[To receive the attached information pack. A presentation will be given at the meeting on Dentistry during Covid-19. A represensative from Public Health England and NHS England and NHS Improvement will be present].
The Deputy Head of Primary Care Commissioning from NHS England and NHS Improvement and the Consultant in Dental Public Health from Public Health England gave a presentation on Dentistry during Covid-19. A briefing report had also been circulated with the agenda. The briefing note had contained a summary of pre-Covid Dental Services including maps. Detailed information on Dental fees had been provided in the note. NHS Dental fees had not changed due to Covid. Some private Dentists had increased their charges. You did not need to be registered with a Dentist like you did with a GP. In theory patients were able to attend any Dentist, it was however true that many Dentists did maintain a list of regular patients. Patients were able to find details of Dental practices on the NHS website, https://www.nhs.uk/service-search/find-a-Dentist
A range of specialist care was available through Hospital or Community Dental Services on referral. In the Wolverhampton area this was provided by the Royal Wolverhampton NHS Trust.
The Deputy Head of Primary Care Commissioning stated that services, due to the pandemic, at present were severely constrained due to limited capacity. This was because of the nature of the work of Dentistry, the need for social distancing and infection control and downtime required between treatments, to change the air. Certain Dentistry procedures were aerosol generating, such as when using drills. It was now normal to have remote telephone triage prior to or instead of being seen face to face. During Covid-19 there was currently no walk-in services available. Dentists had been told to prioritise urgent care and vulnerable patients rather than routine check-ups. Some patients were required to be seen at other centres due to Covid-19. There were some established urgent Dental centres, which could also be used for people in the vulnerable category. They were aware that obtaining care was difficult at present for those without a usual Dentist, but urgent care could be accessed via NHS 111. They were looking to try and improve this pathway as it was often the most vulnerable patients in this position.
The Deputy Head of Primary Care Commissioning remarked that local Dentists and services were working together to try and maintain and recover services. Guidance and support were being provided to Dentists and other services to help them adapt the way they worked. It was however a reality that patients were having to wait longer for the care they needed both at a high street or in a Hospital service and the range of options for treatment may have been more limited than was previously the case.
The Deputy Head of Primary Care Commissioning commented that since the report had been published with the agenda for the meeting, the team had contacted six practices previously identified as not providing a full range of services including aerosol generated procedures and had established that all of these were now offering these procedures and had been since September / early October. She provided the local information on levels of patients exempt from Dental charges as follows:-
Paying Adult Wolverhampton – 67.55%, Midlands – 77.30%, England -77.36%
Non-Paying Adult Wolverhampton – 32.45%, Midlands – 22.70%, England – 22.64%
The Chairman and Vice-Chairman of the Panel had submitted a number of advanced questions following receipt of the report. The Deputy Head of Primary Care Commissioning presented the answers on slides to the meeting.
The first question was as follows, “The report states that people need to be honest about their Covid-19 status when seeking treatment. Do you have any evidence to date that people are not being honest when seeking treatment?”
The Deputy Head of Primary Care Commissioning responded that they had received general anecdotal reports in the Midlands from Community Dental Services of children attending appointments who were off school due to cases of Covid-19 in their year group. They had also received reports from Dental practices regarding patients who had answered negative to Covid-19 screening questions but were later identified at the practice as being symptomatic or isolating. Patients who had symptoms could be seen, but at a location that was separate (either in time or place) to other non symptomatic or isolating patients. This was to protect other patients who were also attending the practice. Patients who were symptomatic or isolating would be turned away and asked to attend elsewhere. The practice would also be forced to close temporarily for deep cleaning and staff testing. This would further restrict care and other patients would have appointments cancelled. There had been little demand at the hot sites, for people with Covid-19.
The second advance question which had been submitted was, “We are concerned about the sustainability of the Dental labs. Can you give us the very latest information on what is being done to try and help them survive and is there anything the Health Scrutiny Panel can do to help?”
The Deputy Head of Primary Care Commissioning responded that this was a perceptive question. They had provided some information in the report on recommendations from a review nationally which identified a risk to Dental labs. She had asked for an update from the Deputy Chief Dental Officer, but he had not yet responded. The levels of face to face activity for routine care remained low including for work such as dentures and therefore the situation was unlikely to have improved significantly in terms of the volume of work available to Dental labs. The Dentals labs were entirely private and were used by the Dental practices. They were therefore an important part of the Dentistry system. She suggested that Members could work to raise awareness of the issue to ensure that work continued centrally to support vulnerable sectors and ensure sustainability of key support industries.
The Consultant in Dental Public Health from Public Health England remarked that the Dental labs were an important part of the system. She was very concerned about the sector because they would be vital in the future.
The third advanced question which had been submitted was as follows, “The report refers to you reviewing the position of hot sites, which are for people with symptoms or isolating patients. Do you think there will be additional sites in Wolverhampton and when will these be opened?”
The Deputy Head of Primary Care Commissioning responded that there was not currently sufficient demand to justify earmarking a specific site as this would necessarily mean that other services at the site would have to be stopped. They were scoping a Black Country hot site that could be mobilised if necessary, at short notice. The location options were limited due to issues with suitable premises for aerosol generated procedures and with access due to co-location with other services. There were longer term plans to seek expressions of interest for weekend Dental slots at local practices and they anticipated some end of sessions slots being reserved for patients with symptoms of Covid-19 or patients isolating, if the demand increased.
The fourth advanced question which had been submitted was, “How can partners work together to improve the oral health of very young children?”
The Consultant in Dental Public Health from Public Health England commented that she was thankful for the opportunity to talk to the Local Authority about oral health and for the interest that the Scrutiny Panel had taken. She spoke about the “Little Trip to the Dentist Campaign (#ALTTTD).” The main focus of the campaign had been on communications to raise awareness with parents and carers of young children of the need to take children to the Dentist and also the key oral health messages for the age group. It had run between 2017 and 2020. All the key messages from the campaign remained applicable and could be accessed at the webpage link:-
She wanted the messages from the campaign to continue to be reinforced into the future. She also felt there was a real opportunity with the introduction of Integrated Care Systems and Primary Care Networks, that they could take a lead on improving the oral health of very young children. They would be able to influence GPs, their practice staff and pharmacists. She also believed there was an opportunity to develop a local Wolverhampton campaign or even at Town level such as Bilston. Such a campaign would try and influence the local population, with a particular focus on targeting groups locally with the greatest health needs. Local knowledge could be used to best influence the most in need groups. They knew that the more targeted the message and the approach, the more successful it would be in encouraging behavioural change in individuals. Co-production of information was key with simple key messaging. She was happy to work with the Council and health partners to help develop such a local campaign. She also felt it important that more voluntary groups help share the oral health messages. She hoped the resources available on the NHS website would be freely shared with them.
The fifth advanced question which had been submitted was, “The A Little Trip to the Dentist Campaign refers to identifying influencers. Who were the type of influencers identified in Wolverhampton?”
The Consultant in Dental Public Health from Public Health England responded that very young children did not make their own decisions, their carers or families did this for them. It was therefore important to influence this category of people. She displayed a slide listing the key influences but cited some of the main one’s as being midwives, the antenatal visitors, early years practitioners and children’s centres. When devising the campaign, they had also looked at the Influencers of Influencers such as Oral health promoters and teams, local Public Health teams and NHS England. They had ensured they were able to relay information.
The sixth advanced question which had been submitted was as follows, “The report highlights that at the time of writing the report, 42 patients had been waiting over 52 weeks and 2042 waiting over 18 weeks for surgery at RWT. Can we ask RWT to comment on these statistics and their plans for the future in relation to oral surgery?”
The Deputy Head of Primary Care Commissioning stated that the most recent data for the Royal Wolverhampton NHS Trust for September showed the position had improved slightly from figures quoted previously in the report, with 42% being seen within 18 weeks and 1718 waiting longer (a reduction of 324) however there were 70 patients waiting more than 52 weeks (an increase of 28). The number of patients waiting more than 52 weeks had increased across all Trusts, it was not localised to Wolverhampton. Trusts had been asked to prioritise care needs, which meant some people were waiting longer than others. The total waiting list had increased slightly by 65 patients. The position for 18 weeks was improving, with referrals being lower than normal, although recovering. Trusts continued to provide urgent care based on prioritisation. There were concerns that the second wave would further restrict elective care due to staffing pressures.
The Chief Executive Officer of the Royal Wolverhampton NHS Trust commented that they were doing better than many Trusts in the West Midlands at the present time. Nationally there was now over 142,000 people who had waited more than 52 weeks for surgery. His priority focus was on cardiac surgery and cancer services.
The final advanced question which had been submitted was, “Do you think Covid-19 has changed the future course of Dentistry Services permanently. For example the increased use of Digital in service provision and more of a focus on required care rather than routine appointments?”
The Deputy Head of Primary Care Commissioning responded that she hoped that it had changed the future course of Dentistry Services. There had been a number of positive areas which had occurred as a consequence of the pandemic. She thought it was a positive move that there would be more of a focus on personalised recall schedules and those with greatest need. Not everyone needed to be seen every six months. It was important to prioritise care for those that needed it most in a targeted manner. The second example of positive change was in the use of digital technology such as virtual consultations, advice and guidance and sharing photographs. This had now become an accepted part of care and could improve the efficiency of services. Covid-19 had accelerated the progression in the use of digital in services, which had been part of the improving services agenda but had not been occurring at a rapid pace, which Covid-19 had forced. The pandemic had further strengthened existing collaborative working through local networks including Local Dental Committees and Managed Clinical Networks. These collaborations were an important part of the Commissioning system. There was now a better holistic approach and innovation had improved.
A Member of the Panel complimented the representatives from NHS England & Improvement and Public Health England on their report and presentation to the Panel. He agreed that Dentistry Services needed to take a more targeted approach based on needs. He spoke positively about the Dentistry Services the NHS provided and commented that the fees charged did not represent the actual costs, which were much higher. He thought prevention was key which would help reduce overall costs for Dental work. He asked for their thoughts on returning to School Dentists.
The Consultant in Dental Public Health from Public Health England commented that prevention was key. The “A Little Trip to the Dentist Campaign”, had tried to succeed in getting children and their families used to going to the Dentist from a very early age, with the right recall schedule based on need. The best place to receive treatment was in a clinical setting. In the past mobile services may have been used, which was still an option in some areas. The best and safest place to receive Dental treatment though was within a Dental Clinic. They still did some work with schools which included providing advice. Wolverhampton still had water fluoridisation, which was key to prevention. Dental Practices in Wolverhampton were able to put on fluoride varnish 2-4 times per year for any child aged 3-16, which helped to prevent tooth decay. There were services available to children that needed a general anaesthetic which were linked to the Royal Wolverhampton NHS Trust and the Community Dentist Service. There was therefore an established system to try and capture the children and bring them within the system so they could receive treatment and also to help prevent tooth decay from starting in the first place.
The Member of the Panel in response asked whether a specialist children’s Dentist in each Town would be of benefit. The Deputy Head of Primary Care Commissioning responded that specialists were in short supply. There were some talented individuals that worked in the Community Dental Service who provided specialist support for paediatric Dentistry. They had recently conducted a review of Community Dental Services across the region and they were completing work to redesign the service. One of the big issues was regarding sustainability and workforce. She thought there was not enough specialists being trained, with many ending up working in Dental Schools and Children’s Hospitals. One of the challenges was to make sure Community Dental Services had access to specialist Dentists. It was important that specialists were used to their maximum potential and efficiency to help the children which required specialist care. Many children would never require access to specialists. Investment in prevention was important, which was why there had been such a focus on the “A Little Trip to the Dentist Campaign.” By the time a child had reached school age, habits had already formed, so early intervention was key to establish routines. Some children already had significant Dentistry problems before they even reached school. The Consultant in Dental Public Health from Public Health England added that her view was all Dental practices should be child friendly.
The Chair thanked the representatives from NHS England & Improvement and Public Health England for an excellent presentation and report. The Scrutiny Officer also paid his complements to the representatives, who had provided the Panel with all the information requested in advance of the meeting.
Resolved Unanimously: That Health Partners give consideration to developing a local Wolverhampton campaign to raise awareness with parents and carers of young children of the need to take children to the Dentist and the key oral health messages for this age group. Clearly it would need to launch at an appropriate time because of the ongoing Covid-19 pandemic.