Decision-making about resources for DENTISTRY May 2006 (as prepared for a challenge about allocations to a dentist under the new dental contract)

  This note explains how Hillingdon PCT makes decisions about the allocation of resources, with special reference to general dental services.

  The overall approach to resource allocation is governed by the standing policies of the PCT based on its statutory responsibilities and mission statement. The PCT is charged with ensuring the provision of health-related services for its population, and has to balance the many calls on its limited budget in order to get the best deal overall for those for whom it has responsibility. The full "Difficult Choices" policy explains how the PCT deals with the broad issues and various specific areas, and is described in chapter 7 (pp56-62) of the annual public health report 2004[72]. This document needs further revision to reflect fully the latest nuances of the latest contracting/commissioning regime, and the recovery position in which the PCT is in at present, but the basic philosophy still stands. Important themes are the reduction in health inequalities and that greater health needs, like those affecting mortality, take priority over lesser ones.

  Historically, the choices available in practice to the PCT for shifting its spend were limited. The expectation has been that the previous year's spend influences the next, with only marginal readjustments in the light of particular national and local priorities and specific growth pressures. With the size of the deficit being reported for 2005-06, a more radical approach is required, since the previous spend was unaffordable. At the time of writing the PCT is still preparing the details of its budget and recovery plan, looking to cut expenditure by March 2007 to a level that would give savings of £25 million (FYE). This needs to be done whilst still delivering the core priorities of the local, regional and national NHS.

  There are various new priorities on the PCT, some of which like the health promotion priority of "Choosing Health" have indicative funding allocations within the allocation to the PCT. However, in view of the funding position of the PCT and the North West London sector as a whole, some of the expected year on year "growth" is being top-sliced before receipt by the PCT to help to address the collective deficit. Although the remaining growth may be adequate for the unavoidable inflationary uplifts, eg for salaries, it is expected there will be no additional resource for new priorities. Hence were it essential to fund new areas, this would require even bigger cut-backs in existing services than required just to reverse the previous overspending. This makes it especially important that any growth areas of spend present exceptional value for money.

  Within this overall background it was decided that there were no grounds for increasing the expenditure on general dentistry. Almost uniquely among the services provided by the PCT, there were no cut backs being proposed for these services, although commissioned dental services including the Community Dental Service were expected to contribute to "savings". In the overall context of the reshaping of the PCT's spend back to an affordable level, this then represents a relative increase for general dental services. This is explained more by the constraints of the new dental contract than an explicit decision to increase the relative priority of general dentistry. According to the general philosophy as described in the "Difficult Choices" policy, and in the absence of a specific national target relating to investment in dental services, it appears dentistry starts 2006-07 more generously treated than might be expected. There certainly appear to be no grounds for increasing the size of the dental spend.

  The allocation of the general dental budget identified for Hillingdon for 2006-07 between practices was made through an explicit process, as agreed with the LDC and consistent with the national guidance (see separate documents).

  It is unlikely that dentistry would emerge as a local priority for increased investment, and especially were this to require additional disinvestment in other services such as those for children, mental health, cancer and so on. One of the documents which is expected to help set the priority agenda for the PCT is the annual report from the DPH (the APHR). In 2003 it was stressed the importance of dealing with inequalities, a government priority. The 2004 report was themed around money, stressing the "Wanless" approach of investing in healthy lifestyles.

  In the 2005 report there is a chapter on oral health (pp43-45). It demonstrated that a higher proportion of Hillingdon's population who lived in deprived areas were likely not to be registered with a dentist. The attached graph presents the same data with each ward ranked according to its deprivation, using the same type of presentation as in the 2003 APHR. The distribution of NHS dentists was inversely related to deprivation, ie there were more dentists in the least deprived areas, which are just those areas where oral health was already good. In the more affluent areas of Hillingdon, like Northwood Hills, it is expected that a higher proportion of those unregistered with a NHS dentist use a private dentist, whereas in more deprived areas the expectation of the unregistered may be that they manage without a dentist.

  The latest data on mean, decayed, missing and filled teeth (dmft) in five year olds was included when these data were presented to the UK Public Health Association conference in April 2006[73]. Northwood Hills was in the lowest dmft category in Hillingdon and there is a particular concentration of dental practices in Northwood Hills. However, several wards in the south of Hillingdon have no NHS dental practices at all, and higher rates of dental need as demonstrated by dmft rates. It was recommended that the new dental contract be used to target resources to even up access to dental services. The Health and Social Care Act 2003 asks for the PCT to commission appropriate services to tackle long standing oral health inequalities.

  The conclusions from the above are:

—  The PCT needs to trim its existing spend in order to meet its statutory responsibility of balancing its books.

—  General dental services have already been generously treated overall compared to other areas of existing PCT spend.

—  Oral health is not a local priority for increased spend.

—  Within the oral health field, general oral health promotion is a higher priority than dental services.

—  Were there to be increased investment in dental services, one of the least appropriate locations for this within Hillingdon would be Northwood Hills—an area already well served by dentists and with low rates of dental need—since this would serve to increase the local inequalities in access to a NHS dentist.

—  Increasing investment in general dental services in an affluent area of Hillingdon would appear perverse whilst other services for the people of Hillingdon are being restrained or cut back.

Dr Hilary Pickles, MA PhD MB BChir FRCP FFPH,

Director of Public Health

  Ward 10= Northwood Hills

  Ward 22= Townfield, a site of a Surestart programme which promoted access to dental services

  For the identification of the other wards, and other examples of the use of this methodology, see APHR 2003

73   Caroline Bowles and Heema Shukla. Using the new general dental services (GDS) contract to reduce health inequalities. Poster at UK PHA Forum 2006 Back