involvement in them, she thought Community Interest Companies (CICs) with salaried employees might be appealing and offer “portfolio careers.”

As expected the CDO had started confidently, and then Paulette Hamilton (Labour Birmingham Erdington) set to work. She had frequently heard the expression ‘put the mouth back in the body’. Were these the CDO’s words, asked the MP. The CDO nodded vigorously and smiled hard, yes they were. Paulette then spoke of the exodus of NHS dentists and the 44% increase in dentists leaving the NHS, coinciding with the first four years of the CDOs tenure. Government finance had reduced and access had got worse, meanwhile a “mass exodus” of organisations such as BUPA were leaving NHS dentistry. Recent data showed that improvement in child oral health had stopped and inequalities were increasing. So, Paulette Hamilton asked, could the CDO outline how far her office and NHS England had come in putting the mouth back in the body? The CDO smiled again and mentioned the starting well project and dental check by one (DCby1). The CDO then said that she hoped to restart starting well and “reinvigorate” DCby1, rather suggesting that their effect had been transient.

The Mouth Care Matters programme aimed at mainly older patients was mentioned. It too needed “reinvigoration.” More schemes were mentioned at which point Paula Hamilton asked if they were continuing now. It appeared from the CDO’s long answer that they are not currently active. “Far from doing nothing I am a woman on an agenda, with a plan” concluded the CDO, despite not having been accused of doing nothing or lacking any number of plans.

To give the CDO her due, Paulette  Hamilton said it was an awesome plan, but did proceed to ask why so many of these things were not happening currently. There were many issues said the CDO. It had not been easy over the last seven years and she had “expended an extraordinary amount of shoe leather”. She took credit for the Select Committee being set up.

Paula now moved to the minister to ask him his three key objectives. They were to make improvements for patients who did not have a dentist, to grow activity, and drive forward on prevention. She then asked how would he get the staff with so many dentists leaving the NHS. Using what we know are misleading percentage figures that include those doing one UDA a year, he claimed there were more NHS dentists. He mentioned skill mix along with the changed guidance and easing international routes to dentists coming to work in the NHS. Amanda Doyle ran through the recent tweaks on UDA base values and new bands for more complex treatment. She admitted that post pandemic recovery had been really slow. To try and show that things were improving she said that March had seen 101% of activity delivered, but did not explain why it might not be a representative month. The access problem was not because of a failure in commissioning, but as a result of dentists who had under delivered.

Rachel Maskel (Lab York Central) asked how workforce was being measured. Neil O’ Brien focussed instead on how the existing stock of dental professionals could be encouraged to do more NHS work, without saying how this might be done. Pressed by Rachel Maskel for numbers, he returned to the issue of how much NHS work they did, before passing the question to the CDO. Her response appeared to focus on hospital and specialist dentists. Great work had been done, she said, discussing long term work plans and the advancing dental care reports, and the dental education reform programme. This was all done without providing any numbers. She then moved on to the potential of skill mix.

Rachel Maskel however, did have some numbers. In York there had been a 126 000 reduction in UDAs over 4 years, 3 practices were closing and there were 5 year waits to see an NHS dentist. Why was the CDO’s plan not working? The CDO suggested that the York ICS speak to Suffolk where there was an innovative scheme being set up. She was “fully supportive” of it and it hoped to deliver a 10 surgery purely NHS practice to Ipswich. She did not go as far to offer her services to any community interest companies intending to run practices in York, as she has successfully done in Suffolk. Rachel Maskel remained unconvinced. Her final question for the CDO was about a career pathway for salaried dentists. The CDO spoke of her own CDO clinical fellowship programme which offered training to be – policy specialists.

Paul Bristow (Cons Peterborough) asked the minister about how underperforming ICBs would be handled. She replied that the recovery was progressing better in urban areas, and that foundation training might be a way of achieving workforce improvements in dental deserts. Responding to another of his questions the CDO made clear that 77% of attendances were within 12 months and where there was no caries or decay to treat. It was clear that adherence to NICE recall guidance will be expected, and no doubt enforced, were ‘healthy’ adults recalled inside two years. The minister appeared to reinforce this. No one asked how one would know patients were healthy, without seeing them.

Paul Bloomfield (Labour Sheffield Central) asked the minister just when, everyone who wanted to see an NHS dentist, would be able to. He kept asking, as the minister repeatedly wandered, and also coined the expression “dental barren ground” to describe those parts of the country fortunate enough not to be fully fledged dental deserts. Neil O’Brien returned to his latest formula in an exchange that included a disagreement about whether Dr Doyle was nodding in agreement with Mr Bristow. O’ Brien’s response now takes the line that, there is no shortage of dentists, the key metric is how much NHS work they do. The UDA percentage hit rate has recently been increasing, ergo they are doing more NHS work. Which completely ignores the low post pandemic baseline.

The CDO then weighed in with her disappointment that dentists were not following the guidance on phased care for high needs patients. In doing so she demonstrated that she has never treated such civilian patients on the NHS, as an associate or principal. Dentists, she continued, were the horses who could be taken to water but preferred to do “unnecessary” check-ups.

Paul Bristow asked about wildly varying UDA rates for similar practices, and the minister returned to phasing, actually suggesting that it allowed dentists to get paid “as much as it takes” to treat a high needs patient. Paul Bristow then asked the killer question, was there, “enough money to provide the service the minister aspired to.” The minister’s response promised no new money.

James Morris (Con Halesowen and Rowley Regis) asked about the huge underspends over recent years from clawback. The minister spoke of a ring fence, which he then had to concede was not enforceable.

Dr Caroline Johnson (Con Sleaford and Hykeham) asked about military families who often found particular problems with access, as they moved around the country. She had asked the MOD if they might be seen be seen by forces dentists. They had responded that there were already 22,000 members of the forces categorised as requiring dental treatment to achieve optimal dental fitness, and some not even fit to be deployed.

The CDO as previous head of the Army dental services, then gave a glowing account of her achievements in that post, which were so good that they had been adopted by the Air force and Navy. She went on to make the case for prevention and made the point that this did not just happen in the dental chair. Dr Johnson then asked if the 22,000 waiting for care in the forces represented an improvement. The CDO suggested that compared to the general population that it was. The CDO went on to point out that the forces had integrated records and e-prescribing which facilitated care, and e-prescribing would be one of her asks for NHS dentists.

Dr Johnson then asked about care for children and the minister emphasised prevention, including fluoridation, and specialist training. The CDO then answered, including a reprise her greatest hits including DCby1, “putting the mouth back in the body”, and working with other healthcare providers. The meeting was then closed by Steve Brine.

Correction: In a previous report GDPUK quoted Chris McCann of Healthwatch England, saying that he knew of no dentists on ICB boards. In her closing statement the CDO pointed out that there was a dentist on the board of Surrey Heartlands ICB. For readers wondering who this is, their name is Sara Hurley.

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