Meeting 20th November 2019

LOCATION

THE HUNTINGDON MARRIOTT HOTEL

DOWNING ROOM

WEDNESDAY 20^th NOVEMBER 2019

7pm Arrival for 7-30pm Start

MINUTES

1. Attendees:

Jaco Craig - LDC Chairman

Mariana De Villiers - LDC Administrator

 Patrik Zachrisson - LDC Treasurer

 Amiras Chokshi

Marlise De Vos

Gawain King

Peter Mullins

Julia Hallam-Seagrave

Deepak Kumar

Meeraj Patel

2. Apologies:

 Maria Ross-Russell

Francis Scriven

Claire Jackman

Bharpur Sanghera

3. Guests:

Tom Norfolk - LDN Chairman

4. General Dental Practice Committee (GDPC) REPORT – Amiras Chokshi

The GDPC Meeting was held on 4^th October 2019.  

Pay scale uplift:

A 2.5% general uplift in the pay element of contract was paid on the 1^st of November 2019 backdated to the 1^st of April 2019.

Contract Reform:

Contract reform remains an issue. Wording has been changed from Contract Reform to Reform of the Contract.

The GDPC discussed the transitional arrangements for moving across to the reformed contract. The proposals from NHS England were unacceptable and would not provide practices with the stability needed for them to successfully transition. As a result, the BDA had proposed an alternative approach, which would be presented to NHS England at an upcoming meeting.

The BDA proposals concurred with NHS England’s view that in the first instance practices would join on a voluntary basis and would only be eligible to join if their current performance was within five per cent of the targets they would need to meet under a reformed contract. Practices entering the reformed contract would then have a transition period of five years to build up or wind down to their targets, with a maximum of ten per cent clawback applied. The exchange mechanism should work in both directions. The introduction of the oral health assessment should be staged based on, for example, patient group by age.

There still needed to be agreement on the national weighted capitation rates and the national non-capitated activity rate.

The weighing for capitation would be based on the age, gender and deprivation of the patient’s address. The calculations would be based on the patients on a practice’s list, which would be used to work out an average for the capitation figure for the practice. This would then affect the number of patients the practice would need to see.

Dental assurance Reviews:

The BSA had recently launched a new set of Dental Assurance Reviews, of which the GDPC had received no prior warning and had not been consulted.

There was a risk that the implementation of these reviews would lead dentists simply not to claim under these circumstances.

Guidance on how claims are judged, what to claim and how to claim can be found on the BSA Website, under In the Spotlight.

https://www.nhsbsa.nhs.uk › compass › resources-dental-practices

Topics currently covered are:

In the spotlight - article 6: children's dentistry 

In the Spotlight - article 5: incomplete treatment

In the Spotlight - article 4: urgent claiming

In the Spotlight – article 3: mouthguards

In the Spotlight - article 2: inlays and onlays guidance

In the Spotlight - article 1: a course of treatment and examination:

 It is well worth looking at these.  As an example: Band 2 Fissure sealant can only be claimed when TWO materials are applied: composite as well as fissure sealant.

Clawback:

Record clawback has been seen in all regions.

Don McGrath presented to the GDPC on the state of clawback and NHS dental finances in Manchester and more generally in England. There had been a significant increase in clawback and in the number of practices affected both in Greater Manchester and nationally. For England as whole, clawback was £138 million in 2018-19. Greater Manchester was by no means the worst affected region in terms of clawback, with others seeing much higher rates both in cash terms and the number of practices affected.

It appears that money is disappearing from Dentistry for various reasons and is not ringfenced for Dentistry.

Pensions:

The BDA’s Head of Pensions, Phil McEvoy, presented on issues relating to the NHS Pension Scheme. The NHS Pension Scheme remained a very good pension scheme. It offers a secure and promised income, not based on investments, and had significant employer contributions. However, the costs of the scheme are increasing. Various scenarios were discussed including pension flexibility and annual allowance vs lifetime allowance.

It was agreed that it would be very informative if the LDC could arrange for the Head of BDA Pensions to give a presentation for all LDC members.

Orthodontics:

There have been delays in some of the orthodontic procurement processes in England. Orthodontic Procurement in this area has been put on hold.

Francis Scriven has provided the following report on orthodontic procurement:

1. It seems like pretty much every lot is being delayed. The reasons are not always clear but it is often due to an error in the tender process. It also seems that many of the outcomes are being subjected to legal challenge and that the more the process wears on the more this is happening.

2. You may or may not be aware but the tender organisation for the Cambridge lots has been changed at the 11th hour. No reason has been given. It was Proactis and is now In-Tend. It seems we will need to learn a new portal, and resubmit all the previous information.

3. The whole tender timeline has been delayed again and the mobilisation period extended.

4. There has not been adequate clarification on how they will equitably assign the lots where they have more than one lot in a town e.g. Cambridge x 4, Norwich x 4, Bury St Edmunds x 2 etc etc. The problem being that it would seem that each lot is bid upon individually. Therefore, you could bid on lot 1 and lose with 80% against say 82%.  But then lot 2 could be won with 78% because it is the highest score for that lot. So do you bid on every lot, if you want to win two lots do you have to bid on all permutations: 1&2 1&3 1&4 2&3 2&4 3&4.

The main issues are that the delays are anti-competitive and in particular favour corporates.

The delays prevent people from being able to secure leases, as it not reasonable to hold an option for what will now amount to about 2 years.

Existing leases will have been renegotiated in preparation for the process and will now have run down to a level that will lose points in the tender process. These leases may be difficult/impossible to renegotiate.

It is not possible to plan a business model when it is not clear the size of the contract you are bidding on.

5. Local Dental Network (LDN) Chairman – Tom Norfolk

The LDN now has an Instagram page: Local dental network east of England. The aim is to build up a group of people in order to communicate relevant up to date information relating to dentistry in a modern accessible platform.

Dental Therapists:

Prescribing abilities of dental therapists to be reviewed in January 2020.

A new training programme at The University of Essex for an undergraduate Dental Therapist BSc degree is being proposed with a possible enrolment date of September 2020. Applications would be through UCAS.

Recruitment of dentists for specialised disciplines in the country remains a problem. It is proposed that a general dental practitioner who works in an approved area would train 1 day/week at hospital to improve skills in order to achieve level 2 accreditation. Free access to hospitals would be available. Oral Surgery would be the first discipline to be supported.  Training could also be possible through digital surgery.

6. Chairman’s Annual Report – Jaco Craig

Having been quite hopeful that this year’s report would look back at how the previous CDO’s pledge of “local resolution for local issues” would be enacted, we are forced once again to sit back and admire the expansion of the “East of England” area ruled over by the Dental Contract Managers.  The uncertainty surrounding the sustainability of NHS dentistry, in its current form or under a New Contract in its current prototype, has done nothing to ease the sense of foreboding GDP’s are experiencing.

The eagerly awaited New Dental Contract remains a pie-in-the-sky, with its likely roll-out being pushed back to 2021. Some progress has been made by the BDA and Department of Health (DoH) in its negotiation of the process and timing of the roll-out, however, much uncertainty remains on the exact constitution of the contract. It would seem the UDA as a measure of activity is to remain. The DoH’s desire to maintain ultimate control when deciding on the type of contract allocated could have a significant impact on the working patterns of NHS practices in future.

The recruitment of Associate dentists willing to work within NHS GDS practice remains a significant stumbling block within Cambridgeshire and Peterborough. With uncompetitive UDA rates within the county, unaffordable PCR and the low morale among NHS GDP’s, as reported in the BDA’s earlier poll, we will likely see the situation worsening as we stumble towards the New Contract with its failed business model.  These same recruitment issues have started rolling in from other areas of England, unfortunately, warnings of a debilitating, future workforce issue, continue to fall on deaf DoH ears.

The Health and Social Care Select Committee has requested input from stakeholders in its review of the current state of NHS Dentistry. A submission was made by C&P LDC regarding some of the issues affecting us locally (submission attached) and we are hopeful that it may have some impact on future decision making. 

The re-commissioning of Orthodontic Contracts has, as in many areas of the country, run into some major stumbling blocks. A flawed tendering system and the inability, read unwillingness, of Commissioners to engage with stakeholders to rectify the flawed process has lead to unacceptable delays in the allocation of new contracts. This has had a significant financial impact on those trying to re-acquire their contracts. Within the county, a determined drive to disperse Orthodontic services away from Cambridge City and its surrounding wards has failed to take heed of the population expansion planned for this area. With none of the clawback money historically re- invested in dentistry, the picture could be quite bleak once the population expansion in the area stabilises.

The LDN has started making strides into developing services with the county, however, much work still lays ahead to establish and develop the “Advanced Mandatory Services” such as a periodontal, restorative and endodontic pathways which should have been a mandatory requirement for the commissioners to establish more than a decade ago at the introduction of the current contract.  Access to adult sedation services remains woefully inadequate and requires urgent review and investment.

We are hopeful that, through the LDN, additional funding and the proper application of clawback money would see NHS dental services within the county being brought on par with its southern neighbours, hopefully, prior to the introduction of any new contract, whenever that may be. 

Submission to Health Social Care Select Committee

By

Cambridgeshire and Peterborough Local Dental Committee

What is the state of the relationship between the NHS and dentistry?

1. There is no appreciation for the regulatory- and clinical pressures faced by GDP’s. A continued bureaucratic- and overbearing approach to contract management has further dampened the spirits as evidenced by the BDA’s survey on the morale of GDP’s working within NHS practice, with roughly 90% unhappy with current arrangements. Given the choice, it is difficult to image new GDP’s entering the profession choosing the delivery of NHS dentistry instead of private practice.
2. With any new changes implemented by NHSE, dentistry has always been an afterthought; the introduction of PCN’s a prime example of this.
3. The ever increasing geographic of Area Teams, coupled with a reduction in commissioning personnel has led to a very impersonal relationship between those managing the contracts and the GDP’s delivering the service.

How satisfactory are the arrangements for the provision of dental services by the NHS?

4. Cambridgeshire and Peterborough currently have a population estimate of 860 000. This is projected to increase to over 1 million in the next 15 years, with Cambridgeshire experiencing some of the biggest population growth in the country. This important fact is largely ignored and most of the commissioning being carried out is based on Needs Assessment Reports that rely heavily on historic data. There is a determined commissioning drive to increase the availability of services in the north of the county which historically had less than optimum levels of provision and should be commended. Unfortunately, with a capped budget, the financial means to accomplish this must come from a reduction of services in the areas of the county that is experiencing the biggest population growth. This is simply not sustainable.
5. There are no Advanced Mandatory Services available for referral to NHS endodontic or -periodontal Secondary Care providers for patients within the county with the restorative pathway largely only available to post-treatment oncology patients. The level of domiciliary services commissioned can only provide treatment to a fraction of the frail and aging population that rely on such a service.
6. The Needs Assessment Report acknowledges that on average, 12% of a population would, at some point in their life, require the need to have a specific dental procedure carried out under sedation, either due to the anxiety of the patient, the nature of a procedure or a combination of these factors. In Cambridgeshire, this provision is a shameful 160 adult sedations per year for a population of 860 000 and rising. Worth noting that it is not commissioned as cases, but rather actual sedation procedures, meaning that where a single patient requires 3 sedation appointments to complete their course of treatment, this would also reduce the total of available sedations by 3. The only options for NHS patients are to either pay privately for these “mandatory” NHS services, which is simply not available to them or have the treatment carried out under a general anaesthetic in a hospital setting, greatly increasing the cost of the procedure to the NHS and the risk to the patient.
7. The recent orthodontic re-commissioning has seen a decrease of 48% in the number of cases allocated to Cambridge City and its surrounding wards, despite it showing the biggest and most rapid population expansion in this county. No consideration is given to the long-term social impact this may have on these children who will be unable to access local orthodontic treatment to correct their malocclusions.

How could access to NHS Dentistry be improved? Are there inequalities in access to dentistry services? If so, why, and what could be done to address them?

8. Historically, the provision of NHS dental services within a community was driven by supply and demand as with any service sector business where the end product requires “hands-on” delivery of that service. Capitation payments made up a very small portion of the remuneration and thus, for the business to be successful, it had to establish itself within a high demand area as the vast majority of its income was generated from the items of service it provided on a face-to-face basis to that community. With the introduction of the 2006 contract, this successful business model was deemed inappropriate as it was impossible to predict the exact annual spend on NHS dentistry. It had no incentive for prevention and its aim was to control every facet of the provision of NHS dental treatment. The new system placed all control with the Dental Commissioners of a designated geographic area, not just in the type and scope of service provision but also its location, which has proved a focal point for Commissioners rather than addressing the actual barriers to access. Due to the open-ended nature of the GDS contract, the locations of NHS dental practices that existed prior to 2006 have remained mostly unchanged and therefore contributes little to the ever, decreasing access to NHS dental services in the area.
9. Access is the only unit of measure NHSE uses to assess the effectiveness and distribution of the dental service it controls. It, however, measures only whether that service is available to a patient, with little consideration as to whether the intended recipient can financially afford to benefit from it. The continued annual increase in claw-back from GDS contracts by Dental Commissioners, none of which was historically re-invested in dentistry, in part reflect the decrease in service uptake by low income patients above the exemption threshold, increasingly due to NHS patient charges for Band 2 and -3 treatments. A large proportion of this population are able to attend/access a dentist to have the disease diagnosed, but cannot afford to have it treated on the NHS. An affordable dental service the disease diagnosed, too few, however, are able to afford having it treated. Dentistry for all it certainly is not. Yet still the Patient Charge Revenue is increasing annually, from £400m in 2006 to over £800m in 17/18 and rising.
10. Concurrently, a reduction in provision of services from the dental practices themselves has contributed to the ever, decreasing access and uptake of service provision. The fixed GDS contract value equates to a capped income that is falling year-on-year as contract uplifts prove to be a fraction of the Retail Price Index, resulting in many practices not being able to retain or recruit new associate dentists to rural areas. It does not allow practices, who are able to increase their capacity and service provision, to do so. Without the ability to make a rural post financially more attractive than a similar one in a metropolitan area, it is becoming impossible to recruit, especially from the younger generation of dentists.
11. Historically these affected contracts were either voluntarily reduced by the dental practices or handed back in its entirety as there was no willingness on the part of the Commissioners to engage with practices and find viable solutions to address the local issues. Attempts at re-commissioning these contracts (read “access”) in future will cost the taxpayer significantly more than it would have done to retain them. It is very likely that access to NHS dental services will continue to decrease in Cambridgeshire without a marked change in focus and mindset, both in local commissioning and national attitude. There cannot be a reliable NHS dental service provision without a workforce to deliver it or an end-user that can readily afford it.  

Are the current arrangements contributing to the widening of health inequality? Are there inequalities in access to dentistry services? If so, why, and what can be done to address them?

12. The current arrangements are woefully inadequate and as the ever-increasing claw-back from dental contracts gets swallowed up in the black hole of NHSE deficits, it is clear that the health inequalities within the county will continue to increase. It is obviously difficult to comment specifically on “inequalities in access” to services within the county when those services do not even exist! With the current long-term commissioning that does not appear to be tailored to localized population expansion, our existing bleak picture is likely to be far worse in 10-15 years.
13. A large number of the populace simply cannot afford to pay privately for the Advanced Mandatory Services that should be readily available to them on the NHS, their only alternative being extraction of the affected teeth. Those that can afford to have them replaced by dentures on the NHS do so; the remainder simply have to do without. It leaves patients with no alternative but to opt for an irreversible treatment modality that could have been avoided.
14. In the absence of additional investment and the establishment of services that should, by definition, have been available to all since 2006, it is becoming increasingly difficult to imagine how the state of dentistry within the county coincides with NHSE’s vision of 21^st century dentistry.
15. Within a fixed budget, it is simply not feasible to keep dispersing existing NHS Dental Services away from the areas of greatest population growth and expect a rosier picture in 10 years. The method of “robbing Peter to pay Paul” will only plug the holes in the crumbling dyke for a limited time. Additional investment is required, commensurate with the population expansion and targeted at the areas of expansion and need.
16. Increased flexibility in contract management is required so that where a practice can predict a possible fall in output for a specific time, example maternity leave where it is proving difficult to engage a locum to cover, the contract can be temporarily adjusted for that financial year rather than face claw-back. These transitional, additional funds will form part of the local dental budget and can be used by the AT for non-recurrent commissioning of additional access or over-performance on other contracts within that financial year.
17. As stated before, recruitment of dentists to deliver the NHS service is near impossible. Without a greater financial commitment to entice dentists to deliver NHS treatment within the county, additional commissioning will prove to be a futile exercise without a workforce to deliver it.

What needs to be included in, or removed from, the forthcoming Dental Contract?

18. It is refreshing to see that a contract is being considered with prevention as its main focus. The concern, however, is in the application of this vision. While the Prototypes are providing a more satisfactory longterm outcome for patients, the business model has proved a failure. For the DoH, due to a significant drop in Patient Charge Revenue (PCR) and access, for the dentists delivering the service, the inability to retain their patient numbers and hence income due to the level of control and data recording required by the DoH.
19. There has been significant debate between the profession and the DoH as to what should or shouldn’t be included in a contract that has prevention of disease as its driver. Primary Care has always been a demand-led service, however, under the GDS Dental Contract; dentistry is the only Primary Care provider that operates a budgeted service. It is the DoH’s need to control every aspect of this budgeted service that has hampered the pilots and prototypes, delaying the inception of a practical new contract for several years now. We are confident that you are aware of the significant drop in patient numbers seen by UDA practices that voluntarily joined the Prototypes.
20. The amount of data recording the DoH requires per patient, whether clinically relevant to that patient’s oral health or not, significantly increases the amount of time spent with each patient and therefore decreases access to its service for the local populace. It cannot accurately assess the quality of the advice or treatment provided, merely records that it has been carried out, serving more as a means to track the money being spent per patient. A decreased level of bureaucratic control and the re-introduction of Dental Reference Officers to assess the quality of the clinical work carried out by NHS dental providers would prove a big step forward in providing a more sustainable dental contract that delivers the quality of service patients expect.
21. The use of a UDA as a unit of measuring activity has failed miserably, hence the drive for a new contract. Any new contract should provide adequate financial reward to GDP’s for prevention of disease, both verbal advice/patient education and hand-on treatment. It should be capitation based and any activity measurement should be done by itemised service. The UDA contract failed due to the perverse unit of measure and the extraordinary bureaucracy attached to the monitoring of its delivery. Incorporating either of these fundamental failings into any new contract will see millions in taxpayers’ money wasted on this exercise, only to be repeated again in 10 years.

7. Treasurer’s Annual Report – Patrik Zachrisson

LDC Levies have been collected in the current year at a £10.00 monthly contribution per performer. Reserves has accumulated over time and has provided financial stability and security for the LDC.

The Cambridgeshire and Peterborough LDC has sponsored part payment of the Professional Dentistry Midlands CPD Event on Saturday, 6^th April 2019 at The Kingsgate Conference Centre, Peterborough. The LDC has also made a financial contribution to the Benevolent Fund.

The LDC will use funds to further support and benefit it’s members.

8. Head of Special Care Dentistry, Cambridgeshire Community Services: Julia Hallam-Seagrave

As from the 1^st of October 2019 Salaried services stopped the provision of OUT OF HOURS services in this area. A new provider has not started yet. There is currently no provision in Huntingdon.

9. Other Business:

Jaco Craig has stepped down as Chairman of the Cambridgeshire and Peterborough LDC.  We thanked him for his devotion, commitment and hard work as Chairman.

Patrik Zachrisson has been elected as the new Chairman.

Amiras Chokshi has been elected as the new Secretary.

• Date of next Meeting:

4^th March 2020.