MINUTES of ameeting of the NHS DENTAL SERVICES TOPIC GROUP held on

THURSDAY 11 SEPTEMBER 2008

ATTENDANCE

Members of the Topic Group:

CountyCouncillors:

M V Bayes, R S Clements, D J Drake (Chairman), E T Roach

District Councillor:

B White, ThreeRivers

Health Service Representatives:

J Greenshields, PCT Dental Finance Lead

S Gregory, Consultant in Dental Public Health

C Neal, Manager, Hertfordshire Complaints Service

J Robinson, Primary Care Trust Commissioning Lead

Dental Practitioners:

S Bhandal, Dentist

R Patel, Dentist

S Wagner, Orthodontist

Others present:

E Gibson, Democratic Services

V Robb, Scrutiny Officer

1. / MINUTES / ACTION
The minutes of the meeting on 6 August 2008 were agreed and signed by the Chairman, subject to the following minor amendments:
Item 2, page 1, Evidence from the Public, ‘East and West Herts’ to read ‘East and North Herts’.
Item 3, page 3, Children’s Dentistry:
first paragraph, change ‘dental nurses’ to ‘dentists’ and amend third paragraph to read:
‘Jane Robinson informed the group that there were some child-only contracts in each of the two PCTs. There were a few NHS dentists who would only see children as NHS patients (while treating their parents as private patients); where they have the capacity the majority of NHS dentists see ‘all-comers’.
2. / EVIDENCE FROM DENTAL AND ORTHODONTIC PRACTITIONERS
The Chairman welcomed Rumeet Patel, Steve Wagner and Sab Bhandal to the meeting and Members received evidence as follows:
Dr Steve Wager(Orthodontist) commented on working within the NHS contract and reported that:
  • his practice had experienced increased delays in being able to carry out treatments due to lack of UDAs allocated under the new contract;
  • they had been flooded with referrals for work, but had been unable to meet need for treatment; could assess patients but did not have the UDA allowances to carry out necessary work;
  • patients were dissatisfied with lack of treatment being offered and practitioners feel frustrated that out of the number of referrals received per month, only a very small proportion of patients could be treated;
  • practitioners did not receive sufficient guidance from the PCT on how to work under the new contract (for example, applying for more UDAs)
  • both practitioners and the public needed to be much better informed by the PCT about the contract and provision of NHS dental treatment
  • the NHS rules for qualifying for treatment were too stringent; for example, unsightly crooked teeth might not be deemed as needing attention because there was no pain involved, but an orthodontist would consider this a condition requiring correction;
  • expressed reservations over the accuracy of the measurement for qualify for treatment (i.e. the actual measurement of the orthodontic work needed) as patients sometimes put orthodontics under pressure to ‘stretch the rules’ in order to get treatment on the NHS.
Dr Wagner made the suggestion that a booklet be produced by the PCT giving a full explanation of where to access treatment, precisely what treatment qualifies as being available under the NHS, what costs were involved for each stage of the treatment and what costs appliedif the patient opts for a mix of NHS and private treatment. Dr Wagner made the comparison with an NHS booklet issued to expectant mothers that sets out detailed, step-by-step information about what care to expect during pregnancy, birth and the post-natal stage.
Dr Wagner commented that positive aspects of the NHS contract were that the PCT could measure what treatments were being delivered and that it sets out a financial basis between practitioners and the NHS. However, it was the level per unit offunding that was felt to be problematic and the amount of UDAs being allocated.
Dr Rumeet Patel made the following comments:
  • felt that the UDA system provided little incentive to see more patients;dentists could accommodate more work if UDA's were available; UDA allocation based on 2006 figures did not meet today’s needs;
  • estimated that in January/February 2009 his practice would have run out of UDAs and would have to ask patients to wait until April, when the practice would be in receipt of the next year’s allocation;
  • felt that the contract did not provide much incentive for newly qualified dentists, largely due to the difference in the rates per UDA. An associate could receive £18 per UDA while a senior could receive £30. Accepted that less experienced practitioners might receive a lower rate, but stressed that the system should be much more open and transparent;
  • felt it was not at all clear how the UDA value was established;
  • felt inhibited in offering more complex services and more up-to-date services (like root canal work using single-use files) due to the costs involved; had fears that patient care was suffering;
  • was concerned about access to emergency treatment, and commented that patients were unlikely to be able to see their own regular dentist when an emergency arises.
Dr Sab Bhandal gave the following evidence:
  • expressed his view that the contract was a good system and that the PCT could monitor the amount and quality of treatments being delivered;
  • PCT could attract dentists to areas in the County where there was need;
  • PCT could oversee training, investment in equipment and professional development and ensure the highest standards of professional practice;
  • commented that when dentists were paid on a per- treatment basis there was a risk that unnecessary treatments could be offered – although stressed that the vast majority of dentists were committed, professional and ethical.
  • agreed that there was a discrepancy between UDAs and that the practices that were suffering the most were the ones where they were now doing more complex work than they had done during the test period because they were now obliged to see the full range of cases.
  • suggested coverage in the press had contributed to mistrust between PCT and dentists.
  • felt PCTs should challenge practitioners more to show how they are performing to the required level.
The Chairman asked the practitioners to comment briefly on ways in which the service could be improved and the following comments were received:
Dr Wagner: improve access to services where there is the most need and improved liaison with PCT to get funding and guidance;
Dr Patel: need for a more fluid way to obtain funding, rather than being based on historical figures;
Dr Bhandal: PCT needed to be better resourced, e.g. needs more staff.
After receiving evidence from the practitioners the Group were advised by Jenny Greenshields, PCT Finance Lead, that UDAs were not set at a standard rate because case loads themselves were not standard. UDA values were established after taking into consideration the complexity of the ‘case mix’ at a practice, for example children’s treatments tend to be more simple, while a case load of older patients would, as a matter of course, involve more complex needs (e.g. bridge work, crowns, dentures). Socio-economic factors would dictate that in more deprived areas, treatments also tended to be more complex.
Jane Robinson commented that the PCT was dedicated to improving liaison with practices and that work was in progress on ‘Oral Health Needs Assessment’ and ‘Oral Health Strategy Commissioning Group’. Outcomes would be collated and information would be provided to the Topic Group.
The PCT would be collecting data from practices and would be open to looking at and revising the allocation of UDAs as working under the contract progresses. The PCT acknowledged the importance of quality assurance.
The Chairman reported that he had received a good response frommembers of the public to his letter in the local press: out of 60 replies 20 were positive and 40 expressed concerns about services.
The Topic Group concluded that improved public information on dental services was essential. / Action:
J Robinson
3. / SPECIALIST SERVICES
The Scrutiny Officer circulated a summary of questions for consideration and the Group considered the paper from Jane Robinson which provided details of specialist services. i.e. orthodontics, sedation, domiciliary services and the PCT dental services.
The Topic Group agreed that Specialist Services be considered in more detail at the October meeting.
4. / QUALITY OF CARE
Members considered ways in which the PCT monitored the quality of care provided; there was discussion on the dental practice inspections and on the clinical inspections that also take place. The PCT offers advice to practitioners and monitors areas for improvement. An inspection certificate was issued, to be displayed in the surgery.
Members noted that all dentists and dental surgery assistants were required to register annually with the General Dental Council and to take part in continuing professional development.
Practitioners were required to provide patients with a treatment plan, showing cost for treatment, and also to display in the surgery a list of charges. It was acknowledged that this practice was variable at present.
With regard to complaints Christine Neal, from Hertfordshire’s Complaints Service, circulated data on complaints received in East and North Herts PCT and West Herts PCT, together with a document entitled ‘How to make a complaint about the NHS’. Christine Neal reported that the PCT had no power to investigate complaints against dentists. Surgeries were required to make information available to the public about how to make a complaint and it was advertised on the PCT website. There was discussion on ways to make this information available in other public places, such a libraries.
Members noted that the complaints service works closely with Jane Robinson’s team in the PCT, who strive to provide the highest standards of public satisfaction. It was noted that patients were encouraged to resolve issues with their practice in the first instance.
There was discussion on access to urgent treatment. Monday to Friday this was provided by appointments set aside for emergencies. These were in the following areas: Watford,
St Albans, Borehamwood, Hitchin, Letchworth, Baldock.
At weekends there were four ‘on-call’ dentists, contactable via a phone number given out on a recorded message at dental practices. NHS Direct then triaged treatment, and the on-call dentist would contact the patient. Where necessary arrangements would be made to see the patient at the dentist’s practice. All dentists must work with a dental nurse in attendance, including for out of hours emergencies.
Hospital Accident and Emergency departments only saw patients who required emergency rather than urgent dental treatment (for example, injury following an accident).
5. / WORK PROGRAMME
Members noted that at the next meeting further evidence would be received from practitioners and from the Chair of the Local Dental Committee.
The Chairman thanked everyone who had contributed to the meeting, particularly the practitioners for taking the time to attend.
6. / DATES FOR FUTURE MEETINGS
Members agreed the next two meetings, as follows:
Wednesday 15 October at 10 a.m.
Monday 17 November 2008 at 10 a.m.

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080911 Minutes 11 September meeting