EXECUTIVE SUMMARY

  1.  The introduction of the new general dental contract in Hillingdon has been relatively trouble free. It was backed up by an oral health needs assessment which has proven useful in directing where any freed up resources were most needed. A history of good collaboration between the commissioner and general dental practitioners meant that the problems which were widely anticipated were not realised locally. Teething Problems: A review of NHS Dental Care in London published in November 2007[68] partly explains the Hillingdon experience in terms of access and take up of dental services.

HILLINGDON, ITS PCT AND DENTAL PROVISION

  2.  Hillingdon has a population of around 250,000 and is situated in outer North West London. It has a mixed population, with greater affluence towards the north of the Borough, with increasing diversity and deprivation towards Heathrow and the South of the Borough.

  3.  In recent years, Hillingdon PCT has been notable for the size of its financial problems, and it has pro rata one of the biggest accumulated deficits in the country. This has put pressures on its management, with frozen posts and considerable turnover in the executive team. The new dental contract could hardly have been introduced at a more challenging time for the PCT.

  4.  For years, there has been reasonable NHS general dental provision in the more affluent parts of Hillingdon, but less so in the more deprived areas. However, complaints about the inability to access an NHS dentist have been few, even though data suggests poor oral health is widespread in the south of the borough and there are wards with no NHS dental surgery.

  5.  The PCT was encouraged to write to the committee with its experiences, to help balance the "submission bias" from areas where the introduction of the new contract proved more problematic. The reasons for the ease of introduction locally are assumed to lie in (a) good long term liaison between the lead commissioner, public health and the dental fraternity and (b) the earmarking of dental funds so these changes were insulated from the more general financial pressures. What has not yet happened, however, is any substantial shift in provision towards the more needy areas nor towards prevention.

THE ROLE OF THE PCT IN COMMISSIONING DENTAL SERVICES

  6.  There have been several changes taking place which have affected the PCT's involvement with dental services, of which the new contract for general dental practitioners has been only part but perhaps the most significant. The PCT also has nearly £2 million of spend on hospital dentistry, which now comes under tariff and in theory under the increasing influence of practice based commissioners.

  7.  There are also dental services provided by the Community Dental Service (CDS) for patients with special needs and a limited range of specialist services. Some oral health promotion activities also take place within this team.

  8.  An oral health needs assessment was undertaken in 2005-06 and will be extended in 2008. It was promulgated to dentists, was featured in the Annual Public Health Report 2005 and made available on the PCT's website (www.hillingdon.nhs.uk). It also formed the basis of a presentation to the UK Public Health Association (UKPHA) in April 2006, and an update has appeared in the latest Hillingdon Annual Public Health Report (also on website).

  9. The oral health needs assessment provides the background for decisions about distribution of any freed up UDA. It proves very helpful in dealing with challenges from dentists who want to set up practice in an area that is already well served by dentists. As an example, appendix 1 presents the arguments used at the time, in a case that went to appeal. Appendix 1 also gives a flavour of the financial pressures on the PCT at the time the new GDS contract was introduced.

  10.  In spite of good intentions and some exceptions, in practice the PCT has had little influence on general dental provision due to the income guarantee extended to those GDPs who decided to take up the new contract in April 2006. However, the main tasks to ensure a smooth hand over from the old contract to the new and manage the primary care dental spend within its envelope were achieved successfully. This has been facilitated by the close working between dental professionals themselves and commissioners at the PCT.

  11. Although the PCT has hosted a Dental Advisory and Liaison Group for over 10 years, in 2005 a Steering Group was also established with the task of introducing the new contract. Although this group has now served its purpose and only meets on a quarterly basis, it has forged ongoing links with the dental profession and has been recognised by the Local Dental Committee (LDC) as an excellent example of joint working.

  12.  Through this joint working, the PCT has over the last 18 months organised a series of clinical governance events aimed at supporting dental professionals achieve the standards set out in Standards for Better Health (2004).[69] Using the national Clinical Governance Framework,[70] these events have covered a range of topics and have attracted large audiences. Evaluation has been positive and the PCT expected to continue these events into 2008.

  13.  The PCT also commissions unscheduled care slots from local dentists. This service is designed for people who need to see a dentist urgently during normal surgery hours but either cannot get an appointment with their usual dentist or they do not routinely go to the dentist.

  14.  In terms of Out of Hours care, the PCT has been fortunate in joining with the other seven PCTs in North West London to provide its out of hours service. The dental nurse triage service operates between 6pm and 10pm weekdays and 9am to 10pm weekends and bank holidays. The triage provider works with NHS Direct and the PCT's GP provider of out of hours services, Harmoni. All patients are filtered through triage before accessing the dental service. The joint working between the sector PCTs has afforded greater economies of scale and provided a service that Hillingdon alone could not afford to commission.

NUMBERS OF NHS DENTISTS AND ACCESS TO NHS DENTAL CARE

  15.  The PCT has 39 contracts for general dental services and four contracts for orthodontic services. In addition there is one contractor who only provides domiciliary services. One NHS GDP opted not to take a new contract in April 2006 which represented 0.4% dental activity in the whole of Hillingdon. Since April 2006, no GDP has terminated his NHS contract for reasons other than sale of premises.

  16.  A recent review of NHS dental care in London (London Assembly, 2007) illustrates the percentage of residents accessing NHS dental care pre and post the introduction of the new contract. In Hillingdon's case, 51.6% of residents accessed care in the two years to March 2006 compared with 53.2% in the two years to March 2007.

  17.  Although the PCT has not conducted a user survey to find out what patients think of NHS services provided, we do monitor calls into our PALS department and/or complaints.

QUALITY OF CARE PROVIDED TO PATIENTS

  18.  Although the quality of care provided has not been compromised by the introduction of the new contract, the banding system seems to have affected the types of treatments offered. Similar to that reported in NHS Dental Reforms: One Year On,[71] the PCT has noticed a marked reduction in Band 3 treatments. Some might argue that this reduction in complex activity is clinically appropriate, the more cynical might suggest that fewer dentists are prepared to do the complex work for little return. The PCT will be monitoring this situation carefully and will consider building in stipulations to its commissioning intentions once the transitional period is over.

  19.  The new contract was funded to free up a dentist's time by 5% to allow them to offer more preventative advice. Anecdotal views given by Hillingdon commissioners suggest it is too soon to see whether the 5% incentive provided has been enough to encourage dentists to do more preventative work. Informed thinking is that dentists are unlikely to provide an enhanced service without additional funding and that a drop in activity has already occurred.

PATIENT CHARGE INCOME

  20.  In 2006-07 the PCT commissioned 353,142 UDA from contractors and 338,827 were delivered. This represents 96% achievement against target. The small shortfall will either be made up by the contractor concerned or funding will be clawed back. In terms of funding, the total ring-fenced allocation for commissioning primary care dentistry in 2006-07 was £6,912k and actual spend was £7,476k. Although when the services were commissioned at the beginning of 2006-07 the PCT remained within its ring-fenced allocation, shortfall on recovery of patient charges has meant the PCT sustained a cost pressure of £564k.

  21.  Similar to other PCTs, Hillingdon does not expect to see a marked improvement in the collection of these charges as the formula used by the DH to make the calculation seems to have been flawed. In acknowledgement of this, the DH has increased funding allocations slightly for 2007-08. However, the PCT will have to take measures to ensure this shortfall is covered and it is likely that when ring-fenced budgets end in 2009, the dental budget will be top-sliced to pay for the shortfall thus reducing the PCT's ability to commission services according to need.

SUMMARY

  22.  Despite the uncertainties regarding funding, the PCT is confident that similar levels of NHS funded dental care could continue to be provided beyond 2009.

  23.  Patterns regarding how this activity will be provided will change with a greater focus on commissioning services according to need.

  24.  The PCT sees itself at the fulcrum of delivering NHS care and the new contract offers greater opportunity to delivery care in innovative ways.

  25.  The PCT will continue to support its local dentists to achieve high standards of clinical governance through its development programme which would not have been possible without the joint working established as part of implementing the new contract.

Professor Yi Mien Koh

Chief Executive

Helen DeLaitre

Acting head of primary care

Professor Hilary Pickles

Director of Public Health

December 2007

69   Department of Health (2007), NHS Dental Reforms: One Year On, London, Department of Health Back

70   Primary Care Contracting (2006), Primary Care Dental Services: Clinical Governance Framework Back

71   Department of Health (2004), Standards for Better, London, Department of Health Back