Potentially, the long term future of the NHS relies on what comes out of the government consultation which will inform the new 10 year plan for the NHS. With that depends the future of NHS dentistry. Since the devolution of dentistry to Integrated Care Boards not much has changed for the delivery of NHS dental care. Mostly as a result of the technical challenges presented by the dental contract. But ICBs have also had to contend with demands for efficiency savings, distracting from the reformation of services, as well as the general election and its outcomes. The LDCs in the LDC Confederation have begun some robust conversations with their ICBs and dental working groups have been established to look at different options and models of care. But these are at relatively early stages and are being considered on a small scale.
While it was great to see dentistry receiving so much interest during the election and the commitment of the then shadow health secretary to meet with the British Dental Association straight away which was kept, since then not much has happened. Until there is a full reform of the NHS dental contract more clarity is required for ICBs on what they can do to protect contracts in their local areas. Current guidance on flexible commissioning is not supportive enough for ICBs to make significant changes to arrangements or to promote proper integrated working.
There are two immediate, and related, issues facing NHS dentistry. Firstly from the commissioning side there is the conflict for ICBs of their responsibilities to reduce health inequalities and improve health outcomes for their populations and a dental contract which is open access and untargeted, i.e. does nothing to support the ICBs obligations. The second is the mixed messaging created by the New Patient Premium.
The first issue requires contract reform which clearly articulates a vision for NHS dentistry and which supports its integration with other local services while freeing up dentists to work effectively with local partners to create effective pathways based on local intelligence and need. Hopefully the Department of Health and Social Care will provide clearer guidance on flexible commissioning to support this until they work with the BDA to develop a reformed dental contract. The recent consultation to inform the 10 year plan for the NHS is an opportunity to start articulating that vision and developing plans for integration in the medium to long term. In August this year the Chief Dental Officer’s dental and oral health bulletin had a focus on health inequalities. This was welcomed but highlighted the difficulties the dental contract places in the way of real integration. Integrated Care Boards have a responsibility to reduce health inequalities and improve health outcomes for their populations. But, they have been given a dental contract which supports neither of these objectives. Unless the dental contract is reformed in a way which supports ICB objectives integration will fail and dentistry will not be able to play its part in reducing health inequalities and improving health outcomes.
So the first thing we need is honesty. Honesty about what NHS dentistry is and what it is for. The NHS Constitution states that “the NHS provides a comprehensive service, available to all”. This is clearly not the case for NHS dentistry. There is insufficient funding allocated for a universal comprehensive service. Even when commissioned activity is almost entirely spent there is no where near comprehensive access. But current contractual arrangements do not allow targeting of resources to reduce health inequalities so dental access remains random and disconnected from other local plans. This leads on to the second issue.
The New Patient Premium (NPP) is a recognition that UDA values are too low. But it is also a stark contradiction to previous messages which were focused on driving two year recall intervals as the norm: “The payment level, of £15 or £50 depending on the treatment required, is in addition to the NHS funding a practice would already receive for this care, and recognises the additional time that may be needed for practices to assess, stabilise and manage the oral health needs of patients who have not received NHS dental care for more than 2 years.” The NPP assigns higher payments to any patient who has not attended that practice for two years, suggesting that two year recalls are not in fact desirable. The NICE guidance states: “Recall intervals for patients who have repeatedly demonstrated that they can maintain oral health and who are not considered to be at risk of or from oral disease may be extended over time up to an interval of 24 months.” (emphasis in the original). A drive for two year recalls requires those patients to have had regular access to the dentist for quite some time before that to demonstrate that it is in their best interests to be on the extended recall. But, what we have seen instead over the years is messages that two years is what should be expected. Data is even reported over a 24 month period for adults presumably in an attempt to normalise this as an attendance period.
In addition, the second rationale for the introduction of the NPP was “because we know that if patients do not already have a relationship with a dental practice, they have struggled more to get appointments and treatment following the pandemic.” This rationale makes it clear that a relationship with a practice is desirable, so the focus should not be on urgent dental care, but on contract reform and reintroducing registration as supported by Healthwatch England. This would make it easier to develop joined up care within Integrated Neighbourhood Teams and ensure that resources were used most effectively.
The implementation of the New Patient Premium prevented many ICBs from engaging with new ways of working to support targeted integration as it was funded from within the existing dental budget. It also meant that many practices used up their budget faster than normal as a result, but for no discernible improvement. However, if the scheme is not continued then practices will be back to their old way of working and potentially under-deliver their contract values. If it continues then the move to integration will continue to be stymied.
So, what can LDCs do? We can keep building relationships, explaining the value of dentistry to general health and wellbeing and to the NHS at large. We can make sure that the small steps that can be taken are taken so that we help move the journey forward. We can make sure that there are enough local examples of innovation and improvement to help inform and influence national discussions. The major changes that are required need to be driven by the local to ensure that integration is supported in a way that helps ICBs protect and grow local contracts. We can work together to keep making the case for improved access and integration, with a financial package that keeps pace with the private dental market to ensure that NHS dentistry is a viable and attractive career option.
Finally, one of the most important things LDCs can do is help to change the narrative away from one of misery and doom to one of positivity and innovation. We know that many colleagues no longer feel drawn to the NHS. It is up to the profession to reverse that and to help colleagues see that together we can make NHS dentistry a system they would be proud to work in.
By doing all of that, LDCs can help make 2025 the year of NHS dentistry and maybe 2026 will see not just the 20th anniversary of the current dental contract but also agreement on reformed way of working.
