1. 17 th November 2008 Dentistry and Oral Health in East and North Hertfordshire and West Hertfordshire PCTs Jane Robinson Primary Care Commissioning Lead Sue Gregory Consultant in Dental Public Health

2. 17 th November 2008 Outline What NHS Dentistry should provide Dental Charges Access to NHS dentistry What the PCT is doing to improve access to NHS dentistry Oral health of children Customer satisfaction Emergency/out of hours provision

3. 17 th November 2008 Primary Dental Services (2003 Act) PCT has a duty to provide or secure primary dental services to the extent it considers reasonable through: GDS contracts; PDS contracts; or provides them itself

4. 17 th November 2008 Commissioning for Oral Health Influence over where new practices establish Stronger local relationship with NHS dentists Commissioning to meet oral health needs of population Commissioning to more explicitly address access

5. 17 th November 2008 Mandatory Services All proper and necessary care and treatment which includes: - the care which a dental practitioner usually undertakes for a patient and which the patient is willing to undergo, including advice and planning of treatment - treatment, including urgent treatment -..the referral of the patient for advanced mandatory services, domiciliary, sedation…..

6. 17 th November 2008 Care and Treatment Examination Diagnosis Preventive care and treatment Periodontal treatment Conservative treatment Surgical treatment Supply and repair of dental appliances Radiographs Supply of listed drugs Issue of prescriptions

7. 17 th November 2008 Patient charges PCT dental commissioning from April 2006 Changes in patients’ charges –Simpler (3 not 400) –Avoids confusion on private/NHS boundary –Breaks link between dentists’ remuneration and charges Money devolved on practice base, not by address of patient

8. 17 th November 2008 This charge will include an examination, diagnosis and preventive advice. If necessary, this will include X-rays, scale and polish if needed, and planning for further treatment. Urgent and out-of-hours care will also cost £16.20 Patient Charge Bands-Band 1 £16.20

9. 17 th November 2008 Band 2 - £44.60 This charge includes all necessary treatment covered by the £16.20 charge PLUS additional treatment such as fillings, root canal treatment or extractions.

10. 17 th November 2008 Band 3 - £198 This charge includes all necessary treatment covered by the £16.20 and £44.60 charges PLUS more complex procedures such as crowns, dentures or bridges.

11. 17 th November 2008 Population per dentist E&North Herts compared with the East of England SHA and England

12. 17 th November 2008 Population per dentist West Herts compared with the East of England SHA and England

13. 17 th November 2008 Dental contracts in Hertfordshire Number of contracts Number of dentists Number of practices West Herts142367117 East & North Herts 12330088 Total265667205

14. 17 th November 2008 Geographical Access to general dental practices in East and North Hertfordshire, 3 miles and 12 miles distances

15. 17 th November 2008 Geographical Access to general dental practices in East and North Hertfordshire, 5 miles and 12 miles distances

16. 17 th November 2008 Geographical Access to general dental practices in West Hertfordshire, 3 miles and 12 miles distances

17. 17 th November 2008 September 08 telephone audit indicated that 62% of practices in E & North Hertfordshire PCT are currently accepting new NHS patients, however Number of patients treated in the previous 24 months period March 2006328,002 March 2007332,184 June 2007329,488 December 2007320,112 March 2008316,396 June 2008316,195 September 2008317,253 % Change since March 2006 -3.3%

18. 17 th November 2008 September 08 telephone audit indicated that 64% of practices in West Hertfordshire PCT are currently accepting new NHS patients, however Number of patients treated in the previous 24 months period March 2006314,537 March 2007307,439 June 2007301,249 December 2007286,192 March 2008275,014 June 2008272,074 September 2008271,659 % Change since March 2006 -13.6%

19. 17 th November 2008

20. Distribution of courses of treatment October to December 2007 East and North Hertfordshire

21. 17 th November 2008 Distribution of courses of treatment October to December 2007 West Hertfordshire

22. 17 th November 2008

24. The Proportion of Adults with No Natural Teeth in England, 1968-1998 Source:National Adult Dental Health Surveys, 1968 to 1998. Kelly M, Steele J, Nuttall N, Bradnock G, Morris J, Nunn J, Pine C, Pitts N, Treasure E and White D (2000).

25. 17 th November 2008 Orthodontics: waiting times at October 08 Practice location Length of time to first assessment appointment Length of time to case start Referral to treatment time Bishop’s Stortford 10-12 months4-8 weeks12-14 months Royston4 weeks4-8 weeks12 weeks Ware6 months30 months3 years Hitchin6 weeks4 weeks10 weeks Stevenage10 weeks3-12 weeks22 weeks Source: Practice based Data

26. 17 th November 2008 Orthodontics: waiting times at October 08 Practice locationLength of time to 1 st assessment Length of time to case start Referral to treatment time Boreham Wood2-3 weeks44-50 weeks1 year St Albans1 week2 years Tring3 months4 months7 months Rickmansworth6 weeks 12 weeks Hemel Hempstead4 months6 months10 months Hemel HempsteadNot accepting8 weeks Harpenden1-14 weeks 28 weeks Harpenden11 weeks8 weeks19 weeks Watford12 weeks6-8 weeks20 weeks Watford4-6 weeks 12 weeks Watford0-7 weeks6-24 weeks31 weeks

27. 17 th November 2008 Emergency Dental Services: Hertfordshire NHS Direct Triage: July 06 to June 07 Call VolumeNo of Calls Calls Answered9071 Symptomatic5954 Health Information40 Other834 Clinical Sorting of symptomatic callsNo of Calls 999 - (Emergency)41 (0.68%) A & E - (Emergency)131 (2.2%) Contact Dentist - <1 hour177 (2.9%) Contact Dentist - <4 hours2255 (37.8%) Contact Dentist - Routine Appointment2113 (35.4%) Contact Orthodontist84 (1.4%) Homecare and Pharmacy1137 (19%) Contact GP109 (1.8%) Other9 (0.15%)

28. 17 th November 2008 Emergency Dental Services: Hertfordshire NHS Direct Triage: September 08 Call VolumeNo of Calls Calls Answered631 Symptomatic478 Health Information9 Other51 Clinical Sorting of symptomatic callsNo of Calls 999 - (Emergency)0 (0.0%) A & E - (Emergency)6 (1.0%) Contact Dentist - <1 hour14 (2.2%) Contact Dentist - <4 hours181 (28.7%) Contact Dentist - Routine Appointment133 (21.1%) Contact Orthodontist6 (1.0%) Homecare and Pharmacy129 (20.4%) Contact GP9 (1.4%) Other0 (0.0%)

29. 17 th November 2008 In hours urgent slots Welwyn Garden City – daily Stevenage – daily Hitchin – daily South East Herts St Albans, Harpenden, Redbourn Borehamwood, Bushey Watford, Rickmansworth Tring, Hemel Hempstead, Bovingdon

30. 17 th November 2008 Responses to Patient Questionnaires on time taken to get a dental appointment, April 2007 to September 2008 Patient’s opinion of time taken to get appointment E& N Herts West Herts number % % It was as soon as was necessary 1,30987.21%1,33887.57% It should have been a bit sooner 1057.00%986.41% It should have been much sooner 231.53%271.77% No response 644.26%624.06% Invalid 00.00%30.20% Total, Samples: 2,779 and 2,778 1,501100.00%1,528100.00% Source: DSD data

31. 17 th November 2008 Responses to Patient Questionnaires on Patient’s Satisfaction with Dentistry Received, April 2007 to September 2008. Source DSD statistics Patient’s satisfaction with dentistry received E& N Herts West Herts Number% % Completely satisfied1,106 73.68%1,138 74.48% Fairly satisfied275 18.32%278 18.19% Fairly dissatisfied35 2.33%32 2.09% Very dissatisfied26 1.73%24 1.57% No response57 3.80%53 3.47% Invalid2 0.13%3 0.20% Total: Samples: 2,779 and 2,778 1,501100.00%1,528100.00%

32. 17 th November 2008 Responses to Patient Questionnaires on Patient’s Understanding of NHS/Private Dentistry Received, April 2007 to September 2008. Patient's understanding of treatment provided E& N HertsWest Herts Number% % Invalid70.47%130.85% No response503.33%493.21% Just NHS treatment1,30787.08%1,31385.93% Combination of NHS and Private704.66%986.41% All Private treatment90.60%60.39% Unsure583.86%493.21% Total Samples: 2,779 and 2,778 1,501100.00%1,528100.00% Source DSD statistics

33. 17 th November 2008 East & North Hertfordshire PCT residents patient flow report from April 2008 to June 2008 (Flow Out) Health Body Number of patients % of patientsUDAUOA E & N Hertfordshire77,85990.20%170,267.357,354.20 Enfield2,2882.70%4,992.80942 W Hertfordshire2,2012.50%4,449.101,497 Non neighbouring1,6281.90%3,919.75187 West Essex1,3891.60%2,869.70167 Cambridgeshire5160.60%991.353 Luton4000.50%1,003.201 Bedfordshire3100.40%563.4069.8 Total outflow8,73210.20%18,789.302866.8

34. 17 th November 2008 Patients treated in East & North Hertfordshire PCT patient flow report from April 2008 to June 2008 (Flow In) Health Body Number of patients % of patientsUDAUOA E & N Hertfordshire77,85980.20%170,267.357,354.20 West Essex4,8325.00%10,229.80521 Bedfordshire3,7063.80%7,680.00890 W Hertfordshire2,8502.90%5,830.504 Unknown2,6532.70%5,834.70412 Cambridgeshire2,2962.40%4,047.00454 Non neighbouring1,4481.50%3,250.0578 Enfield1,1721.20%3,305.6078 Luton2210.20%436.75202 Total outflow19,17819.70%40,614.402639

35. 17 th November 2008 West Hertfordshire PCT residents patient flow report from April 2008 to June 2008 (Flow Out) Health Body Number of patients% of patientsUDAUOA West Hertfordshire68,85386.00%148,285.3012,044.00 E & N Hertfordshire2,8503.60%5,830.504 Non neighbouring1,9852.50%4,701.0051 Harrow1,8872.40%3,844.6571 Hillingdon1,7222.20%3,698.85180 Barnet1,4371.80%2,674.001,160 Buckinghamshire7390.90%1,255.6586 Enfield4920.60%1,117.5050 Bedfordshire3110.40%735.1064 Total outflow11,42314.40%23,857.251666 Source: DSD Statistics

36. 17 th November 2008 Patients treated in West Hertfordshire PCT patient flow report from April 2008 to June 2008 (Flow In) Health Body Number of patients% of patientsUDAUOA West Hertfordshire68,85384.80%148,285.0012,044.00 Buckinghamshire3,1433.90%6.551,333 E & N Hertfordshire2,2012.70%4,449.101,497 Non neighbouring1,9442.40%3,635.001,266 Unknown1,8172.20%4,133.45235 Bedfordshire1,4031.70%2,384.901,351 Harrow7390.90%1,592.9538 Barnet6160.80%1,368.053 Hillingdon3630.40%677.75223 Enfield1000.10%262.200 Total inflow12,32615.10%18,509.955,946 Source: DSD Statistics

37. 17 th November 2008 Oral Health in Children 2005/06 Average number of decayed, missing and filled teeth in 5 year old children Source: Surveys co-ordinated by the British Association for the Study of Community Dentistry

38. 17 th November 2008 The proportion of 5-Year Old children with experience of caries, Nationally, Regionally and Locally 2005 to 2006 Source: Surveys co-ordinated by the British Association for the Study of Community Dentistry

39. 17 th November 2008 School Dental Inspections Research in the 1980s started to question the aims and effectiveness of the screening examinations. The results of a large Randomised Control Trial have demonstrated that school dental screening is ineffective at a population level in reducing levels of untreated disease and increasing attendance of those who need treatment.

40. 17 th November 2008 On 7 November 2006, the UK National Screening Committee recommended to the UK Chief Dental Officers that there is no evidence to support the continued population screening for dental disease among children aged 6 to 9 years. The Committee’s recommendation was based in part on the view that the resources currently used for screening could be used more effectively in other ways to tackle oral health inequalities

41. 17 th November 2008 Improving Children’s Oral Health Requires partnership working from the following stakeholders: Dental teams Public Health specialists Oral Health Promotion Team Health visitors Health improvement specialists Sure start and children’s’ centres Healthy schools programmes Local authorities Voluntary groups

42. 17 th November 2008 Oral Health Promotion Activities Aimed at Reducing Oral Health Inequalities in Young Children TOPICFOCUSGOOD PRACTICE DIET AND NUTRITION INFANT FEEDING  Promote breastfeeding  Coma recommendations  Oral Health input into local infant feeding strategies and guidelines POLICY GUIDELINES  Promote the development and adoption of nutrition and healthy eating guidelines SUGAR CONTENT  Discourage addition of sugars to weaning foods/drinks and vitamin supplements  Encourage reduction in sugar content of soft drinks/breakfast cereals, confectionary, etc.  Encourage caterers to reduce sugars in prepared foods  Encourage vending machine providers to include sugar-free choices PUBLIC INFORMATION AND SUPPORT  Improve consistency of all dietary messages re: importance of reducing the frequency of consumption of sugary drinks and foods  Ensure effective dietary education for those at risk of dental caries and erosion  Restriction of promotion of food and drinks high in sugar, particularly for children ORAL HYGIENE EARLY TOOTHBRUSHING  Encourage parents and carers to start toothbrushing with fluoride toothpaste within the first year of a child’s life BODY AND ORALHYGIENE  Incorporate oral hygiene teaching into Personal and Social Education teaching TRAINING AND SUPPORT  Improve the effectiveness of oral hygiene instruction provided by oral and health professional

43. 17 th November 2008 Hertfordshire Oral Health Strategy and Commissioning Group Primary & Secondary dental care commissioning is outside of Practice Based Commissioning Integrated approach to budget and decision making Engagement of primary and secondary care clinicians in assessing needs, developing care pathways and commissioning decisions Lay representation

44. 17 th November 2008 Dept of Health additional growth funding 08-09 Indicative Gross Allocation £000s Indicative Patient Charge Revenue £000s Net Allocation £000s UDAs – Indicative Planning Assumpti on East & North Hertfordshire PCT 1,2922581,03455,355 West Hertfordshire PCT 1,9986001,39879,945

45. 17 th November 2008 Additional Growth from PCTs West Hertfordshire and East and North Hertfordshire PCTS have added an additional recurring allocation to total £2million to further improve access to general dental services

46. 17 th November 2008 West Herts - Hertsmere Practices in Potters Bar, Borehamwood and Bushey have received the following additional growth: 2008-0916,700 Units of Dental Activity 5,567 patients 2009-1031,400 UDAs10,467 patients

47. 17 th November 2008 West Herts – St Albans and Harpenden 2008-0918,500 Units of Dental Activity 6,167 patients 2009-1036,400 UDAs12,133 patients Practices in London Colney, St Albans and Harpenden have received the following additional growth:

48. 17 th November 2008 West Herts- Watford and 3 Rivers Practices in Watford, Rickmansworth, Croxley Green, Chorleywood and Abbots Langley have received the following additional growth 2008- 0915,275 Units of Dental Activity 5,092 patients 2009-1036,325 UDAs12,108 patients

49. 17 th November 2008 West Herts- Dacorum Practices in Tring and Hemel Hempstead have received the following additional growth: 2008- 095,600 Units of Dental Activity 1,867 patients 2009-1014,000 UDAs4,667patients

50. 17 th November 2008 East and North Herts – SE Herts Practices in Ware, Hoddesden, Waltham Cross, Hertford, Flamstead End, Cuffley and Cheshunt have received the following additional growth: 2008- 0922,550 Units of Dental Activity 7,517 patients 2009-1035,400 UDAs11,800 patients

51. 17 th November 2008 East and North Herts – N Herts & Stevenage Practices in Baldock, Stevenage, Hitchin and Letchworth have received the following additional growth: 2008- 0921,465 Units of Dental Activity 7,155 patients 2009-1044,980 UDAs14,993 patients

52. 17 th November 2008 East and North Herts – Welwyn/Hatfield Practices in Welwyn Garden City, Hatfield, Panshanger and Welham Green have received the following additional growth: 2008- 096,400 Units of Dental Activity 2,133 patients 2009-1017,424 UDAs5,808 patients

53. 17 th November 2008 East and North Herts- RBBS Practices in Bishop’s Stortford and Buntingford have received the following additional growth funding: 2008- 098,800 Units of Dental Activity 2,933 patients 2009-1018.102 UDAs6,034 patients

54. 17 th November 2008 Total Hertfordshire Growth allocated to date West Hertfordshire PCT 2008-0956,075 UDAs18,693 patients£1,345,800 2009-10118,125 UDAs39,375 patients£2,835,000 East and North Hertfordshire PCT 2008-0959,215 UDAs19,738 patients£1,421,160 2009-10115,904 UDAs38,635 patients£2,781,744

55. 17 th November 2008 Supporting Patient Access PCT telephone number for information Up to date information on individual practice’s capacity NHS Choices website Increasing public awareness Communications plan (December 2008)

56. 17 th November 2008 Reconfiguration of Acute Services In patient beds for oral and maxillofacial surgery were centralised at Luton & Dunstable Hospital in 2004. This serves Bedfordshire, Luton, east and North Herts and the northern part of West Herts. Most oral surgery and all orthodontics is undertaken as out patient or day stay at the local district general hospital Reconfiguration will have little effect