Commissioning: further issues - Health Committee Contents

Written evidence from the British Dental Association (CFI 14)


1.1  The British Dental Association (BDA) is the professional association and trade union for dentists practising in the UK. Its 23,000-strong membership is engaged in all aspects of dentistry including general practice, salaried services, the armed forces, hospitals, academia and research, and includes students.

1.2  The BDA is pleased to contribute to this follow-up inquiry, which addresses many of the issues that we raised in our written submission of evidence. In particular, we have long advocated the value of local clinical expertise in the commissioning process, greater patient and public involvement and integrated health and social care patient pathways.

1.3  The Health and Social Care Bill 2011 states that the NHS Commissioning Board will commission primary care dentistry. In a recent statement, Lord Howe confirmed that the NHS Commissioning Board would also commission secondary care and community dentistry. Our members very much support this arrangement, as we have long pressed for a national contract with room for local flexibility both prior to and following the implementation of the 2006 dental contract.

1.4  We strongly urge the Committee to consider the need for clarity of the role, function, authority and accountability of the NHS Commissioning Board and its relation to local authorities and Public Health England. This clarity at an early stage is essential to ensure continuity of service and patient care in an uncertain transition.

1.5  The burden of regulation is a threat to commissioning appropriate services and we ask the Committee to consider the practical working relationships required to ensure that the Commissioning Board and consortia function with appropriate reference to the relevant regulatory bodies. The BDA advocates a reduction in the burden of regulation - both financial and administrative - that has the potential to compromise dentists' ability to provide essential services to patients. We believe there is a growing recognition that the regulatory burden is now excessive.

1.6  There is a concern that education of the dental team is heavily reliant upon practice placement and actual care provision by undergraduates and dental care professional students. The need to coordinate service change and reconfiguration and at the same time to assure continued access to workforce development is essential to deliver a modern and efficient dental health service.


2.1  We support the Committee in seeking clarity about the authority of the Board to deliver its objectives and we recommend that the Committee consider this as a matter of urgency.

2.2  This issue is particularly important to dentistry, as the Department of Health is in the process of piloting a new dental contract, which is due to be rolled out in 2014. With the introduction of the Care Quality Commission to an already significant regulatory framework, we are operating in an information vacuum. The Coalition is yet to publish appropriate guidance on the structure and responsibilities of the Commissioning Board, and at a time of such significant change, this lack of information is unacceptable. It is essential that we receive clarity on how services will be commissioned in order to ensure that there is no compromise to the availability and accessibility of care for patients and the public.

2.3  Restricted NHS budgets and the increased focus on public health mean that workforce planning becomes even more important. Without knowledge of how the NHS will operate over the coming years, we risk missing an important opportunity to review how best to provide services to a population undergoing significant demographic shifts and changing oral health needs. The ageing of the "heavy metal generation" will put an increased demand on the need for complex restorative dentistry, and we need assurances that the Board will consider these demands.

2.4  We ask that the Committee consider the need for appropriate representation of the various healthcare professions on the Commissioning Board to ensure that key areas of care are not overlooked.


3.1  In agreement with the Committee, we require clarification on the proposed lines of accountability between the NHS Commissioning Board, the Department of Health and the Secretary of State, particularly in light of the proposed new powers for public health of the Secretary of State. We have concerns that the Secretary of State is delegating powers to the board for issues that will become ever-more complex during the transition period while accepting greater responsibility for public health issues that may not yield results for several years. Our main concern is there will be no ministerial accountability for short-term transitional issues that beset the NHS. NHS clinicians and front-line staff are the life-blood of the NHS and they deserve a full and fair system of accountability from their political masters.

3.2  Because of this distinction between responsibility and accountability, we are concerned that high quality and evidence-based commissioning will not be underpinned by solid public health and epidemiological data, knowledge and expertise. In seeking to strengthen the role of public health, the government has instead separated the core foundation of health and wellbeing from health service provision and we must caution the government, through the Committee, to think very carefully about creating a distinct divide.

3.3  With regard to future service design, we question the management of data collection during the period of transition when PCTs and SHAs are abolished in 2013 and the commissioning consortia become operational. We have concerns because the consortia boundaries will be different to the PCT boundaries and therefore much existing health and demographic information will no longer be relevant. Although dentistry will not be part of the GP consortia, all boundary changes, for the purposes of data collection, will have major implications for continuity of care based on robust data collection, as it will not be possible to monitor any changes over time.


4.1  We wholeheartedly agree with the Committee, "it is essential for clinical engagement in commissioning to draw from as wide a pool of practitioners as is possible in order to ensure that it delivers maximum benefits to patients". Our 2009 local commissioning report[41] advocated clinical engagement and during the transition period, we restate our view that "clinical engagement has never been more important". Sir David Nicholson[42] stressed on 17 February 2011 in a letter to the NHS the value of clinical expertise to support the NHS Commissioning Board when he stated that the "Commissioning Board will have strong clinical input across all of its functions".

4.2  NHS dental services have long had clear networks providing clinical expertise on commissioning high quality services despite the recent problems with the dental contract. These networks involve consultants in dental public health, Local Dental Committees (LDCs), dental practice advisers and individual practitioners and there is a huge wealth of social capital within NHS dentistry. We are seeking to ensure that the Commissioning Board has formal mechanisms through which to benefit from appropriate expert professional expertise through a dental advisory committee.

4.3  We would like to see managed clinical networks[43], as in the example of oral surgery in Croydon[44], being established and promoted to support effective commissioning and for the Board through its local structures to make full use of the long established network of LDCs.


5.1  The Board must bear in mind the other services that it will commission that are outside the potential remit of consortia and local primary care providers. It must not simply focus on medical services. We have recently raised concerns about the economic climate leading patients in England to cancel dental appointments and defer treatments they need, according to our research. The unfortunate knock-on effect of these decisions is an increase in the number of patients presenting at surgeries requiring emergency treatment. Our survey[45] showed that 59% of dentists questioned had seen their patients cancel appointments, while 68% reported decisions to defer treatment. The Commissioning Board cannot afford to focus purely on the conflict between primary medical care and consortia; they must also consider the wider healthcare economy.

5.2  There is also a lack of clarity in how secondary care dental services will be commissioned. It is recognised that it would be inappropriate for GP commissioners to commission secondary dental care. The Board will need to have understand the intimate relationship between secondary dental provision and dental education as the majority of secondary dental care is undertaken in dental schools/hospitals

5.3  In commissioning specialist care such as orthodontics and oral surgery, which currently takes place in primary care, the Board will need specialist advice and knowledge and understanding of local population needs. As previously stated, this means there is a need to ensure the Board has knowledge of local expertise.

5.4  The NHS Commissioning Board will need to be very aware of the increasing burden of regulation on healthcare professionals and in particular dentistry. There are a growing number of oversight bodies regulating healthcare professionals and the number of these bodies is ever increasing. We believe that it would be disproportionate for dental services to be subject to licensing by Monitor.

5.5  As stated in paragraph 1.3, access to the salaried/community services via the NHS Commissioning Board is essential to guaranteeing appropriate access to care for vulnerable groups.


6.1  We draw the Committee's attention to the needs of vulnerable groups when considering the issues described in paragraph 107. Many vulnerable members of society will encounter both health and social care services and we support the Committee in its aim to promote the development of new arrangements for fully integrated services whilst reviewing those already in place.


7.1  Major service reconfiguration has affected salaried or community dentistry in the last few years under the transforming community services mandate. As a basic position, we have stated our concerns about full adoption of social enterprise options: namely, the likely lack of NHS terms and conditions for new starters, the loss of NHS status, the potential fracturing of the cohesiveness of care for vulnerable patients and the governance structures of such institutions. Again, we have long advocated clinical engagement in all discussions with PCTs about service reconfiguration and we continue to urge open dialogue during the transition.


8.1  The Any Willing Provider model is the current status quo in the mixed economy of dentistry. However, some PCTs have already commissioned postcode-limited contracts for specialist care. This restricts patient choice and distorts waiting lists in a locality.

8.2  The adverse effect of this model comes from the fact that small and single-handed practices, which have established running costs that are currently acceptable to the NHS and provide high quality service to patients, may be under-cut by corporates who are able to provide a service for less. We want to ensure that patients have continuity of access to high quality care but we have concerns about the impact on dentists currently in practice. Every effort should be made to balance the effects of producing a "cost efficient" service with safeguarding the interests of those who have dedicated years of loyal service to the NHS and its patients.

8.3  This is likely to have a subsequent impact on disadvantaged communities in low socio-economic areas, which often suffer from low access and may not appear as commercially attractive to the big corporate providers. We are concerned that this will harm communities, and in some cases, may act as a barrier to patient choice. This is especially pertinent given the government's own stated aim of, "helping people live longer, healthier and more fulfilling lives; and improving the health of the poorest, fastest".[46]

8.4  Consequently, we would like to see a statement on the NHS dental offer and would welcome a guarantee of adequate provision for NHS services in all areas of the country. We have some unpublished research[47] on perceptions to NHS dentistry by socio-economic group C2DE. These respondents told us that a combination of issues resulted in a proportion of people who completely avoided visits to dental surgeries, opting instead to "put up with" various conditions, from missing or broken teeth to painful teeth and gums. Respondents were either unaware of the existence of the NHS dental surgeries in the area or believed that there were too few. We support the commitment, in the 2011-2012 NHS Operating Framework, to improving access to NHS dentistry for those who seek it.


9.1  Alongside Consultants in Dental Public Health, there are other important sources of local professional expertise; Dental Practice Advisers, Local Dental Committees and, in some areas, Oral Health Advisory Groups.

9.2  The BDA is concerned that there is no statutory duty on local authorities, through the Health and Wellbeing Boards, to consult local representative committees when devising a health and wellbeing strategy and a joint strategic needs assessment.

9.3  We suggest that their ability to respond to dental needs, to inform the joint health and wellbeing strategy, the joint strategic needs assessment and the National Commissioning Board, and to encourage integrated working across local healthcare providers will be significantly enhanced by the statutory responsibility to include representatives of relevant health professions in their constitutions and to consult them.

9.4  The BDA believes that LDCs have much to offer Health and Wellbeing Boards, joint strategic needs assessments and health and wellbeing strategies, but they can only do so if they are formally recognised and have the resources to function effectively. The 2006 NHS dental contract regulations severely affected the ability of LDCs to recruit members and to collect the required levy. We therefore propose the strengthening of the arrangements for LDCs.


10.1  We remain very concerned about how PCTs will ensure all debt is eradicated before the changeover to the NHSCB and how this will be handled. Dental money is ring-fenced although we know anecdotally that savings made in NHS dentistry are being used to reduce deficits in other areas. Until the NHSCB assumes responsibility, PCTs have a statutory duty to provide NHS dental services to anyone who seeks it, and we urge that debt eradication should not take priority over dental service provision for local communities.

10.2  PCTs are currently re-commissioning millions of pounds worth of specialist care provision in orthodontics in the form of PDS contracts. These contracts will be for five years or more, yet the organisations that will have commissioned these services will not be in place for audit, accountably or responsibility. The Committee needs to obtain clarity in how the handover of the responsibilities will occur for orthodontic PDS contracts and to ensure that specialist services are not decommissioned in favour of eradicating PCT debt.

10.3  The Coalition government has a clear commitment to reduce the incidence of dental decay in five-year-olds. This commitment will be impossible to meet without investment, yet given the anecdotal evidence above, we are concerned that PCTs will look to reduce their deficits and will not invest heavily enough in this commitment.

February 2011

41   BDA (2009) Local Commissioning Working Group report Back

42   Nicholson, Sir D. (2011) Equity and excellence: Liberating the NHS - managing the transition. Gateway ref 15594.

Available: Back

43   Skipper, M (2010) Managed Clinical Networks. British Dental Journal 209(5), 241-2. Back

44   Kendall, N (2009) Improving access to oral surgery services in primary care. Primary Dental Care, 16(4):137-42.  Back

45   BDA (2010) Omnibus survey Back

46   Department of Health (2011) Healthy Lives, Healthy People: our strategy for public health in England. CM7895 Back

47   Dental non-attendees qualitative research report (2010 - unpublished)  Back

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Prepared 5 April 2011