Agenda item

Hugh O’Keefe (BOB ICB Senior Programme Manager – Pharmacy, Optometry and Dental Services) has been invited to present a report on Dentistry Provision in Oxfordshire.

The Committee is invited to consider the report, raise any questions and AGREE any recommendations arising it may wish to make.

Hugh O’Keefe (BOB ICB Senior Programme Manager – Pharmacy, Optometry and Dental Services), Dan Leveson (BOB ICB Place Director, Oxfordshire) had been invited to present a report on Dentistry Provision in Oxfordshire. Ansaf Azhar (Director of Public Health) was also in attendance.

The BOB ICB Senior Programme Manager for Pharmacy, Optometry and Dental Services explained that the report included an update on the progress made since the last HOSC meeting they attended the previous year. They had been dealing with continuous issues related to dental practices leaving the NHS, which had become a serious concern, and the report covered their actions in response to these departures.

The Committee asked whether there was any indication as to the geographical spread of practices in Oxfordshire that had not met the minimum target contracted activity required for NHS dentists to avoid financial recovery, and what the reason was for Oxfordshire’s inferior performance to Buckinghamshire and West Berkshire. The BOB ICB Senior Programme Manager explained that contract delivery before the pandemic used to run at about 90% in Oxfordshire, and there had been more of an impact from the pandemic in the longer term in Oxfordshire. It could not be said that there was a particular area in Oxfordshire that was doing much better than others, although West Oxfordshire and the Vale of the White Horse were seeing slightly lower levels of provision.

As the distance from the capital increased, challenges arose, particularly in more rural areas. Similar patterns were observed in Buckinghamshire and the West of Oxfordshire, but not so much in West Berkshire. These areas, especially the West of Oxfordshire, faced significant challenges, with numerous practices deciding to leave the NHS and go private. This trend was more prevalent in this county than in other parts of the system. Since 2021, about 5% of the capacity was lost, with approximately three-quarters of that loss occurring in Oxfordshire. About half of the loss was specifically in the West of Oxfordshire as practices in these rural areas were making decisions to leave the NHS.

The Committee enquired as to the challenges facing patients trying to access local NHS dental services. The BOB ICB Senior Programme Manager clarified that, in contractual terms, dentists were only responsible for patients while conducting the course of treatment, so they were not registered. Due to the pandemic, many patients discovered that they had not attended for more than two years and when they then called back in to the dentist they appeared as new patients.

The recovery of access was fairly rapid early on in 2022. Since then, it had been slowing, and the report discussed some of the issues including gaps in treatment, leading to worse oral health, meaning those treatment plans were taking longer to complete. Thus, the backlog was taking time to clear because of the needs that were presenting.

In answer to the Committee’s query about the low NHS pay to dentists, the BOB ICB Senior Programme Manager explained that when the NHS contract was introduced, it was argued that it would have a ‘swings and roundabouts effect’, as dentists would only need to see some patients for a short period of time for a check-up while other patients would need longer treatment. There had always been a recognition that there was some cross-subsidisation with private work in dentistry, as even if a dentist had a substantial NHS contract, they nearly always had private work that went with it. The problem was that this contracting model was impacted by COVID and dentists were tending to see patients with more complex needs, so the swings and roundabouts effect was not working as well. Some of the national changes aimed to adjust the pricing and bring in a new minimum price, as the pricing used for the dental contract was based on activity carried out in a reference year in 2004/5.

The dental contract had been introduced in 2006 and pilots for a different type of contract had been run since then, however they had an impact on access. Practices that took part in these schemes devoted more time to seeing patients, which led to a fall in access and patient charge revenues.

The Committee enquired about the basis of the NHS contract and the effect on dentists that did not meet their targets. The BOB ICB Senior Programme Manager elaborated that the contract provided unit payments based on treatment bands, and dentists were paid units of dental activity (UDAs) based on the numbers of treatment bands they did in a given year, within a capped allocation. Some practices opted to leave due to the risk associated with delivering these units, especially when dealing with patients with more complex needs that required more treatment, but only represented a fixed unit payment. The introduction of flexible commissioning was partly to help patients who had been struggling to get into the system, with practices participating in the scheme opening up to see these patients. It also helped practices reduce their business risk by converting a portion of their activity target to access sessions, allowing them to receive the same amount of money without having to hit as high an access target.

The Committee asked whether any efforts were being made by ICB or NHSE to influence the government to increase financial uplifts applied to dental contracts.

The BOB ICB Senior Programme Manager explained that there were contract changes in 2022 and 2024, and when these changes were considered collectively, there were benefits to dental practices. A new patient premium was introduced to incentivise dental practices to take on new patients. There was talk about a new contract in 2025, but there was a financial barrier to introducing a new contract, as the dental system was heavily dependent on patient charges, which in turn depended on patient attendance. There was a significant risk to financial stability if substantial changes were made, therefore previous changes have been incremental.

The Committee enquired about progress on ensuring that new dentist trainees were registered swiftly. The BOB ICB Senior Programme Manager answered that arrangements had been made for overseas dentists to be added to the performer list more quickly, as previously, they had to undergo an examination process before they could start working on the NHS.

The Committee asked what was being done to help those patients from dental surgeries that had handed their contracts back. The BOB ICB Senior Programme Manager explained that a programme had been implemented, which involved approaching local practices to try to replace the activity that had been lost due to contract hand backs. In Oxfordshire, there had been some success and about another 20,000 units of dental activity (UDAs) had been commissioned, the equivalent of 3 1/2 surgeries. However, there were still significant gaps, and it was recognised that the flexible commissioning was an interim solution. The next stage was to go out to formal market procurement with the aim of seeking new practices to come into the areas where capacity had been lost.

The Committee queried how the ICB made sure that patients were being given correct and accurate information about where they can go to access the NHS dentists. The BOB ICB Senior Programme Manager highlighted that flexible commissioning had been helping with the access issue. When the scheme was started, practices were nervous about widely publicising their access because they feared being inundated with patients due to limited access. As a result, a requirement was introduced in the contract for practices to update their information. More practices were opening up in Oxfordshire, which was an early sign that the extra activity being put into the system was helping practices.

The Committee asked whether the ICB would be commissioning new contracts, particularly in those areas with no NHS dentists and what the time scale was for opening new practices in areas that expressed interest. The BOB ICB Senior Programme Manager acknowledged that in the past, seeking expressions of interest in very rural areas could yield no responses, and recognised that it was not enough to commission without ensuring this could be delivered. However, expressions of interest had been received in some of these areas in Oxfordshire with little NHS provision. There was a timeline from the start of procurement to opening of about 18 months to two years. Finding and obtaining planning permission for premises represented the majority of that time.

The Committee enquired whether having patients on their books prevented dentist surgeries from taking on new patients. The BOB ICB Senior Programme Manager replied that a significant portion of the capacity was being utilised by patients who were regular attenders. The ICB had been attempting to restore this capacity as swiftly as possible, enabling practices to move beyond merely recalling individuals who had previously been in the system. They had suggested extending recall times, as it was not clinically indicated that everyone needed to attend as frequently as every six months. This could also create additional capacity for new patients.

The Committee asked whether the NHS was conducting any work to help increase awareness of the importance of oral health and hygiene. The BOB ICB Senior Programme Manager explained that the oral health promotion service in the area was run by the local authority. However, dentists had played a crucial role in promoting oral health and ensuring access, emphasizing the importance of quickly integrating children into the system. This was to prevent situations where a child's first visit was due to a serious dental problem, which could instigate fear. The ICB had been considering moving beyond just looking at access, which had been a significant focus area, and starting to delve into a more preventative agenda.

The Committee enquired as to what was being done in schools to monitor children’s oral health. The Director of Public Health clarified that Oxfordshire was one of the local authorities that still commissioned an oral health needs assessment and conducted an oral health survey. They commissioned the Community Dental Service, which included liaising with school health nurses to influence oral health in children and carry out preventative activities. They tried to incorporate preventative oral health messages through their other physical health services. There was a pathway in place linking with the Community Dental service, for children with oral health needs, and the committee could be provided with more detail on this at a later date.

The Committee asked what steps have been taken to support the oral health of residents with mental illnesses. The BOB ICB Senior Programme Manager replied that there was a community dental service in Oxfordshire that had seen residents with mental illnesses, with dentists who had undergone special care training, and there were numerous ways that patients could access this service.

The Committee enquired as to whether, in evaluation of the programme, they had looked at how people from areas of health inequality had been affected. The BOB ICB Senior Programme Manager clarified that flexible commissioning aimed to identify deprived patient groups like looked after children and asylum seekers. There was always a cohort of patients who did not attend the dentist and only went when they were in pain, which tended to link to deprivation. The scheme assisted them in getting to the dentist because although it was not designed for urgent treatment, it was picking up on that need in the population to get patients into the system.

The Committee asked what the ICB’s position on fluoridating Oxfordshire’s water supply was, and whether any consultations were planned around this. The BOB ICB Senior Programme Manager responded that there were no plans at this stage to have consultations about fluoridating the water supply. The information that came from the 2024 contract changes referenced water fluoridation, but it was referencing the schemes that were currently running. The BOB ICB Place Director, Oxfordshire added that this was a Public Health matter and not something the ICB was commissioned to do.

The Committee AGREED to issue the following recommendations to the ICB:

1.     It is reiterated that underspends should be spent in Oxfordshire, and that priority is given to areas within Oxfordshire that have experienced the worst shortfall in capacity. It is recommended that the ICB prioritises areas within Oxfordshire in light of the increased need within the County relative to other areas under the BOB footprint.

2.     To support the creation of new practices within Oxfordshire with urgency, and to explore avenues of funding to support the ICB in developing solutions in this regard.

3.     That urgent progress is made in improving the accuracy and the accessibility of information on dentistry services available to people; and that where groups are targeted for help, they can benefit from an effective outreach.

4.     For the Oxfordshire system to seek to influence a timely consultation in Oxfordshire on the fluoridation of the County’s water supply.