Members to receive an updated report on the provision of NHS dental services commissioned in Leicester, Leicestershire and Rutland together with an overview of the ongoing effects of the Covid 19 pandemic and the steps being taken to restore and recover service provisions.
5.50pm The Chair agreed to a short adjournment to resolve technical and audio issues with participants joining the meeting via Zoom for this item.
5.58pm Meeting resumed.
The committee received an updated report in relation to dental services commissioned across Leicester, Leicestershire and Rutland and an overview of the ongoing Covid 19 pandemic effects on those services as well as the steps being taken to restore and recover service provision.
Rose Marie Lynch, Allan Reid, and Catriona Peterson from NHS England were present to provide responses to any points raised.
Rose Marie Lynch, NHS England and NHS Improvement briefly introduced the report summarising key points which included:
· An overview of the background and clarification as to how NHS dental care was provided;
· Details of dental contracts in place across Leicester, Leicestershire, and Rutland as wells as extended or out of hours cover and secondary care;
· NHS dental care access was routinely at around 50% of the population, and dental practices had a duty to see people who needed treatment, however the number of people attending private services is not known;
· The timeline for impact upon dentistry of the pandemic was referred to as set out in the report together with the ongoing impact and effects;
· Significant impacts were largely due to measures introduced around infection prevention control and the national guidance that dental practitioners had to adhere to, e.g., introduction of “downtime” a period where the surgery must be left empty following any aerosol-generating procedure (AGP) i.e., fillings, root canal treatment or surgical extraction.
· Information about the Urgent Dental Centres (UDC’s) provision and Urgent Care pathway was noted. Four urgent dental care centres (UDC’s) established during pandemic remained in place across Leicester, Leicestershire, and Rutland; their openings offered optimum coverage with a pathway to access through general dental practices or the 111 service.
· Since the pandemic schemes had been commissioned with purpose of increasing patient provision and to enable additional activity at weekends, this had led to availability of 152 additional sessions for dental treatment. Providers had also been engaged to provide dedicated slots to the 111 service generating an additional 56 appointments each week across LLR for urgent treatment.
· NHS England were now looking at commissioning a child access team as it was recognised children’s oral health and routine dental care had been impacted by the pandemic.
· Steps were also being taken to invest in adult oral health and to address oral health inequalities.
Allan Reid, NHS England provided further details regarding oral health in Leicester, Leicestershire, and Rutland during which it was noted that:
· Based upon the last national survey of 5 year old state school pupils (2021) Leicester City had the 2nd highest childhood tooth decay levels in the region. Within Rutland, child decay was slightly higher than the regional and national average and in Leicestershire, Charnwood district had the highest tooth decay rates in the county.
· Charts within the report set out the prevalence of dental decay in 5 year olds by ward areas and included profile areas where action was to be targeted.
· Priorities and actions to tackle children’s dental decay included school initiatives such as increasing access to supervised toothbrushing in nursery and school settings and upscaling of prevention measures.
· Regarding adult oral health, the focus was on oral cancer, Leicester was seen as a hotspot with diagnosis and death rates consistently higher than the national average, that was felt to be related to tobacco use and areas of deprivation. National oral cancer registration rates showed Leicester at 23/100,000 population compared to national rate of 15/100,000 and that also caused concern for impact on dental services in terms of early care.
Members discussed the report and there was some surprise at the differentiation in the rates of dental decay especially in areas where the demographics might be considered the same and/or where there was less deprivation than in the city e.g., Queniborough compared to Quorn. It was also noted that in the city the Beaumont Leys ward had comparatively good figures compared to Spinney Hills ward, yet both had lower socio-economic levels in terms of deprivation, and it was queried whether any research had been done into why areas with the same demographics or socio-economic backgrounds were so different and whether this related to access to services and if so, the steps being taken to address that.
It was advised that geographically the survey could be dealing with very small numbers, with cohorts as low as 15 in some areas and that could account for some of the differential between areas, especially those of a similar demographic. Sampling was done using a detailed sampling framework, however, there was also the issue of consent and sometimes the consent rate level was lower, therefore the minimum number being sampled in an area could be 15 but in practice it was usually up to 30 children sampled.
Members questioned the age of the data and its reliability and queried when more recent data would be available. It was explained that in terms of timeliness the survey was carried out every 2 years, the age of the children sampled was varied every 2 years and it was noted the last survey conducted was of 3 year olds and the next would be young people aged 12 years. Conducting the survey involved a massive collation of data and school access for sampling. It was noted that the survey due to take place last year had been postponed due to the Covid 19 pandemic.
Members discussed the level of access to dental services and expressed concerns that people in some areas were not able to access urgent dental treatment and that there was ongoing delay in returning to routine dental care. It was queried whether there was any over mapping of where services were available and where people were accessing services. It was also questioned why the Oakham UDC had been closed.
In response it was noted that UDC’s were part of the covid urgent dental care systems set up when it was known that general dental practices were closed. Specific practices were chosen on contracted open hours and their geographical spread. Existing dental practices were now reopening for urgent treatment but with measures in place to comply with government guidance. With regards to South Leicestershire there was not currently a contract in place that met the needs of the urgent care practices set up for covid but there were other dental practices there.
In relation to Oakham, the general dental practice was still practicing and the nearest UDC was in Hinckley. A UDC was initially mobilised in Oakham but analysis of patient referrals and usage showed there was little uptake in the area, so it was relocated to Hinckley where more need was identified.
Regarding the commissioning and provision of dental practices, this was targeted at areas of highest need wherever possible, and surveys were used to determine if there were gaps in areas. The Oral Health surveys pre pandemic had not highlighted any gaps in provision. It was accepted there was an issue accessing dentists at the moment, and it was about managing the expectations of the public and restoring those services. The availability of routine check-ups remained likely to be limited only to vulnerable people and those with ongoing dental issues but the number of providers recalling patients for routine check-ups continued to increase.
Members were concerned that the situation regarding child dental decay did not appear to be improving and with the impact of the pandemic, dentists closed for routine appointments and people unregistered for dental care the situation looking forward would deteriorate further. Members also noted that the data around trends did not include Rutland.
Allan Reid, NHS England apologised for the omission of data relating to Rutland and undertook to provide this outside the meeting. It was advised that the data used to look at trends went back to 2008 and this did show an improvement across all of Leicestershire, and it was expected that would be replicated across all areas. Data from the most recent survey of 3 year olds would be available in Summer 2022 and would be analysed for any trends.
Members considered the information around LLR dental service performance and challenged the statement that 50% of people were accessing NHS dentists while dental practices were being charged with dealing with 60% of Units of Dental Activity (UDA’s) suggesting that equated to just 30% of people across LLR being able to access dental services.
Members expressed their dissatisfaction that dental service performance showed dental practitioners were not delivering 60% UDAs, but they continued to receive 100% monies towards cost of operating services. There was also disappointment at the lack of clarity to address the backlog of patients who had missed out on routine appointments and non-urgent treatment, and it was noted that there was no time indicator yet of when there would be 100% restoration of services.
The issue of people accessing private dental care provisions through lack of choice and because of necessity was raised and it was queried why private practice were able to continue providing routine appointments and treatment if they had to comply with the same government guidance.
Members were informed that private practices allowed more time for their patient appointments and that was a key factor. NHS practices worked at a higher rate, and it was more difficult for them to see volumes of patients under the current guidelines.
In relation to LLR provider delivery of contractual activity and the figures in the chart it was clarified that the chart did not show how big a contract was, e.g., a small practice might only see a few patients a day, and other reasons such as single handed practitioners and having to keep appointments to an hour. There was also the knock on effect of areas with higher levels of decay requiring treatment which required higher downtime between appointments.
In relation to vulnerable groups and especially those with learning disability it was advised there was SEND work locally within local health steering groups around improving access. Data was recorded regarding dental access, and it was recognised that needed to be better and NHS England had been explicit on the need to prioritise vulnerable groups. In terms of any statutory entitlement, it was noted that although it was a priority and there was an annual health check requirement there was no statutory entitlement.
It was noted that the Healthwatch report was focused on aspects around the SEND pathway and a detailed response to the recommendations within that report was requested. The Healthwatch report had been shared with health partners and the recommendations were being considered along with steps that could be taken to form an action plan.
Discussion progressed onto Adult Oral Health, and it was queried whether some of the checks around oral mouth cancers could be conducted by other health practitioners if people were not seeing dentists.
Allan Reid, NHS England explained that regular oral checks might pick up issues such as a non-healing ulcer and that could be picked up by care home staff for example, they could then notify a GP to look at that or make a referral to dentist. However, whilst such issues could be identified and noted a confirmed diagnosis had to come from the centre i.e., dentist. It was suggested that further consideration should be given to oral checks being conducted by someone other than a dentist as GP practices may be aware of patient lifestyles and perhaps could factor in surface level checks for people at risk especially those not accessing dental practices.
Drawing discussion to a conclusion the Chair identified that the mapping of need for dentistry services did not. The Chair commented that although this was a vastly improved report to that received previously it did expose issues and there was concern that it could not be described where gaps in provision were across Leicester, Leicestershire and Rutland. The Chair expressed interest in seeing where this would fit into place based plans of the Integrated Care System in future.
1. That the missing data in the report regarding Rutland statistics be shared with members as soon as possible outside this meeting;
2. That a detailed response on SEND pathway access be shared with members outside this meeting as soon as possible;
3. That a written update be provided to Healthwatch in relation to the recommendations within their report and a copy of that provided to the Chair and Vice Chair of this Committee;
4. That an update report on Dental Services in LLR be brought to a meeting of the Committee in 6 months, to include input from ICS on place based plans and further detail on recovery rates and progression since the last update.
5. That consideration be given to mapping the needs in dentistry services to identify the gaps in provision across LLR.