What a difference a year makes…
Over a year after her appointment as CDO for England, Seb Evans speaks to Sara Hurley about how the last 18 months have gone and her plans for the future.
Sara Hurley was appointed the new chief dental officer (CDO) for NHS England 18 months ago. When she first came into the role she was described as ‘a breath of fresh air’. Coming from outside the NHS with a military background, Sara would bring a new perspective to the NHS. The announcement was surrounded by a sea of optimism as Sara spoke publicly about how she wanted to ‘put the mouth back in the body’ and remind politicians about the importance of dentistry.
Despite all that pressure and optimism, things seem to have gone a little quiet on the CDO front since then.
Despite appearing at numerous conferences and exhibitions, very little seems to have changed. Chancellor Philip Hammond failed to offer any further funding to NHS dentistry and the finishing date for the prototypes contracts seems to be being pushed further and further back.
‘I didn’t necessarily recognise in my early couple of months, before Eric and Janet came on, that the office of CDO was very much made up of one or two people,’ Sara explained. ‘We are now the office of CDO with partnerships.
‘I like the idea that there are lots of programmes going on in different areas. People are very good at delivering their own particular programmes. What nobody was necessarily doing or had been set up to do was to look across the whole piece. I believe we now have that portfolio. When I can see that the FGDP are doing something, at the same time I understand that HEE need to be delivering the enabler to make that happen, the BSA is making sure it’s working off the same hymn sheet, is there a piece of software that could be developed or is there a part of the NHS Digital work stream that could help? We now look at that.
‘I wouldn’t say it’s so grand that we’re conducting the orchestra because we’re not. I think there’s a series of bands in the room, they might be playing slightly different tunes, but at least we’ve got the beat now, and I think we’re more in harmony.’
Sara’s team has been busy building relationships with all the bodies across the profession. That way the office of CDO can help advise bodies which direction to turn, so everybody is ‘singing from the same hymn sheet’. Does that mean raising oral health up the political agenda has been forgotten about? Well as Sara says dentistry ‘always seems to get a bit of a kicking, we’re an easy target.’ But as she points out, the agenda for the politicians at the moment has been dominated by medical and junior doctor colleagues, making it more difficult to get any positive press for dentistry. ‘Today the radio was saying you can’t get GP appointments out of hours,’ Sara said. ‘The irony is, although we have people turning up at GP surgeries for dental problems, you can usually get a dental appointment far more easily than you can get a GP appointment. But this is something we’re taking back to the commissioners to address.’ Despite seemingly not having much success in raising the profile of oral health in politicians’ eyes, it still is very much a part of her plan, it’s just a matter of getting the timing right.
The prototype contracts have been going for six months now. Before this there was the pilot phase, which lasted from 2011 until March 2016. Eric Rooney explained that there are 79 practices taking part in the prototype contracts and they fall into two blends – blend A and blend B. The differences between the two blends is the way dentists are remunerated for their work. With blend A, capitation remuneration (the amount paid to look after a patient for the year, irrespective of the amount of work you do for the patient) covers band one type activity in the current GDS contract (your check-ups, scale and polish, assessment, etc). Everything currently delivered under band two and three will be remunerated through units of dental activity (UDAs). With blend B, this time the capitation, the amount you get to cover the year’s worth of things you do for the patient, covers what in the GDS would normally be band one and band two. It’s not just a check-up, the assessment and prevention, but it’s also fillings, extractions and other things in band two as well. The only amount that is paid for under UDAs is what the GDS would pay for through band three, so that’s crowns and bridges, etc.
These two blends are what the prototypes are testing. Dentists have been crying out for a new contract seemingly since 2006, when the previous change was introduced. So, what has been taking so long?
‘What I think is important is that this is about moving forward with a potential for this contract to be rolled out further,’ Eric Rooney, deputy chief dental officer, said. ‘Any new joiners to the programme from now on, would not be starting from the position the pilot practices have come into this.’ Eric continued by explaining that the office of CDO wants to get this right first time and that it takes time to try and test all the new aspects of the contract.
In 2006 there was an overnight switch to the new dental contract, which didn’t seem to fit any prototype that had been mentioned before that. Could this happen again or will one of the current blends of prototype make up the final contract? Well, nobody can honestly say. The new contract is a collaborative effort with the office of CDO, the BDA, the Department of Health (DH), the Care Quality Commission and NHS England all sat around the table.
However, Sara was quick to point out: ‘It’s for us to commit to learning as much as possible on the way, whether it be from what happened in 2006 in terms of the introduction, what we’ve learnt from the pilots and what we’ve learnt from the first six months of the prototypes. We’ve seen oral health improve, we saw what fee per item was good for, the issue behind the 2006 contract, with what they knew, it was admirable. What we have learnt is with introducing a new contract, we need to include the profession. Not everyone will be happy with the final outcome, but oral health has moved on. We need a new model of care. I think the collaborative approach from all the agencies and having the patient at the heart of this is the most vital thing we can do. It’s an overdue change but we don’t want to rush it.’
There have also been rumours of clawbacks for prototype practices not reaching their allocated number of patients seen. When pressed on this, Eric pointed out that any decisions on clawbacks would be a matter for the NHS England commissioning system.
When will the new contract be delivered?
There are numerous rumours going around about the contract delivery date, the latest being that the contract will be rolled out in March 2018. When pushed on this Sara pointed out that all the information is available for everyone to see. Eric explained: ‘There’s a standard guide. Basically, we’re in the prototype phase at the minute, we’ve started the evaluation. That will take a year’s worth of activity to really get some good quality views. We are undertaking an interim report at the moment just to take the temperature of where things are at, and the purpose of that is to provide some support for the programme board to take a view about 2017, to begin extending this.
The timetable that is on the slides that we’re using talks about 2018/19 as a potential, only a potential, for rolling it out a bit further after that.’ But unlike in 2006, Eric was quick to point out that they’re after a more gradual introduction rather than a ‘big bang’ change.
‘Just imagine a series of ink blots around the country starting to expand out,’ Sara said. ‘We’re looking for the optimal rollout and we’ll be suggesting it to DH. Of course, it’s NHS England that will ultimately own the offering of the contracts. It will ultimately be practitioners that decide whether they’re going to accept that contract or not.
‘Our ambition is to move to a capitation, registration model. It’s not about is it blend A or B, it’s probably going to be a combination of things. How do we move away from the UDAs, what is the activity and how do you recognise, record and remunerate the activity? We want a good outcome and we don’t want to rush this.’
Reducing extractions under general anaesthetic
Figures last year were released showing 14,445 children under five were admitted to hospital for extractions under general anaesthetic. It’s the main reason children are admitted to hospital in England.
There are lots of different people involved in tackling this and helping to halt those rising numbers, but like Sara says ‘Prevention is necessary, but it’s something that can be driven by the dental community.’ Getting children in for regular visits is the main way Sara believes dentists can help to tackle the extraction crisis. ‘That’s where Smile4life comes in, which looks at how can we be a bit more innovative and make sure capacity is available locally. The other thing is practitioners being ready and willing to take the patient who walks through the door, be recognised and remunerated for that.’
Smile4life will be launching in England in September. It is a combination of schemes that are all designed to help improve the nation’s oral health. ‘Whether it be Teeth Team in Hull, or Smile4life up in Cumbria, can we bring all these fabulous people together, start sharing their ideas and have a kite mark? It’s going to be an umbrella of programmes. If we can then have some more national partners to help us spread it, give us an identity and tie in with Public Health England’s Change4life, their programme about sugars, that’s the real concept behind it.’
There have been improvements in oral health in England and Sara points to the dental profession as major contributors to that, along with fluoride toothpaste and diet. ‘It’s those little hard to reach groups. It’s a collaborative effort.’
The sugar tax has been brought in by the government primarily to tackle obesity in children. It often feels like oral health is left out of the sugar tax discussion despite it potentially having a hugely positive impact. ‘If the outcome is that we get a sugar tax that reduces the amount of sugar and encourages individuals not to pick up that can of fizzy pop and look for an alternative, then that’s absolutely fantastic,’ Sara pointed out. ‘In this case we were intimately involved with the production of the policy guide that originally sat on David Cameron’s desk. The whole document got considerably shrunk down. We’ve learnt a lot about how we get our foot in the door, and we’re now recognised faces and contributors.
‘We’ve ended up with a sugar tax, it’s not the only piece of work that’s going to help us improve the health of the nation and improve the oral health at the same time. It’s something, and it’s one of the multiple strands. Does it need oral health and dental on there? Would have been nice, but it’s delivered us an outcome, we’re now looking for the next area to focus our efforts.’
Increasing dentist visits
Recent figures from NHS Digital showed that almost half (48.3%) of adults in England haven’t seen an NHS dentist in the last two years. The BDA has pointed to patient charges as a way to ‘lower demand for NHS dentistry’ and with patient charges set to rise, that figure could get worse.
‘It’s not within our gift to be able to go and say stop charges,’ Sara explained, pointing to the huge gap in the NHS budget. ‘We have and continue to be advocates for explaining why in many cases charges will be one of the hurdles that stop people attending. Having said that, when you look at the fact that two thirds of courses of treatment completed in the past year were undertaken for patients exempt from charges, and all children’s prevention and care is exempt from charges, we still have 30% of children in England not being brought by parents or carers for care.’
Clearly there are other barriers to knock down and Sara is acutely aware of this, but it’s understanding the figures she’s more interested in. ‘If you were to say there are 10 people that want to go to the dentist and they’re all queueing up waiting for an appointment but we can only offer six appointments, and we’ve got the evidence to show that, then that’s a different story,’ Sara explained.
‘There’s a difference between need and demand and that’s going to take some real understanding. So, how can we tackle the 56%? I think it’s possibly a meaningless statistic without having some better background. It gives us a trend, but I think so many things have changed in terms of the commissioning landscape and patient expectation, more UDAs is not necessarily the answer unless they are targeted and we have also addressed the confounding access issues.’
Eric continued: ‘There’s some evidence, in all the systems we’ve had, that 50+% is pretty standard in terms of the population’s behaviour. Some people like to invest in the future and buy into the idea of going to the dentist regularly in order to keep themselves healthy and be reassured by the check-up.
‘There are other people who simply want to use the services when they’ve got a problem. As much as we try to encourage people to come and to take that preventive approach, it just doesn’t feel right for them. What we do need to ensure is that when they do get a problem, we’ve got services that can cope.’
After a busy 18 months establishing the office of CDO, the department seems well set up going forward. So, what’s the plan for the next 18 months?
‘I think working more closely with NHS England, we’ve got some areas that we’re going to say “You could be doing this better”. We’ve got to be a little more forceful,’ Sara explained.
Local dental networks (LDNs) are key for the office of CDO too over the next year. Eric Rooney explained that initially the LDNs were acting as separate bodies all pulling in their own directions, but as the year has progressed he feels they’ve all gradually managed to pull together. ‘We really see the local dental network chairs as an extension of our team, it’s another bit of the ink blot if you like. We’ve had a number of meetings with them over the year, bringing them together and sharing good practice. These are the key people at a local level who need to drive commissioning and the local strategy for dental services going forward. So that’s one of the things we want to continue to do next year.’
Eric is also calling for the local dental networks to be clearly established in NHS England’s developing commissioning structures so that dentistry has a voice.
He highlighted the difficulty of integrating dentistry into the care for patients with diabetes and care for the elderly. ‘We can’t do it from here [the office of CDO], we can have the helicopter view, we can help shape, encourage and steer, but really it’s the people on the ground working together who need to do it.’
It all sounds promising. Sara and her team are helping to open dialogues with regulatory bodies, commissioners and with the profession itself and get everybody talking to eachother. Comments on social media sites and blogs often mention the need for a leader in the profession, somebody to stand up and fight in front of politicians for dentistry. With Sara Hurley and the office of CDO, dentistry in England now has its voice. But judgements will only be made on actions, not just on what is said. So, whilst the first 18 months certainly sound promising, we wait to see the action over the next 18 months.