NHS England - Yorkshire and the Humber
York Scrutiny Committee – Dentistry

January 2022

1 Background

NHS England (Yorkshire and the Humber) is responsible for the commissioning and contracting of all NHS dental services.  Dental services commissioned by NHS England for North Yorkshire residents include:

· Primary care (general high street dentistry).  Primary care dentistry is accessed by patients directly, typically at high-street dental surgeries. 

· Community Dental Services (CDS) – primary and specialist dental care for patients who cannot be managed by a primary care practice, for example house bound care home residents who cannot leave their home for health care appointments. By referral only.

· Orthodontics – by referral from a dentist.

· Urgent care - available via primary care practices directly or NHS111.

· Secondary care – specialist services by referral only.

Dentistry for the armed forces is commissioned separately by the NHS England Armed Forces team and the Health and Justice Team commissions dentistry in prisons.

2 Dental Provision in York

NHS England currently commissions approximately £10m of primary care dentistry at 20 practices in York.  The contracts, based on the commissioning of a number of Units of Dental Activity (UDAs), were agreed in 2006.  The tariff per UDA was agreed locally by the PCT in 2005/6, differs by practice and is set in the providers contract, which are in perpetuity.  The average UDA rate for Yorkshire and the Humber is £30.30 and the average across the 20 practices in York is £31.70.

Practices are expected to deliver their full contracted activity, however, a minimum of 96% is accepted as meeting the terms of the contract, which under-delivered activity rolled forward.  If a provider does not meet the 96% minimum, then the provider must repay NHS England for the costs of the activity not delivered.

· Year ended March 2020 - Primary care providers across York delivered 96.6% of their contracted Units of Dental Activity (UDA) for the year ended March 2020 [across Humber Coast and Vale ICS footprint, the total delivery was 93%; across Yorkshire and Humber 94.5% of commissioned UDAs were delivered]. 

· Year ended March 2021 - For the 2020/21 year, revised contractual targets were mandated, in response to Covid, in line with updated national standard operating procedures and infection prevention control measures. Nineteen providers met these revised activity targets at year end; NHS England is supporting the practice that did not meet these minimum standards.

The average UDAs commissioned in York, per head of population is higher than the Humber Coast and Vale ICS and higher than the Yorkshire and Humber average.

For the two years up to June 2021, York had higher than the Humber Coast and Vale averages for both children and adults for the percentage of the population accessing an NHS dentist.

There is one community dental service (CDS) provider, one orthodontic provider and one secondary care trust providing services to York residents. 

All available funding is committed to current contracts – see paragraph 3.

3 Key Challenges

· Access/inequalities: NHS England inherited a range of contracts, from Primary Care Trusts, when it was established and these ‘legacy’ arrangements mean that there is not a consistent pathway to services across the region as a whole and little options with regard to contract arrangements (see the next point), in terms of both the contract that is in place and all budgets for dentistry committed to existing services.

There is no out of hours urgent care provider in York, therefore York residents must travel to the nearest out of hours urgent dental centres, which are located in Harrogate, Leeds or Hull.

· Primary care national contract for dentistry: rolled out in 2006, this is held by a General Dental Practice (GDP) in perpetuity (subject to any performance concerns), with little flexibility for either the commissioner or the provider.    

This is a national issue and there is a working group looking at dental contract reform, however there is no timeline to indicate when this will be completed. 

Unlike GP contracts, dental contracts are based on activity and not on patient list size. 

There are limited opportunities to commission differently, given primary care contracts are in perpetuity, and therefore little scope to re-distribute resources to promote oral health prevention and support dentists in treating high needs patients. However, across Yorkshire and the Humber, including City of York, a ‘flexible commissioning’ approach was introduced in 2019 (but deferred on 24 March 2020).  By mutual agreement, five practices in York joined this scheme which looks to use the practice team’s skill mix to address oral health inequities through interventions which facilitate those that have the greatest need and experience challenges accessing dental care.  There is a commitment to expand this scheme when the current national standard operating procedure and contractual targets allows. 

· Procurement: procurement rules introduce further challenges to levers to change to commissioning arrangement; it is not possible to introduce innovative ways of working without testing the market.

· Recruitment and retention:difficulties faced by many practices (who are responsible for employing their practice staff) recruiting and retaining staff, which is not confined to York.  Dental contracts do not dictate how practices will staff or resource their service delivery, therefore NHS England do not keep records of practice employed staff.

· Finance allocations:unlike GP services, dental contracts are not list based and are activity based, as established in 2006, based on activity provided within practices during 2004/05.  Population growth does not generate additional funding, so it is a challenge to improve access where there are new housing developments. 

· www.nhs.uk – provided by NHS Digital, which supports patients to navigate the healthcare system. Dental practices are asked to keep their profile page up to date but this is not contractually mandated in the 2006 contracts. Any new contracts, or contract variations, NHS England agrees with providers, across Yorkshire and the Humber, includes this as a compulsory deliverable.

· Patient perceptions – it may not always be clear to patients how NHS dental services work, for example:

o ‘Registered’ lists - Patients often think that they are registered with a dental practice in the same way that they are registered with a GP, however, this is not the case.  GP practices contracts are based on patient lists, but dental practices are contracted to delivery activity.  Practices are obliged to only deliver a course of treatment to an individual, not ongoing regular care however many practices do tend to see patients regularly. 

o NHS Services being free at the point of delivery – Dental services are subsidised with fee paying, non-exempt adult patients contributing towards the cost of NHS dental treatment with the contribution determined by the course of treatment; unlike other NHS services, which are provided free at the point of delivery.   The national dental charges are set, on three-band tariff, each year.  Practices must display this information within their clinics.

o Private dental care - Many dental practices offer both NHS and private dental care, which, as independent contractors, they are at liberty to do.  Mixed practices, offering both NHS and private treatment, tend to have separate appointment books for both NHS and private treatment, with staff teams often employed to provide these different arrangements.  NHS provision must be available across the practice’s contracted opening hours and demand for NHS treatment is such that they could have used up their available NHS appointments and practices may, therefore, offer private appointments to patients.

4       Workplan Priorities for York

To improve access and reduce inequalities, an innovative approach to contracting was introduced across Yorkshire and Humber in 2019.  The ‘Flexible Commissioning’ model translates some of the contracted UDAs into a resource envelope, which the provider can utilise to deliver care in alternative ways, i.e. dental nurses providing services for hard to reach children and other vulnerable groups of patients. There are five York practices on this scheme. 

Using the core contract, by way of a variation to contract terms, this approach enables practices to move away from the traditional approach to dentistry, with units of dental activity provided by dentists replaced with dental care professionals (nurses, therapists and hygienist) undertaking a variety of oral health and preventive measures, increasing opportunities for access for those that are vulnerable.

As well as Yorkshire and the Humber initiatives, such as the development of flexible commissioning and improving access, partnership working and patient and public engagement, workplans specifically aligned to the City of York includes:

· Development of an out of hours urgent care service accessed via NHS111.

· Intermediate minor oral surgery services to be procured.

· Discussions underway with the secondary care trust focussing on commissioning additional specialist services, for specialist restorative dental treatment.

5 Impact of Covid-19 Pandemic - The Delivery Model Since March 2020

The dental sector has faced particular challenges since March 2020, due to the proximity between a dental professional and a patient’s airway and the relatively high proportion of aerosol generating procedures (AGPs) undertaken.  Because of the use of a high speed drill and the high risk of transmission via AGPs, dental services were not permitted to see patients for face to face care at the start of the pandemic and this, together with the need to work within infection control guidance, has led to a backlog of unmet need, delayed and suspended treatments.

During the first wave of the pandemic, in the interest of patient and dental staff safety, routine and regular dental services were paused, practices were asked to close and urgent dental centres (UDCs) were established to provide access to urgent services to patients in pain.

Practices could reopen for the provision of face to face care in June 2020, subject to having the appropriate personal protection equipment and have steadily increased the activity that they can provide since that time.

Whilst all NHS dental practices are open and able to safely provide a full range of treatments, the reduced capacity across the dental sector means that they have been asked to continue to follow the advice of the Chief Dental Officer, which is to prioritise patients according to their clinical need. 

In return for income protection, practices were required to meet a set of limited conditions, including:

· a requirement that they deliver at least 20% of normal activity volumes for the period of July to December 2020;

· a minimum of 45% of pre-covid activity for the period of January to end of March 2021;

· a minimum of 60% of pre-Covid activity from April 2021 until September 2021;

· a minimum of 65% of pre-Covid activity from October to December 2021;

· a minimum of 85% of pre-Covid activity from January to March 2022.

Whilst restoration of NHS dental activity continues, it will be some time before dental services return to providing care in a similar manner and to the activity levels that patients previously experienced, with many dental practices are still catching up on the backlog from when they were closed during the first national lockdown.   

Given the challenges with access and providers working through their backlog, practices have been asked prioritise seeing patients with the greatest clinical need i.e. those requiring urgent dental care and vulnerable patients which likely means a delay for patients seeking non-urgent and more routine dental care such as check’s ups.

A return to full capacity, which will be dependent on the further easing of Covid-19 control measures, will be required before practices can provide more routine and regular dentistry.

Progression to resume routine dental care is being risk-managed by individual practices. In the interim we are working with our NHS dental providers to explore opportunities to increase the clinical treatment capacity available within the constraints of the Covid pandemic and infection control measures to ensure that care can be delivered safely for both patients and staff. We are therefore asking patients for their understanding and co-operation during this unprecedented and difficult time for the NHS.

As is the case across the health and social care sector, practices are not only having to put in place contingencies to ensure minimal disruption to patient care, wherever possible, to manage staff absences (whether those staff are unwell with Covid, are not able to work due to isolation requirements or staff are not able to access testing in a timely manner) but are also experiencing increased numbers of patients cancelling appointments at short notice.  These factors are impacting on practices’ ability to deliver services to patients and to the resumption of services.

6 Resumption – General Overview

The focus of NHS England’s dental commissioning team is to support providers to resume services, in line with Standard Operating Procedures and IPC guidance.  This in turn will directly benefit patients, who may be experiencing difficulties accessing regular and routine care given practices are following the National Standard Operating Procedures, issued by the Chief Dental Officer.

7       Communicating with the public

NHS England has been posting messages on social media platforms on a weekly basis and has shared these messages with Healthwatch, CCGs, Local Authority Directors of Public Health and MPs.  Some examples of these posts are shown below. 

Tweet: Please be aware that dentists are currently still prioritising vulnerable patients or those with urgent dental needs; it is therefore unlikely that routine dental care such as dental check-ups will be available at this time. #helpushelpyou

Tweet: Please note that appointments for some routine dental treatments, such as dental check-ups, are limited at this time as dentists prioritise vulnerable patients and those with urgent dental needs. #helpushelpyou

Tweet: Please ONLY visit a dental practice if you have an appointment and telephone to book an appointment only if essential – dentists are currently prioritising the vulnerable or those with the most urgent need. #helpushelpyou

Tweet: Toothache should initially be managed with over the counter pain relief until an appointment can be made. Chemists are open and a Pharmacist can advise you what is the best pain control to meet your needs #helpushelpyou

Tweet: Lost fillings, crowns or bridges, broken teeth or braces are not deemed to be clinically urgent and patients are advised to contact their local dental practice when they re-open. #helpushelpyou

Tweet: Only ring NHS 111 out of hours when your dental needs cannot be met by self-care and cannot wait till your practice is open to contact them for advice. #helpushelpyou

Report prepared by:

Debbie Pattinson, Dental Commissioning Lead

North East and Yorkshire (Yorkshire and the Humber)

Date: 12.1.22.v3