Agenda item

To consider and discuss dental provision in the North Devon area

 

 

 

NOTE:  Appendices A to D provide responses to set questions that were sent to the panellists to seek their views prior to the publication of this Agenda.

 

a)    Partner at Torrington Dental Practice/Associate Professor of Primary Care Dentistry, Peninsula Dental School – Appendix A

 

b)    Specialist Orthodontis, (Exeter area) currently providing orthodontic provision for North Devon – Appendix B (to follow)

 

c)    Specialist Orthodontist (Bude) – Original provider of orthodontic provision in North Devon – Appendix C

 

d)    Area Development Manager My Dentist – Appendix D

At the start of the meeting Councillor Spear, Chair of the North Devon District Council Policy Development Committee welcomed North Devon and Torridge District Councillors and the public and advised on the format of the meeting. It was confirmed that both Committees would first run through the formal items on their agendas.

 

Councillor Patrinos (Dentistry Lead) was invited to start the discussion on Dentistry and welcomed the panel. Members were reminded of the reasons for calling the meeting and case studies were used to highlight the issues around access to provision locally and nationally.  It was explained that one of the panel – My Dentist - were now unable to attend the meeting, but had offered to answer any questions raised for them following the meeting.

 

The Panel introduced themselves and summarised their professional backgrounds in the local area:

•           Paul Waits – Specialist Orthodontist and Dentist

•           Ian Mills – Partner at Torrington Dental Practice and Associate Professor in Primary Care Dentistry at Peninsula Dental School. Chair of Devon Oral and Dental Health.

•           Chris Gooderham – Dentist with specialist interest in Orthodontics.

 

North Devon District Council Policy Development Committee were asked for their questions

 

The figure of £2 billion a year has been stated as the required level of funding needed to get Dentistry back to where it should be. The panel were asked if the figure felt right to them. 

 

Members were advised this would depend on the model of NHS dentistry care being provided. Detail regarding the current spend and allocation provided some context for members regarding the situation.

 

The panel reflect on the current economic situation and the impact this had on funding of NHS dental budgets. It was felt there needed to be responsible decision making at a higher level regarding what is done with the current dental budget and it was suggested this needed to be delivered more equitably than it is currently.

 

It was felt that NHS dentistry was not able to deliver the kind of service that was portrayed as the target with the current level of staffing and funding in place. The reliance on private sector to deliver aspects of care was highlighted. The lack of staff and training provision and the current NHS contract were highlighted as issues that needed to be considered and it was felt that just extra funding may not be the required fix.

 

 

 

 

 

Why had the current situation come about, what were the main problems and possible solutions?

 

Panel advised of the NHS contract changes launched in 2006 and explained in detail to members how the change in practice had impacted on provision – the banding and Unit of Dental Activity values were explained, in terms of treatment and their impact on provision of care – examples were then provided for context.

 

It was felt this was when a big exodus of staff began and the contract hadn’t improved since being introduced. It was felt that the Unit of Dental Activity system needed to be changed before considering the financing of the sector.

 

The panel members also noted that NHS access had been in decline for a long time; the 2006 contract was seen as one of the key points in the decline in provision, along with the removal of registration - also in 2006.  Members were advised of the National Audit Office 2021 report on the decline in funding, alongside patient experience of service provision and costs.

 

Implications for the workforce were also touched upon. This included workforce patterns, access to dental schools and the lack of statistical data to analyse how may full time dentists there are, and how many are working in the NHS. The importance of attracting and supporting international dental graduates to work in the area and stay was also noted.

 

During discussion on the understanding of dental health over the decades it was highlighted that child dental decay had significantly increased in the last few years alone. The importance of prevention work as a response to reduce future loading and suffering was explained – it was felt to be a key role for dentists and incentives to work with schools was suggested.

 

Some of the statistics on children’s oral health were shared with members.

 

In children between the ages of 5-9 the most common hospital admissions is due to dental extractions – 48,000 dental extractions every year and the majority would be preventable. It was noted that oral health in the country was improving but the burden of disease was within the most deprived areas. 

 

Plymouth data was shared with members from 2021, which found 21% of 5 year olds had physical decay. When considering the data in terms of the wards 56% of decay was in children from the most deprived areas and 7% in the most affluent. 

 

The impact for young people who experience these extractions, in terms of their future care and experience, was also highlighted.

 

It was asked if the variance in costs between NHS and private dentists could be considered profiteering from overcharging?

 

A case was provided as an example, but the panel felt it wasn’t possible to comment without all the details.

 

Overall panel members didn’t think there was profiteering and the costs of providing high quality healthcare were highlighted as a factor to consider. However, the opportunity for outliers was recognised and some of the charging practices of local providers were noted.

 

The lack of practitioners providing care was also explained as an opportunity for some practices to increases their charges.

 

 

There is a  perception that dental health is deteriorating, what were the reasons behind the decline?

 

Panel members explained why they didn’t think that there was a deterioration in oral health overall, but there was a deterioration being seen in terms of specific groups within the community.

 

It was recognised that there is still a group of patients within our communities who cannot access care, and oral health is deteriorating for them and this was felt to reflect the inequality in society. The Panel reflected that the NHS was established to address inequality and it was felt the current contract was actually exacerbating the problem.  It was also noted that the population was also living longer and people’s expectations of care provision had changed – all impacting on the demand.

 

Again, workforce was noted as an issue and the panel went on to provide a detailed explanation of the challenges around training and recruitment in the area. It was felt this could be an opportunity for cross-working with the councils. 

 

Some statistics from a survey completed by Plymouth were shared with members:

•           57% of responding practices had a dentist vacant. Some had up to 6 vacancies for dentists at their practice.

•           48% practices also had a dental nurse vacancy.

 

The challenges around training were explained and it was felt there was an opportunity for joint work with the councils around marketing the area to dentists as a place to live and work.

 

 

 

 

 

 

 

How can the council make it more attractive for dentists to work in the area and how can we promote dentistry as a career to homegrown students? How could this link to the Joint Economic Strategy?

 

Panel felt this was one of the actions to take forward from the meeting.  The need for shared working around lobbying, health promotion in schools and care homes and the discussed workforce issues were all highlighted. 

 

Panel were asked how somewhere like Petroc could link with Plymouth University around training to then overcome the issue of a lack of placements for graduates locally?

 

The Panel advised that dentistry was a degree course, but highlighted work taking place to explore apprenticeships for other dental professions and noted work taking place in Yeovil College – members were advised contacts could be shared.

 

Torridge District Council External Overview and Scrutiny Committee asked the following questions.

 

Do you think dentistry doesn’t have the status that other clinical provision has in this country? Do you think the issue of a lack of premises is also an issue?  

 

As part of the question the newly established working group on Health and Well-being for the JPPC was noted and the links to dental health were felt to be an important strategic consideration in terms of the health of the population. 

 

The panel reflected on the number of applications to study dentistry – 8 or 9 applications per place – and felt there is demand.  It was felt there was an issue in terms of recruitment to positions in the NHS and looking at how to retain staff. The promotion of dentistry as a career path at school was also felt to be a way to inspire younger people to pick dentistry.

 

Member noted that northern Devon was one of the more deprived areas in the country and asked what impact this had in terms of the access to NHS dentists locally and equality of care. It was also asked if newly qualified dentists were struggling to access affordable housing – in the same way nurses and teachers were?

 

The panel reflected that it was more the challenge of finding accommodation rather than affordability.

 

In terms of the local community the scale of inequalities in Devon were recognised. The hidden nature of rural poverty was recognised and the importance of having an NHS dental programme for those people was re-stated – this was felt to be a possible area of joint work.

 

The challenges of working and running a practice within the current contract were noted, it was explained how running a practice was becoming increasingly expensive and it was felt the current contract hadn’t yet taken this into consideration.

 

There was a detailed discussion on recruitment and retention of staff within dentistry and how to continue to attract people to the profession and working within the NHS. It was felt there needed to be some national incentive for students, given the levels of debt now incurred to study. The need for system reform so that graduates would be happy to work in the NHS was felt to be key.

 

The concerns around the current contract were restated throughout these discussions and the barriers this creates when trying to recruit and retain staff were highlighted alongside the need for reform. 

 

It was asked what one thing Joint Committee members could take back from the meeting to help.

 

The Panel advised of the need to lobby national government and to be a voice for North Devon and Torridge.

 

With a focus on workforce, the following solutions were suggested

 

The need to map out dental practice and their vacancies to gain robust data was highlighted, and it was suggested to engage with dental practices regarding how to support with recruitment and retention.

 

It was felt there was an opportunity to work with the dental community to showcase northern Devon as a place to work. As well as to provide those professionals with a welcoming environment to come and work– with the provision of support and information on where to go for information and advice.

 

In the longer term it was felt there was a need to promote dentistry as a career within the local schools and colleges.

 

The Chief Executive of North Devon District Council (NDDC) went on to explain the role of the 2 District Councils and how they link to Devon County Council.

 

Following a question regarding how the 2 District Councils were able to support work in the future the NDDC Chief Executive went on to advise of the partnership work of the 2 district Councils and how they work with other Districts in the County, along with the County Council.

 

Panel were advised that work to attract skills provision in the area and  promotion of the 2 districts as places to work was already something the Councils did and there was felt to be an opportunity to share this and work collectively to promote northern Devon to dental professionals interested in working in the area.

 

It was confirmed that both Councils would be able to lobby for change on a regional and national level. Devolution was also highlighted as a something to consider and feed into.

 

Members agreed on the importance of an evidence base to demonstrate what the issues are was highlighted. It was also suggested there was a potential to use the Local Plan working group on Health and Wellbeing. It was explained that this group could be an opportunity to highlight the need to include / give prominence to dental provision as one of the vital health provisions within the large planning applications that are received.

 

The Panel went on to highlight an additional role of schools in terms of Oral Health Promotion – toothbrushes in schools was one of the Labour Manifesto promises.  The effectiveness of this in reducing decay in other areas of UK and nationally was explained. The logistics of delivering this locally were detailed - the Devon ICB were noted as commissioners – and it was felt that some work to coordinate this locally would be beneficial, especially in terms of those areas that fall through the net.

 

The Chair of External Overview & Scrutiny Committee for TDC went on to ask the following questions, some that had been raised by constituents.

 

•           Had there been an increase in mouth and throat cancers? Was this due to a lack of dentists and was this monitored?

It was explained by the Panel that there had not been an increase in incidents, however dentists were seeing later presentation – the impact was explained to be higher for those from areas of deprivation. Lack of access to routine dental care and the impact of this on later presentation and then poorer outcomes.

 

•           Out of hours dental care - It was explained that the advice from 111 was to call the out of hours phoneline, but there had been no response on this line when called. 

The impact of changes to dental access / registration were noted here, along with changes to the contract in 2006. It was explained how there had been a privately run Dental Access Centre, one in Barnstaple, but due to workforce issues this had been pulled back and the option now was to call 111 and A&E. Advice was given on how to access care in these situations.

 

•           The impact of rural inequalities and public transport links for rural areas, would there be a benefit to having a mobile dentist travelling in the rural areas?

The impact of public transport for rural areas was noted, and the mobile dentist idea was felt to be ineffective for a rural area.  A better form of care was felt to be getting the patients into the practice for their care. Domiciliary Services were noted and felt to be a better form of care.

 

The inequalities for rural areas when public transport was poor and the smaller dental practices in rural areas were closing, leaving larger hubs in the towns was noted.  It was felt that a hub and spoke model was felt to be a more efficient form of care, though considered less cost effective.

 

The importance of fixing the NHS model was again restated in terms of improving outcomes in those rural and deprived areas.

 

The role of commissioners in terms of awarding these contracts, looking at the corporate model and the ethics involved was felt to be key to turning this around. The need to lobby Commissioners in relation to these issues were stated.

 

North Devon District Council Resolved:

That standing orders be suspended for the Policy Development Committee of North Devon Council to allow questions from members of the invited public present.

 

At the discretion of the Chair of External Overview & Scrutiny Committee of Torridge District Council members of the public were invited to speak.  

 

 

Public Questions:

 

Why is Dentistry not a part of the NHS? Why aren’t dentistry professionals salaried employees? Would this help with the issues of provision and premises?

 

It was explained that following the establishment of the NHS in 1948 dentistry was free at the point of care. However, within 2 years the Government had introduced charges. The differences in terms of dentists and GPs were explained, along with the impact of historic decision making at a national level.

 

The panel explained the role of Community Dental Services, who support those with additional needs. It was explained these services were hugely underfunded and that Dental Practices were more likely to forward those patients with additional needs on to these specialist services because of the UDA targets highlighted earlier in the meeting. The impact for patients was also explained.

 

 

 

 

 

 

The commissioned UDAs in Barnstaple (it was explained there is a ceiling on these) were mainly held by a corporate body. It was asked why, given they have no dentist to fulfil the commitment, they continue to get commissioned UDAs and apply for funding for the service when they have no feasible way to deliver?

 

It was suggested this was a question for the commissioners of the services and Devon ICB. The panel understood the frustration and the issues in relation to the workforce.

 

A Parish Councillor raised concerns about emergency care for dentistry. It was explained that the local community (Braunton) had a lack of dentists and there were community concerns regarding access to emergency dental care for children and adults.  There was a lack of knowledge regarding how to access emergency care and people were sharing their experience of being on hold for long periods and then missing emergency appointments for that day. It was explained this wasn’t just out of hours and there were also concerns about the amount of travel people were doing to access emergency care. 

 

It was explained that Out of Hours care was provided through NHS England.

 

Panel advised that those responsible for the commissioning of emergency care within working hours -South West Area Local Team / Devon ICB - have identified a huge gap in provision and commissioned Urgent Dental Care sessions from specific practices. It was also confirmed they would back this up by commissioning Stabilisation Sessions - a course of follow-up treatment with a practice. The complexity of a fragmented service was recognised, along with the potential for patients  to have to attend sessions in different locations across the district.

 

 A follow up question was raised in relation to the problems people are having in accessing appointments in the first place and then the issue of those people without an NHS dentist. The panel sympathised with the situation being described and the continued need for lobbying in order for more rapid change.  NHS England and Devon ICB and MPs. 

 

The need to recruit dentists and dental therapists was again restated as key to improving the provision.

 

Need to ensure that this proposal above is thought out.

 

Members thanked the panel for the high quality of the answers.

 

During discussion members asked whether there was a need to lobby for incentives, so Dentists were able to increase hours.  The Panel reflected on the working hours of dentists. It was explained that it would be better for focus to be on the issues around increasing staffing and training, increasing the skills within the sector and attracting more people to move to the region to work.

 

Members highlighted recent work by North Devon Council to promote the council at graduate fairs and asked if the same approach had been taken for dentistry. The Panel advised of the work that had taken place to promote dentistry and it was felt that joint working and sharing of work on this was a quick win.

 

Actions and Next Steps

 

The Vice Chair advised that he had made a summary of the key points from the discussions held and the Committee would consider these alongside the formal minutes at the next meeting of the Committee.

 

The Chair of the External Overview and Scrutiny Committee, Torridge District

Council thanked the panellists for their attendance at the meeting and their openness in the discussions of the issues and spoke of her desire to work together to see improvements going forward.

 

The Chair of the Policy Development Committee, North Devon Council thanked the officers involved in attendance at the meeting. She also thanked the Corporate and Community Services officer for North Devon Council for her support during the meeting and the Clerk to the Committee for her hard work behind the scenes to facilitate the arrangements in the run up to the meeting.