17th November 2008

Dentistry and Oral Health in East and North Hertfordshire and West Hertfordshire PCTs

Jane RobinsonPrimary Care Commissioning Lead

Sue GregoryConsultant in Dental Public Health

17th 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

17th 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

17th November 2008

Commissioning for Oral Health

Influence over where new practices establish

Influence over where new practices establish

  

Stronger local relationship with NHS dentists

Stronger local relationship with NHS dentists

Commissioning to meet oral health needs of population

Commissioning to meet oral health needs of population

Commissioning to more explicitly address access

Commissioning to more explicitly address access

17th 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…..

17th 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

17th 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

17th 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

17th 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.

17th 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.

17th November 2008

Population per dentist15, 2006/07 and 2007/08

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2006/07 2007/08

Population per dentist E&North Herts compared with the East of England SHA and

England

17th November 2008

Population per dentist West Herts compared with the East of England SHA and England

Population per dentist15, 2006/07 and 2007/08

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500

1,000

1,500

2,000

2,500

3,000W

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17th November 2008

Dental contracts in Hertfordshire

Number of

contracts

Number of

dentists

Number of

practices

West Herts 142 367 117

East & North Herts

123 300 88

Total 265 667 205

17th November 2008

Geographical Access to general dental practices in East and North Hertfordshire,3 miles and 12 miles distances

17th November 2008

Geographical Access to general dental practices in East and North Hertfordshire, 5 miles and 12 miles distances

17th November 2008

Geographical Access to general dental practices in West Hertfordshire, 3 miles

and 12 miles distances

17th 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 2006 328,002

March 2007 332,184

June 2007 329,488

December 2007 320,112

March 2008 316,396

June 2008 316,195

September 2008 317,253

% Change since March 2006

-3.3%

17th November 2008

September 08 telephone audit indicated that 64% of practices in West Hertfordshire PCT are currently accepting new NHS patients,

howeverNumber of patients treated in the previous 24 months period

March 2006 314,537

March 2007 307,439

June 2007 301,249

December 2007 286,192

March 2008 275,014

June 2008 272,074

September 2008 271,659

% Change since March 2006

-13.6%

17th November 2008

Total number1 of patients2 seen as a percentage of the population

in the previous 24 months ending at the specified dates4,5,7

0%

10%

20%

30%

40%

50%

60%

70%

80%

East & NorthHertfordshire PCT

East of England SHA England

31 March 2006 31 December 2007

17th November 2008

Proportion of Courses of Treatment, October - December 20071

0%

10%

20%

30%

40%

50%

60%

Band 1 Band 2 Band 3 Urgent Other

East & North Hertfordshire PCT East of England SHA England

Distribution of courses of treatment October to December 2007

East and North Hertfordshire

17th November 2008

Distribution of courses of treatment October to December 2007

West HertfordshireProportion of Courses of Treatment, October -

December 20071

0%

10%

20%

30%

40%

50%

60%

Band 1 Band 2 Band 3 Urgent Other

West Hertfordshire PCT East of England SHA England

17th November 2008

Proportion of dentists by age band as at 31 March 2007East and North Hertfordshire

52% 47% 48%

48% 52%53%

0%

20%

40%

60%

80%

100%

East & NorthHertfordshire PCT

East of England SHA England

39 and under 40 and over

17th November 2008

Proportion of dentists by age band as at 31 March 2007West Hertfordshire

47% 47% 48%

53% 52%53%

0%

20%

40%

60%

80%

100%

West HertfordshirePCT

East of England SHA England

39 and under 40 and over

17th November 2008

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).

17th 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 months 4-8 weeks 12-14 months

Royston 4 weeks 4-8 weeks 12 weeks

Ware 6 months 30 months 3 years

Hitchin 6 weeks 4 weeks 10 weeks

Stevenage 10 weeks 3-12 weeks 22 weeks

Source: Practice based Data

17th November 2008

Orthodontics: waiting times at October 08

Practice location Length of time to 1st assessment

Length of time to case start

Referral to treatment time

Boreham Wood 2-3 weeks 44-50 weeks 1 year

St Albans 1 week 2 years 2 years

Tring 3 months 4 months 7 months

Rickmansworth 6 weeks 6 weeks 12 weeks

Hemel Hempstead 4 months 6 months 10 months

Hemel Hempstead Not accepting 8 weeks 8 weeks

Harpenden 1-14 weeks 1-14 weeks 28 weeks

Harpenden 11 weeks 8 weeks 19 weeks

Watford 12 weeks 6-8 weeks 20 weeks

Watford 4-6 weeks 4-6 weeks 12 weeks

Watford 0-7 weeks 6-24 weeks 31 weeks

17th November 2008

Emergency Dental Services: Hertfordshire NHS Direct Triage: July 06 to June 07Call Volume No of Calls

Calls Answered 9071

Symptomatic 5954

Health Information 40

Other 834

Clinical Sorting of symptomatic calls No of Calls

999 - (Emergency) 41 (0.68%)

A & E - (Emergency) 131 (2.2%)

Contact Dentist - <1 hour 177 (2.9%)

Contact Dentist - <4 hours 2255 (37.8%)

Contact Dentist - Routine Appointment 2113 (35.4%)

Contact Orthodontist 84 (1.4%)

Homecare and Pharmacy 1137 (19%)

Contact GP 109 (1.8%)

Other 9 (0.15%)

17th November 2008

Emergency Dental Services: Hertfordshire NHS Direct Triage:

September 08Call Volume No of Calls

Calls Answered 631

Symptomatic 478

Health Information 9

Other 51

Clinical Sorting of symptomatic calls No of Calls

999 - (Emergency) 0 (0.0%)

A & E - (Emergency) 6 (1.0%)

Contact Dentist - <1 hour 14 (2.2%)

Contact Dentist - <4 hours 181 (28.7%)

Contact Dentist - Routine Appointment 133 (21.1%)

Contact Orthodontist 6 (1.0%)

Homecare and Pharmacy 129 (20.4%)

Contact GP 9 (1.4%)

Other 0 (0.0%)

17th 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

17th 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 % number %

It was as soon as was necessary 1,309 87.21% 1,338 87.57%

It should have been a bit sooner 105 7.00% 98 6.41%

It should have been much sooner 23 1.53% 27 1.77%

No response 64 4.26% 62 4.06%

Invalid 0 0.00% 3 0.20%

Total, Samples: 2,779 and

2,778

1,501 100.00% 1,528 100.00%

Source: DSD data

17th 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 % Number %

Completely satisfied 1,106 73.68% 1,138 74.48%

Fairly satisfied 275 18.32% 278 18.19%

Fairly dissatisfied 35 2.33% 32 2.09%

Very dissatisfied 26 1.73% 24 1.57%

No response 57 3.80% 53 3.47%

Invalid 2 0.13% 3 0.20%

Total: Samples: 2,779 and 2,778

1,501 100.00% 1,528 100.00%

17th 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 Herts West HertsNumber % Numbe

r%

Invalid 7 0.47% 13 0.85%

No response 50 3.33% 49 3.21%

Just NHS treatment 1,307 87.08% 1,313 85.93%

Combination of NHS and Private 70 4.66% 98 6.41%

All Private treatment 9 0.60% 6 0.39%

Unsure 58 3.86% 49 3.21%

Total Samples: 2,779 and 2,778

1,501 100.00% 1,528 100.00%

Source DSD statistics

17th November 2008

East & North Hertfordshire PCT residents patient flow report from April 2008 to June 2008 (Flow Out)

Health Body

Number of patients

% of patients UDA UOA

E & N Hertfordshire 77,859 90.20% 170,267.35 7,354.20

Enfield 2,288 2.70% 4,992.80 942

W Hertfordshire 2,201 2.50% 4,449.10 1,497

Non neighbouring 1,628 1.90% 3,919.75 187

West Essex 1,389 1.60% 2,869.70 167

Cambridgeshire 516 0.60% 991.35 3

Luton 400 0.50% 1,003.20 1

Bedfordshire 310 0.40% 563.40 69.8

Total outflow 8,732 10.20% 18,789.30 2866.8

17th 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 patients UDA UOA

E & N Hertfordshire 77,859 80.20% 170,267.35 7,354.20

West Essex 4,832 5.00% 10,229.80 521

Bedfordshire 3,706 3.80% 7,680.00 890

W Hertfordshire 2,850 2.90% 5,830.50 4

Unknown 2,653 2.70% 5,834.70 412

Cambridgeshire 2,296 2.40% 4,047.00 454

Non neighbouring 1,448 1.50% 3,250.05 78

Enfield 1,172 1.20% 3,305.60 78

Luton 221 0.20% 436.75 202

Total outflow 19,178 19.70% 40,614.40 2639

17th November 2008

West Hertfordshire PCT residents patient flow report from April 2008 to June 2008 (Flow Out)

Health Body

Number of patients % of patients UDA UOA

West Hertfordshire 68,853 86.00% 148,285.30 12,044.00

E & N Hertfordshire 2,850 3.60% 5,830.50 4

Non neighbouring 1,985 2.50% 4,701.00 51

Harrow 1,887 2.40% 3,844.65 71

Hillingdon 1,722 2.20% 3,698.85 180

Barnet 1,437 1.80% 2,674.00 1,160

Buckinghamshire 739 0.90% 1,255.65 86

Enfield 492 0.60% 1,117.50 50

Bedfordshire 311 0.40% 735.10 64

Total outflow 11,423 14.40% 23,857.25 1666

Source: DSD Statistics

17th 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 patients UDA UOA

West Hertfordshire 68,853 84.80% 148,285.00 12,044.00

Buckinghamshire 3,143 3.90% 6.55 1,333

E & N Hertfordshire 2,201 2.70% 4,449.10 1,497

Non neighbouring 1,944 2.40% 3,635.00 1,266

Unknown 1,817 2.20% 4,133.45 235

Bedfordshire 1,403 1.70% 2,384.90 1,351

Harrow 739 0.90% 1,592.95 38

Barnet 616 0.80% 1,368.05 3

Hillingdon 363 0.40% 677.75 223

Enfield 100 0.10% 262.20 0

Total inflow 12,326 15.10% 18,509.95 5,946

Source: DSD Statistics

17th November 2008

Oral Health in Children 2005/06Average number of decayed, missing and filled teeth in 5

year old children

1.47

1.13

0.9

1.78

1.231.29

0

0.4

0.8

1.2

1.6

2

ENGLAND East ofEngland

Bedfordshire Luton E & N Herts West Herts

Source: Surveys co-ordinated by the British Association for the Study of Community Dentistry

17th November 2008

The proportion of 5-Year Old children with experience of caries, Nationally, Regionally

and Locally 2005 to 2006

41.1

26.7

32.1

3834.1 34.8

0

10

20

30

40

50

Source: Surveys co-ordinated by the British Association for the Study of Community Dentistry

17th 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.

17th 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

17th November 2008

Improving Children’s Oral HealthRequires 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

17th November 2008

Oral Health Promotion Activities Aimed at Reducing

Oral Health Inequalities in Young Children TOPIC FOCUS GOOD PRACTICE

DIE

T A

ND

NU

TR

ITIO

N

INFANT FEEDING Promote breastfeeding Coma recommendations Oral Health input into local infant feeding strategies and guidelines

POLICYGUIDELINES

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

PUBLICINFORMATION 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

OR

AL

HY

GIE

NE

EARLYTOOTHBRUSHING

Encourage parents and carers to start toothbrushing with fluoride toothpaste within the first year of a child’s life

BODY ANDORALHYGIENE

Incorporate oral hygiene teaching into Personal and Social Education teaching

TRAINING ANDSUPPORT

Improve the effectiveness of oral hygiene instruction provided by oral and health professional

17th 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

17th 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

1,292 258 1,034 55,355

West Hertfordshire PCT

1,998 600 1,398 79,945

17th 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

17th November 2008

West Herts - Hertsmere

Practices in Potters Bar, Borehamwood and Bushey have received the following additional growth:

2008-09 16,700 Units of Dental Activity

5,567 patients

2009-10 31,400 UDAs

10,467 patients

17th November 2008

West Herts – St Albans and Harpenden

2008-09 18,500 Units of Dental Activity

6,167 patients

2009-10 36,400 UDAs 12,133 patients

Practices in London Colney, St Albans and Harpenden have received the following additional growth:

17th November 2008

West Herts- Watford and 3 Rivers

Practices in Watford, Rickmansworth, Croxley Green, Chorleywood and Abbots Langley have received the following additional growth2008- 09 15,275 Units

of Dental Activity

5,092 patients

2009-10 36,325 UDAs 12,108 patients

17th November 2008

West Herts- Dacorum

Practices in Tring and Hemel Hempstead have received the following additional growth:2008- 09 5,600 Units of

Dental Activity

1,867 patients

2009-10 14,000 UDAs 4,667patients

17th November 2008

East and North Herts – SE HertsPractices in Ware, Hoddesden,

Waltham Cross, Hertford, Flamstead End, Cuffley and Cheshunt have received the following additional growth:2008- 09 22,550 Units

of Dental Activity

7,517 patients

2009-10 35,400 UDAs 11,800 patients

17th November 2008

East and North Herts – N Herts & Stevenage Practices in Baldock, Stevenage,

Hitchin and Letchworth have received the following additional growth:2008- 09 21,465 Units

of Dental Activity

7,155 patients

2009-10 44,980 UDAs 14,993 patients

17th 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- 09 6,400 Units of

Dental Activity

2,133 patients

2009-10 17,424 UDAs 5,808 patients

17th November 2008

East and North Herts- RBBSPractices in Bishop’s Stortford and Buntingford have received the following additional growth funding:

2008- 09 8,800 Units of Dental Activity

2,933 patients

2009-10 18.102 UDAs 6,034 patients

17th November 2008

Total Hertfordshire Growth allocated to date

West Hertfordshire PCT

2008-09

56,075 UDAs

18,693 patients

£1,345,800

2009-10

118,125 UDAs

39,375 patients

£2,835,000

East and North Hertfordshire PCT

2008-09

59,215 UDAs

19,738 patients

£1,421,160

2009-10

115,904 UDAs

38,635 patients

£2,781,744

17th 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)

17th 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