Response to the Mayor of London’s Draft Health

Inequalities Strategy

30.11.2017

London Local Dental Committees

Federation of London Local Dental Committees

1

INTRODUCTION

The Federation of London Local Dental Committees welcomes the publication of Better Health for all

Londoners and the opportunity to respond to it. The Federation is a membership body of 11 Local Dental

Committees in London representing approximately 3,000 NHS dentists working in general dental

practice. Our submission consists of a short introduction and summary of our recommendations and

actions before responding to the Mayor’s priorities as set out in the consultation. Following our

response to the questions we set out some more general information which we hope is helpful in

placing primary care dental services in context. Finally, we provide additional information in an annex

about how primary care dental services work. Throughout the document we provide examples of how

the LDCs are working with local stakeholders. We would be very happy to expand on any point

mentioned in this response either in person or in writing.

Local Dental Committees (LDCs) exist throughout the UK. They are the democratically elected

representative body for primary care NHS dentists at the local level. They have existed since the creation

of the National Health Service to support and represent dentists and to help plan services in local areas.

There are a total of 90 LDCs in England, with 16 in London. Eleven of the LDCs in London have joined

together to create the Federation of London Local Dental Committees and together they represent

approximately 3,000 primary care NHS dentists. The Local Dental Committees and the Federation are

committed to working with local partners to ensure that dental services are in the best position to meet

the needs of local populations. In this document where we refer to LDCs or LDCs in London we mean

this to apply only to those 11 LDCs which are part of the Federation of London Local Dental Committees.

The Local Dental Committees in London welcome the Mayor’s draft Health Inequalities Strategy and the

opportunity to comment on it. We consider that dental services can make a real impact on the aims and

objectives set out by the Mayor by helping people live more fulfilling lives and helping them to make

healthy life choices. We look forward to working with the Mayor, the London Assembly and other

stakeholders in improving the health of all Londoners.

Dentistry can play an important role in Londoners’ lives. Enabling them to eat, drink and socialise

comfortably1. Public Health England is running an Adults in Practice Survey in 2018 to assess the oral and

dental health of the adult population which attends the dentist. The survey is expected to engage 3000

dental practices nationally and 45,000 patients. In London we expect an average of 10 practices per

borough to be involved, and about 5,000 patients. The data collected should be used to inform local

authority Joint Strategic Needs Assessments and the LDCs look forward to working with their local

Health and Wellbeing Boards on delivering strategies designed to improve oral health.

1 The World Health Organisation is clear that oral health is essential to general health and quality of life: http://www.who.int/mediacentre/factsheets/fs318/en/ retrieved 13/10/17

http://www.who.int/mediacentre/factsheets/fs318/en/

2

SUMMARY OF RECOMMENDATIONS

1. Children’s oral health plans to be included in every school and early years setting as well as in all

action on obesity plans. The Mayor’s Healthy Early Years London Awards programme should

include an element on oral health.

2. Appointment of a children’s oral health adviser to support the Mayor and his team with the

oversight and assessing the effectiveness of children’s oral health initiatives.

3. The LDC’s recommend that funding from the ‘sugar tax’ to be used for oral health promotion.

4. To help reduce health inequalities among those with mental health conditions, exacerbated by

poor lifestyle choices such as smoking and alcohol misuse, the Mayor should raise the importance

of oral health with his mental health stakeholders such as Thrive London.

5. Smoking remains prevalent among those with the greatest need. To tackle this, the Mayor must

work with partners to ensure that sufficient and easily accessible stop smoking services are

available in every borough.

6. We call on the Mayor to demand that NHS England and the Department of Health work with the

British Dental Association to make NHS patient charges clearer, removing their collection from

dental practices and ensuring that those with the greatest need are empowered to access dental

care.

7. Mayor to encourage all Health and Wellbeing Boards to engage with their Local Dental

Committees.

8. Mayor’s office to have oversight of a Public Health England London Region led de ntal needs

assessment to ensure that there is sufficient funding for dental services in London

9. Mayor to ensure that each borough provides comprehensive translation services for those

patients which require it.

10. Mayor to support every provider of adult social care services to partner up with a dental practice

or CDS to ensure timely and routine access to dental care.

11. We recommend a Mayor of London led campaign informing different community groups about

the dangers of shisha, smokeless tobacco, betel nut and other carcinogenic products use in a pan-

London campaign in conjunction with local authorities.

12. The Mayor to initiate a system of recognition for providers and teams who have made significant

contributions to their local community in improving oral health.

3

FEDERATION ACTIONS

1. The Federation of London Local Dental Committees will engage with stakeholders to improve the

oral health of Londoners. We do this through effective information sharing.

2. We will provide a forum for professional engagement through member Local Dental Committees

to ensure that the professional voice is heard.

3. Local Dental Committees will work with the Local Dental Network and Health Education England

to identify training requirements in general dental practice in the capital.

4. The LDCs will work with the British Dental Association and its General Dental Practice Committee

to ensure that where appropriate issues are raised at the national level.

5. The Local Dental Committees are working with their local Cancer Research UK facilitator to help

improve cancer referrals and promote healthy living advice.

6. The Federation of London Local Dental Committees will engage with the Directors of Adult Social

Care, Directors of Public Health in the boroughs, the London Dental Network and, when

appointed, the Mayor’s Adviser on Children’s Oral Health to ensure that there is a coordinated

Pan-London approach to improving children’s and older adults’ oral health.

7. The Federation of London Local Dental Committees is working with NHS Digital to implement an

efficient system for dental practices to obtain NHS.net email addresses to facilitate referrals and

secure communication.

8. We are working with representatives from the National Association of Primary Care to understand

how General Dental Practice can fit with new models of working to improve the patient journey.

9. We will continue to engage with the Centre for Sustainable Healthcare’s project on dentistry and,

once recommendations are made help ensure that they are implementable in primary care dental

settings to assist with the Mayor of London’s objective in improving air quality.

10. The Federation of London Local Dental Committees facilitates regular meetings between the LDCs,

NHS England (London Region) and other stakeholders on Sustainability and Transformation Plan

footprints. We want to ensure that these are valuable primary care meetings which will help the

STPs achieve their objectives. We will be expanding our stakeholder list for these meetings to

reflect the changing delivery structure.

11. We will continue to keep our website, www.ldc.org.uk, up to date with the latest news and

activities so all dental stakeholders in London have an effective one -stop-shop for oral health in

London.

http://www.ldc.org.uk/

4

RESPONSE

Healthy Children

1. Is there more that the Mayor should do to reduce health inequalities for children and young

people?

As recognised, albeit fleetingly, in the draft Health Inequalities Strategy children’s oral health in London

is extremely poor in many places. The dental profession in London is keen to have the support of the

Mayor in turning the situation from national disgrace to shining example. The extent of preventable

tooth decay in London’s children can be seen in the graph below 2:

Over 50 per cent of the boroughs in London record poorer children’s oral health than the national

average. The LDCs want to see the Mayor of London take the lead on addressing this issue and ensuring

that London’s children do not suffer unnecessarily from a largely preventable disease. While

commissioning and contract monitoring responsibility for all dental care has been retained by NHS

England, responsibility for children’s oral health has been devolved to local authorities. The Faculty of

Dental Surgery published a report in 2015 that highlighted the poor state of children’s oral health and

2 More detailed information is available in the presentation attached to the annex of this response kindly

provided by Public Health England (London Region)

5

the need for action3.

As the British Dental Association point out in their response to the Health Inequalities Strategy, what is

lacking at the moment is a coherent, pan-London oral health improvement strategy. We are pleased to

be working with the London Dental Network to address this and will work the LDN on its

implementation. To provide the Mayor’s office with oversight of children’s oral health improvement,

and to increase accountability we make two recommendations to the Mayor building on his own first

two recommendations that 1. London’s babies have the best start to their life; 2. Early years settings and

schools support children and young people’s health and wellbeing:

LDC Recommendation 1. Children’s oral health plans to be included in every school and early years

setting as well as in all action on obesity plans. The Mayor’s Healthy Early Years London Awards

programme should include an element on oral health.

LDC Recommendation 2. Appointment of a children’s oral health adviser to support the Mayor and his

team with the oversight and assessing the effectiveness of children’s oral health initiatives.

We applaud those local authorities which are taking the initiative in improving children’s oral health but

reiterate the importance of engaging the profession in these initiatives. The National Institute of Health

and Care Excellence (NICE) is emphatic about the importance of council led school oral health

programmes and the LDCs would work with the London boroughs to deliver this4. The success or failure

of most initiatives ultimately comes down to funding, however. To support initiatives, and to reinforce

the link between sugar intake and tooth decay, we recommend that the funding from the so-called

sugar tax be used to fund oral health promotion for children5. Intake of sugary drinks has a negative

impact on oral health as well as obesity and as dentists and dental public health provides dietary advice

we consider that this would be an appropriate way to spend this funding. We appreciate that this may

be initially beyond the direct power of the Mayor of London, but would urge the Mayor to work with the

Treasury, Department of Health and Minister for London to secure the use of this funding f or oral health

initiatives. We were pleased to see this sentiment expressed by Maggie Throup MP in the recent debate

on children’s oral health. She stated that:

“Tackling obesity also tackles tooth decay, so I welcome the sugary drinks levy and the

ring-fencing of the moneys raised from that for children, but I want to go one step

further. Could some of that money be dedicated to teaching children how to clean their

teeth—perhaps through the breakfast clubs some of that money will be dedicated to?”

3 The state of Children’s Oral Health in England Faculty of Dental Surgery (Royal College of Surgeons of

England) 2015 available from https://www.rcseng.ac.uk/library-and-publications/college-publications/docs/report-childrens-oral-health/ 4https://www.nice.org.uk/news/article/councils-should-provide-oral-health-programmes-in-schools-says-

nice retrieved 14/11/17 5 A visceral example of the impact of sugar on teeth in children can be found in this clip from Jamie’s

Sugar Rush https://www.youtube.com/watch?v=Oj9CRK26DIo retrieved 04/10/17

https://www.rcseng.ac.uk/library-and-publications/college-publications/docs/report-childrens-oral-health/https://www.rcseng.ac.uk/library-and-publications/college-publications/docs/report-childrens-oral-health/https://www.nice.org.uk/news/article/councils-should-provide-oral-health-programmes-in-schools-says-nicehttps://www.nice.org.uk/news/article/councils-should-provide-oral-health-programmes-in-schools-says-nicehttps://www.youtube.com/watch?v=Oj9CRK26DIo

6

With such statements being made by a member of the Health Committee, who is also Chair of the APPG

on Adult and Childhood Obesity, we are confident that the Mayor of London could galvanise cross party

support on this issue.

LDC Recommendation 3. The LDCs recommend funding from the ‘sugar tax’ to be used for oral health

promotion

The LDCs support the SugarSmart initiative that has been taken up by some, but not all, London

boroughs. The Healthy Schools Programme, supported by the Mayor of London, has a great online

resource which provides case studies of good practise for schools to learn from. Unfortunately, although

we are aware of several great examples of oral health interventions in schools such as Colville School in

Westminster, only one example is to be found on the Healthy Schools Programme website.

2. How can you help to reduce health inequalities among children and young people?

The British Society of Paediatric Dentistry and the Chief Dental Officer recently launched the Dental

Check by One initiative. This initiative allows practices with an NHS contract to overachieve against their

contractual obligations over and above the normally permitted 102 per cent of the contract value to 104

per cent, provided the additional spend is on children. Working with NHS England, local authorities, local

Healthwatches and, we hope, with the Mayor’s office, we want to raise awareness of the importance of

taking children to the dentist by the time their first tooth has appeared and by increasing awareness

that checks and treatment are free for children.

Ealing, Hammersmith and Hounslow Local Dental Committee is working with Ealing Borough Council and NHS England London Region to promote and deliver two children’s oral health campaigns. NHS England identified Ealing as one of the 13 high needs areas in the country. As the graph above shows, Ealing has the worst children’s oral health in London. Extractions for decayed teeth is the main cause of hospital admission for children in England between the ages of five and nine and is largely preventable. The initiatives in Ealing aim to embed prevention to reduce the pain and distress caused to children by this unnecessary decay. The Starting Well programme will offer interventions at the individual, practice and community level to children under the age of five, with a focus on high risk groups. Participating practices will identify a ‘champion’ to embed preventive practice in all levels through engagement with local partners. The LDCs are pleased to support this initiative with its emphasis on embedding dentistry and oral health in the wider health and social care environment.

The Local Dental Committees in London have worked with, and supported the changes to, paediatric

referrals in London led by the London Dental Network. This has resulted in a pan-London approach,

criteria and referral form for paediatric dental referrals leading to reduced waiting times and, we

anticipate, improved outcomes6.

The Local Dental Committees will continue to work with the London Dental Network to identify training

6 The impact of the new referral system is currently being assessed by NHS England (London Region)

7

need among general dental practitioners for dealing with children, and work with Health Education

England and the Local CEPNs to ensure that this training is delivered where it is needed.

The Kensington, Chelsea and Westminster Local Dental Committee is working with the Public Health

Department of the two boroughs to improve the oral health of children through a buddying scheme

between schools and dental practices. The scheme supports different ways of working depending on

capacity but will involve participating practices going into schools and encouraging visits of children to

the dentist. The Public Health Department is finalising a video which the Federation of London Local

Dental Committees will host on their website.

3. What should be our measures of success and level of ambition for giving London’s children a

healthy start to life?

There are several measures that we consider appropriate in ensuring that London’s children have a

healthy start to life.

1. The number of schools participating in children’s oral health programmes,

2. The support given by the local authorities to these programmes through their engagement with

the Local Dental Committees, and

3. The commitment to funding to deliver these programmes.

4. The clearest indicators will, however, of course be the increase in the number (and proportion) of

children seeing a dentist regularly and the drop in hospital admissions for children requiring

extractions under general anaesthetic.

5. The final indicator, and the one which will demonstrate the long term commitment to improving

children’s oral health, is the allocation of dedicated budgets to continue these initiatives year on

year so that no child suffers from a preventable disease.

8

Healthy Minds

4. Is there more that the Mayor should do to make sure all Londoners can have the best mental health

and reduce mental health inequalities?

There is a strong correlation between having a mental health condition and poor oral health 7. As well as

severe mental health conditions such as schizophrenia which will affect an individual’s abi lity to self-

care, there is a correlation between anxiety and depression and oral health: two mental health

conditions which the Mayor’s Strategy identifies as an increasing risk among Londoners. The connection

between mental wellbeing and good oral health goes both ways.

“In my experience, patients with bad teeth often feel under-confident, unattractive and reluctant to engage with others. This may lead to problems in various parts of their lives.” ~ Dentist

Firstly, those with mental health conditions are more likely to engage in poor lifestyle habits such as

smoking, poor diet and alcohol misuse which will have an impact on their oral health 8. We have been

extremely concerned that some boroughs do not actively support the provision of stop smoking services

and instead rely on the generic, centrally funded system9. As one of the most significant causes of health

inequalities, and an issue identified in most Health and Wellbeing Board Strategies, we would expect

sufficient stop smoking services to be available in every area.

Secondly, those experiencing poor oral health may go on to develop increased social anxiety as a result

of self-consciousness about appearance, or increased isolation because of oral pain, appearance or

discomfort10. This is particularly true for those with the greatest need, such as the homeless. We expand

on these points in our general section below. As well as access to routine primary dental care we are

concerned that orthodontic services in the capital are not being supported. Orthodontics provides great

benefit. London is one of the most digitally connected cities in the world, as a result young people in the

capital are exposed to a range of influences about body image. Perceptions of acceptable appearance

and self worth have changed greatly in this digital age and many teenagers will face increased anxiety in

socialising if they feel their appearance does not match up with an ideal 11. As a result, sufficient access

to orthodontic services to help prevent anxiety, bullying and other social disorders provides a social

good which is of vital importance to the people it affects12. Access to affordable dental care, both

7 “The oral health of people with anxiety and depressive disorders - a systematic review and meta-

analysis” Kisely S, Sawyer E, Siskind D, Lalloo R. 2016 in Journal of Affective Disorders 8 As noted in the Health Inequality Strategy pg. 47. 9 A list of all stop smoking services in north west and south London is available on the Federation

website. 10 E.g. http://dentistry.dundee.ac.uk/big-social-impact;

http://www.who.int/bulletin/volumes/83/9/editorial30905html/en/ 11 As found in a YouGov survey for the British Dental Association: https://www.bda.org/news-

centre/press-releases/bad-teeth-hurting-career-prospects retrieved 03/10/17 12 See, e.g. http://www.smile-onnews.com/news/view/could-bullying-be-linked-to-dental-appearance

retrieved 03/10/17

http://dentistry.dundee.ac.uk/big-social-impacthttp://www.who.int/bulletin/volumes/83/9/editorial30905html/en/https://www.bda.org/news-centre/press-releases/bad-teeth-hurting-career-prospectshttps://www.bda.org/news-centre/press-releases/bad-teeth-hurting-career-prospectshttp://www.smile-onnews.com/news/view/could-bullying-be-linked-to-dental-appearance

9

general dentistry and orthodontic, is, therefore, an important element to safeguarding the mental

wellbeing of some Londoners, and an element of reducing health inequalities among those Londoners

facing stress and anxiety.

LDC Recommendation 4. To help reduce health inequalities among those with mental health conditions,

exacerbated by poor lifestyle choices such as smoking and alcohol misuse, the Mayor should raise

the importance of oral health with his mental health stakeholders such as Thrive LDN

LDC Recommendation 5. Smoking remains prevalent among those with the greatest need. To tackle this,

the Mayor must work with partners to ensure that sufficient and easily accessible stop smoking

services are available in every borough.

5. How can you help to reduce mental health inequalities?

By working with local authorities and patient groups to ensure that those with the greatest need have

access to primary care dental services, and working with the NHS to make sure that patients are aware

of the costs of services, dentists in London will help give Londoners back confidence to engage socially

with their peers. We support the call of the London Dental Network to ensure that every patient who

has a psychiatric assessment is given an appointment at a suitable dental service to assess their oral

health management and need. Having a healthy mouth will help reduce anxiety and depression by

helping people feel less self-conscious and so boosting their ability to socialise, one of the key ways of

reducing anxiety and depression. By providing those with severe mental health conditions with an oral

health assessment and ongoing care to help address and maintain their oral health, unnecessary

discomfort and stress can be reduced.

It is time that the role good oral health has in helping maintain dignity is recognised, promoted and

properly funded.

The LDCs will work with the Local Dental Network and other London partners to ensure that care

pathways support patients with mental health conditions to access appropriate dental care through the

Community Dental Services and other adult special needs services. Due to the routine nature of

accessing dental care, dentists can often be in a good position to recognise risk factors for mental health

conditions such as eating disorders and degenerative diseases such as Parkinson’s. We will work with the

Local Dental Network to ensure that pathways for patients presenting with these conditions at a general

dental practice are robust.

6. How can we measure the impact of what we’re doing to reduce inequalities in mental health?

We suggest that colleagues at Public Health England would be best placed to recommend measures of

impact. Likewise mental health stakeholders such as MIND or local healthwatch may be able to provide

measures of impact on reducing oral health inequalities for those with mental health issues.

10

Healthy Places

7. Is there more that the Mayor should do to make London’s society, environment and economy

better for health and reduce health inequalities?

General Dental Practitioners have a limited ability to influence many of the issues identified by the

Mayor in this section. We would highlight two areas which do have an impact on oral health, however:

objective 2 “Health inequalities are reduced through planning and making our streets healthier” and

objective 4 “The negative impact of poverty and income inequality on health is addressed”. While the

focus on healthy streets in the draft strategy is about making them safer and more inviting to use to

encourage increased physical activity, we take this opportunity to encourage the Mayor to consider how

to address advertising and the availability of food choices and snacks which negatively impact health.

We support the Mayor’s statement that poverty worsens health, reducing access to nutritious food and

increases isolation, and refer to our statements above in relation to Healthy Minds. The possibility of

having to pay for dental care can be off putting, with patients sometimes unclear why, if the treatment

is provided by the NHS, they have to pay. Many of the most vulnerable, including those with Alzheimer’s

and other dementias face being fined if they or their carers unwittingly claim exemption from charges,

as well as the elderly more generally13. We expand on this issue below in our response to Healthy

Communities. While we recognise that the Mayor has no authority to reform the dental contract, alter

the charging regulations for dental services or implement other much needed reforms to dental

services, we do call on the Mayor to work with NHS England, the Department of Health and British

Dental Association on making NHS patient charges clearer, removing their collection from dental

practices and ensuring that those with the greatest need are encouraged to access dental care, rather

than scared off by possible fees.

LDC Recommendation 6. We call on the Mayor to demand NHS England and the Department of Health

work with the British Dental Association on making NHS patient charges clearer, removing their

collection from dental practices and ensuring that those with the greatest need are empow ered to

access dental care.

By making these changes, making access to dental care less intimidating, London can be made a more

healthy place and the impact of poverty on health can be somewhat reduced. A vital element of ensuring

that oral health is built into initiatives which are developed to improve health more generally, will be

ensuring that Health and Wellbeing Boards recognise that LDCs are vital stakeholders in the borough. As

noted above, in our response to Healthy Children, some boroughs are engaging strongly with their Loca l

Dental Committees and the relationship is helping to improve oral health in the local area. We would like

to see such strong relationships across London championed by the Mayor.

LDC Recommendation 7. Mayor to encourage all Health and Wellbeing Boards to engage with their Local

Dental Committees.

13 http://www.bbc.co.uk/news/education-41639456 retrieved 25/10/17

http://www.bbc.co.uk/news/education-41639456

11

8. How can you help to reduce inequalities in the environmental, social and economic causes of ill

health?

The Local Dental Committees work closely with the British Dental Association to raise awareness of the

issues facing patients and dentists. We will also work with the London Dental Network on the

implementation of the oral health strategy.

As noted elsewhere in our response, we know that one of the main barriers to dental care, especially for

those with the greatest need, is the cost. This is true for patients and prospective patients, regardless of

whether those patients would qualify for exemption from NHS dental charges or not. The confusing

system of patient charges for NHS care blurs the line in some patients’ minds of private and NHS care

and is a deplorable barrier to care, made even worse by confusing messages from the government that

the NHS is free at the point of care. This is why the LDCs in London wrote to the Department of Health

recommending that patient charges be removed from NHS dental care, and until that happens for there

to be no more messages that the NHS is free at the point of care. We will continue to work with

partners, both political and at the BDA to fight for all barriers to effective care to be removed.

The oral health improvement initiatives mentioned throughout our response, in Westminster, Ealing,

Lambeth, while welcomed and supported by the profession are the exception, not the rule. As noted

above, these initiatives are not co-ordinated and we are concerned that best practice is not being shared

effectively. To help with this coordination the LDCs will work with the Local Dental Network to engage

with the Directors of Public Health and Directors of Adult Social Care through London Councils and we

would appreciate the Mayor’s support in our future engagement.

The London LDCs are involved in the Centre for Healthcare Sustainability’s review of dentistry. Part of

this is looking at how the profession can reduce its carbon footprint. We will work with stakeholders on

assessing how the final recommendations from this work can be effectively implemented in London. This

will ensure that dentists are doing what they can to help the Mayor achieve his aims for improved air

quality in London.

The Local Dental Committees were invited to send a representative to the Centre for Healthcare

Sustainability’s working group on Dental Sustainability. This group is looking at how the British Dental

Industry can reduce its use of natural resources and any ecological damage it causes. Not only will

reduce dentistry’s carbon footprint help impact on greenhouse emissions, but will contribute to a

cleaner environment, benefitting the whole community.

We look forward to assessing how dental practices can contribute to a healthier environment,

influence strategy and promote sustainability within the dental sector. The LDCs will continue to work

with stakeholders on this internationally important issue and share recommendations to improve the

sustainability of dental care.

12

9. What should be our measures of success and level of ambition for creating a healthy environment,

society and economy?

A healthy environment will be one which enables people to make choices which keep them healthy and

happy. We believe that for oral health this will be seen through an increase in access for the most

vulnerable and a reduction in avoidable caries rates among children and adults. For LDCs, would consider

increased engagement from Health and Wellbeing Boards as a key step in this direction and so, an

indicator of expected future success in creating a healthy environment, society and economy.

13

Healthy Communities 10. Is there more that the Mayor should do to help London’s diverse communities become healthy and

thriving?

We support the Mayor’s objective that: “All Londoners have the necessary skills, knowledge and

confidence to improve health” but are concerned that many communities remain marginalised from

healthcare in general, and dental care specifically. The aforementioned issues with confusion over NHS

dental services having a charge while the message that the NHS is free at the point of service is a major

source of confusion, frustration and fear for many people. The recent report by Camden Healthwatch,

noted below, investigated experiences and barriers to accessing general dental practice. The report

supports our concerns around pricing and confusing messages around the NHS being free at the point of

use. This confusion has led to patients being unfairly fined for claiming exemptions from fees incorrectly.

We consider that it is the messaging perpetuated by government and NHS that leads to unnecessary

problems as evidenced by this focus group participant:

“I got billed £150 by NHS even though I have NHS card plus £100 penalty, I had to

provide proof.”

It seems most likely that this participant has been misled by contradictory messages about the NHS

being free at the point of service, and therefore not unreasonably thinking that having an NHS number

entitled them to free dental care. This sort of experience undermines confidence in the practice and may

lead to a general distrust of the health system. The report further highlighted concerns that many

patients from BAME groups are more likely to access dental care episodically rather than routinely, as

that is the cultural or social norm, but is contrary to NHS advice. Routine access is important not only for

the individual but also in relation to the Mayor’s first priority: Healthy Children. Instilling in families the

long term understanding about the importance of oral health will be vital to ensuring that the oral health

of children improves.

The way dental funding is allocated through UDAs means that the money cannot be used to its

maximum benefit. The population of London has grown over the years. The number of UDAs available to

treat the growing population is not keeping pace. Any uplifts are to the value of an individual UDA, which

does not affect the total amount of care available14. Access data shows that access to NHS dentistry in

London is lower than the national average. As noted in our introduction, we are pleased to see a Public

Health England led Needs Assessment on dentistry for the adult population. This should engage the

Mayor’s office to ensure that there is Mayoral oversight to support practitioners to meet the needs of

their populations, and those who look to the Mayor for a voice.

14 Due to the cost implications of providing care if the number of UDAs increase the value of UDAs would

also have to increase to take account of the increased overheads required to meet additional demand.

Both aspects need to increase. We provide a summary of how the UDA system works in the annex.

14

LDC Recommendation 8. Mayor’s office to have oversight of a Public Health England London Region led

dental needs assessment to ensure that there is sufficient funding for dental services in London.

A further barrier to care is the unclear system around translation services. Presently dentists have to

make their own arrangements for translators to attend appointments and then invoice the NHS to

recoup the cost. This is inefficient and not cost effective. We consider that dental patients should have

access to Council funded translation services as part of a more holistic approach to integration and

accessing services. A single mechanism for a patient to follow to access a translator would be more

efficient and would empower patients rather than using clinical time to arrange for a translator.

“A translator service should be available to the public and not arranged by the dentist as this is inefficient use of clinical and administrative time. Often the patient then has to attend multiple visits, which can be both inconvenient for the patient and improper use of resources. Dental clinical time should be focussed on patient care.” ~ Dentist

LDC Recommendation 9. Mayor to ensure that each borough provides comprehensive translation

services for those patients who require it.

Kensington, Chelsea and Westminster Local Dental Committee sent a speaker to local events on dental care for those with severe deafness. The Royal Borough of Kensington & Chelsea Social Services team contacted the LDC for speaker at a joint event held with the Royal Association for the Deaf to provide information on simple clinical issues and advice on self care and visiting the dentist. Following the event some service users reported that they had had better experiences of visiting the dentist and the Borough reported that: “The dental health workshop has certainly benefited the Deaf BSL residents”. The event was so popular that it is due to be repeated in February 2018.

We take this opportunity to ask the Mayor to support the joining up of services for those who are among

the most vulnerable. The oral health of older adults, especially those in care homes, is often

overlooked15. Many of those relying on carers because of conditions such as Alzheimer’s and other

dementias, Parkinson’s and old age more generally are at potential risk of greater health inequalities

exacerbated by poor oral health management. As this cohort of people age, many are doing so with

more of their natural teeth. The aforementioned conditions can have a severely negative impact on a

person’s ability to manage their own oral health care, and because of the presence of natural teeth, this

can lead to poor oral health. Many medicines that people in care will take can lead to a reduction in the

amount of saliva produced in the mouth. This in turn can lead to oral health problems including an

increased risk of decay. According to the National Institute of Health and Care Excellence (NICE), more

than half of older adults who live in care homes have tooth decay, compared to 40 per cent of ov er 75s

who do not live in care homes. Other problems will be caused by those who have no teeth, but who

15 As identified by the Care Quality Commission The State of Health Care and Adult Social Care in

England 2016/17 pg. 92.

15

have lost dentures or who have ill-fitting dentures. Ill-fitting dentures or other oral pain can lead to

dehydration and malnutrition, which if not identified early on can lead to unnecessary hospital

admissions. A regular oral health assessment by a dentist can help identify these issues early on, thereby

reducing the chance of an unnecessary hospital admission16. The Federation of London Local Dental

Committees supports NICE’s statement that “All residents should have an oral health assessment when

they move into the care home, with the result recorded in their care plan.” The guidance further

suggests that staff should help residents find a dentist if they wish17. This is why in July 2017 we wrote to

the Department of Health recommending that they work with the Care Quality Commission to make sure

that providers of social care have a relationship with a general dental practice or community dental

service to safeguard the oral health of residents18. The Faculty of Dental Surgery has recognised the

importance of addressing the changing oral health needs of older adults in their 2017 report Improving

older people’s oral health19. The Faculty of General Dental Practice recently published new guidance on

dementia friendly dentistry20. Launching the guidance, Paul Batchelor, Vice-Dean of the Faculty said:

“By ensuring high standards of care, dentists can help minimise some of dementia’s

potential effects, particularly those also associated with poor oral health, such as

worsening of diet and social isolation, and a concomitant decline in general wellbeing”

The importance of oral health management is also supported by Alzheimer’s UK who commented on the

Faculty of Dental Surgery’s report saying:

“Ensuring that someone with dementia is able to access regular, dementia friendly,

support with their oral health is essential. The impact of symptoms can mean someone

with dementia has difficulties with eating and drinking, something that is made more

challenging when oral health is poor, in addition to self-caring for healthy teeth and

gums. Additionally both pain and infection can worsen the confusion associated with

dementia. As with everyone, poor oral health can also negatively impact someone’s

quality of life in general, exacerbating the impact dementia can have on self -identity and

confidence to socially integrate.”

These issues are reiterated on page 6 of the 2017 Nuffield Trust briefing Root causes: Quality and

inequality in dental health. The importance of ensuring that care home residents have access to good

16 Walls, A. G., Steele, J. G., Sheiham, A., Marcenes, W., & Moynihan, P. (2000). “Oral health and

nutrition in older people”. Journal of Public Health Dentistry, 60(4), 304-7. 17https://www.nice.org.uk/about/nice-communities/social-care/quick-guides/improving-oral-health-for-

adults-in-care-homes 18 A copy of the Federation’s letter is available from: https://ldc.org.uk/ldcs-write-department-health-

reminding-nhs-dentistry-not-free/ 19 Available from https://www.rcseng.ac.uk/dental-faculties/fds/ 20 Dementia Friendly Dentistry Faculty of General Dental Practice (Royal College of Surgeons of England)

2017 available from https://www.fgdp.org.uk/publication/dementia-friendly-dentistry

https://www.nice.org.uk/about/nice-communities/social-care/quick-guides/improving-oral-health-for-adults-in-care-homeshttps://www.nice.org.uk/about/nice-communities/social-care/quick-guides/improving-oral-health-for-adults-in-care-homeshttps://ldc.org.uk/ldcs-write-department-health-reminding-nhs-dentistry-not-free/https://ldc.org.uk/ldcs-write-department-health-reminding-nhs-dentistry-not-free/https://www.rcseng.ac.uk/dental-faculties/fds/https://www.fgdp.org.uk/publication/dementia-friendly-dentistry

16

oral health care is also mentioned in the latest Healthwatch report to Parliament21. The support of the

Mayor in raising the profile and importance of regular oral health checks for this cohort of patients will

make a real difference to their quality of life and potentially reduce the strain on secondary care.

In 2012 the British Dental Association showed that care homes face high levels of staff turnover and a

lack of training in oral health22 as well as showing that the number of residents in care homes accessing

primary care dentistry is far below the national average23. We urge the Mayor to use his authority to

encourage London boroughs to work with social care providers in their area to join up these services.

LDC Recommendation 10. Mayor to support every provider of adult social care services to partner up

with a dental practice or Community Dental Service to ensure timely and routine access to dental

care

11. How can you help to support thriving communities?

The LDCs, as the representative bodies of local dentists, are committed to ensuring that the environment

supports people to make the best decisions for their health. The LDCs will also encourage practices to

sign up to the SugarSmart programme in boroughs where it is running to ensure a consistency of

message across all sectors that the public engages with.

The Nuffield Health’s recent briefing Root causes states that24:

“dentistry is not a feature of the new models of care being trialled across the country.

This seems to be a missed opportunity to tackle poor dental health while taking on other

problems such as obesity and diabetes.”

This is why the Local Dental Committees in London are committed to working with the National

Association of Primary Care and other stakeholders to develop the Primary Care Home Model. This

model is being piloted for general medical practice around England but in London the LDCs will take a

lead to engage with practitioners from other disciplines to see how a model can be developed which

truly places the patient at the heart of care. Further details about the Primary Care Home Model can be

found below, and updates on our engagement will be available on the Federation of London Local Dental

Committees’ website: ldc.org.uk

The Primary Care Home is an initiative promoted by the National Association of Primary Care with the

21http://www.healthwatch.co.uk/sites/healthwatch.co.uk/files/20171101_ -

_healthwatch_england_annual_report_2016-17_-_speak_up.pdf retrieved 02/11/17 22 Dentistry in Care Homes 2012 BDA. Available from https://www.bda.org/dentists/policy-

campaigns/research/patient-care/Documents/dentistry_in_care_homes.pdf retrieved 05/10/17 23 BDA op. Cit. pg. 8. 24http://www.qualitywatch.org.uk/sites/files/qualitywatch/field/field_document/QW%20dentistry%20briefing

_WEB.pdf retrieved 02/11/17

http://www.healthwatch.co.uk/sites/healthwatch.co.uk/files/20171101_-_healthwatch_england_annual_report_2016-17_-_speak_up.pdfhttp://www.healthwatch.co.uk/sites/healthwatch.co.uk/files/20171101_-_healthwatch_england_annual_report_2016-17_-_speak_up.pdfhttps://www.bda.org/dentists/policy-campaigns/research/patient-care/Documents/dentistry_in_care_homes.pdfhttps://www.bda.org/dentists/policy-campaigns/research/patient-care/Documents/dentistry_in_care_homes.pdfhttp://www.qualitywatch.org.uk/sites/files/qualitywatch/field/field_document/QW%20dentistry%20briefing_WEB.pdfhttp://www.qualitywatch.org.uk/sites/files/qualitywatch/field/field_document/QW%20dentistry%20briefing_WEB.pdf

17

Support of Simon Stevens, the Chief Executive of NHS England. This model is designed to encourage

groups of primary care practitioners to work together on delivering care for a defined patient base,

usually between 30,000-50,000. The purpose is to redesign pathways around patient populations,

rather than around disease.

Current pilots of the Primary Care Home Model do not involve dental practices as the contractual

mechanisms are very different for GPs and dentists. Dentists do not have registered patients on the

NHS anymore so mapping populations across to the other primary care partners may be difficult. That

being said, primary care reform is on the agenda for NHS England and the LDCs are keen to engage as

early as possible to ensure that dentistry can fit with new models of care.

By focusing care on populations and not disease it is anticipated that additional resources will be freed

up. The British Dental Association recently estimated that 600,000 GP appointments are for dental

issues and that 135,000 patients with dental issues attend A&E. By embedding primary care dentistry

in this new model of working from the outset we are confident that together we can improve patient

services in London.

Key to new ways of integrated working is communication. This is why Brent and Harrow Local Dental

Committee volunteered to be a pilot area for a new portal to help dentists get NHS Mail accounts.

These accounts facilitate secure communication within the NHS and with partner organisations in

social care. The LDCs consider access to NHS Mail vital to supporting effective patient care and are

very supportive of the national plan to finally roll it out across primary care dental services. Once

practices have migrated to NHS Mail 2 we will work with stakeholders and partner organisations such

as NHS Digital to test how its new functions will reform primary care communication and improve the

patient experience.

The LDCs in London will continue to work with Local Healthwatch as detailed in our annex below to

ensure that there is good two way communication between practitioners and the patient voice.

12. What should be our measures of success and level of ambition for creating healthy and thriving

communities?

Engagement with diverse communities should be the chief measure of success. Lower hospital admission

rates for conditions related to poor air quality, as well as regular research into the stress and self -

reported wellbeing of Londoners would allow the Mayor to assess whether his objectives are leading to

happier communities.

18

Healthy Habits

13. Is there more that the Mayor should do to help to reduce health inequalities as well as improve

overall health in work to support Londoners’ healthy lives and habits?

As identified in the draft strategy diet, alcohol abuse and tobacco use are the main causes of lifestyle

related health inequalities and we support the Mayor’s prioritisation of these issues. We support the

Mayor’s objective to reduce levels of childhood obesity and as mentioned in our response to Healthy

Children above, we consider that including oral health in obesity strategies will be an important move to

making this objective a reality. In relation to this and the Mayor’s proposed actions we reite rate our

proposal from section one that the Mayor appoint a children’s oral health adviser to provide input and

feedback on the oral health elements of all children’s health plans operated in the capital.

The second objective, relating primarily to tobacco use we have covered in our response to Healthy

Minds and we support the Mayor’s proposals to reduce tobacco use in London as well as tackling

troubling levels of alcohol use. It is noticeable, however, that the Health Inequalities Strategy does not

mention the importance of tackling shisha, smokeless tobacco and betel nut use. These carcinogenic

products are widely used among different communities, communities that are already at risk of greater

health inequalities for many reasons identified in the Mayor’s draft Strategy. In 2014 the British Society

of Oral Medicine and Cancer Research UK issued a statement on mouth cancer diagnosis and prevention

which identified five key interventions for reducing mouth cancer risk including25:

● Continued action on reducing tobacco use

● Renewed action on reducing alcohol consumption to within recommended levels

● Continued action to reduce areca nut (betel) use.

The statement and recommendations above had wide ranging support from the Chief Dental Officers of

England, Wales, Northern Ireland and Scotland; the Royal Colleges Dental Faculty Deans in England,

Edinburgh and Glasgow; the British Dental Association (BDA); the British Dental Health Foundation

(BDHF); the British Society for Oral and Maxillofacial Pathology (BSOMP), the British Association of Oral

& Maxillofacial Surgeons (BAOMS), the British Association of Oral Surgeons (BAOS), and the Association

of British Academic Oral & Maxillofacial Surgeons (ABAOMS).

The National Institute for Health and Care Excellence (NICE) identified smokeless tobacco use as a cause

for concern among South Asian communities, resulting in the publication of guidance in 2012 for

directors of public health26. We consider that the Mayor should ensure that this guidance is followed in

areas of London where communities are likely to be at high risk of exposure 27. A report by Barts and the

25 “Statement on mouth cancer diagnosis and prevention” C Scully, J Kirby in British Dental Journal. 2014

Jan;216(1):37-8. 26 Smokeless tobacco: South Asian communities Public Health Guideline 39 2012. Available from

https://www.nice.org.uk/guidance/ph39/chapter/1-Recommendations 27 While khat has been made illegal, classed as a class C drug like cannabis, betel nut commonly sold as

paan is legal.

https://www.nice.org.uk/guidance/ph39/chapter/1-Recommendations

19

London in Tower Hamlets showed that while knowledge about the carcinogenic effects of tobacco were

known by the majority of respondents, the majority of respondents were unaware that betel nut and

paan would increase likelihood of developing oral cancer28. The same report also showed a dramatic

increase in awareness following production of information leaflets. Importantly, this report found that

only 39 per cent of those involved attended a dentist regularly, with 38 per cent of those not attending

failing to do so because they felt there was no need. The NICE guidance calls on local authorities to

ensure that their Joint Strategic Needs Assessments gather information on when and how cessation

advice is promoted and provided to potential users of smokeless tobacco29. Engagement should also be

undertaken by the local authorities with communities identified. The Mayor should support local

authorities in this engagement and further recommend that the profession is engaged through the Local

Dental Committee to ensure that oral health advice is provided at the same time - to both highlight the

risks of oral cancers caused by smokeless tobacco and reinforce oral health messaging.

Some local authorities are actively pursuing campaigns to highlight the risks of shisha use, and we would

support a joined up approach across London. Cancer Research UK and The British Heart Foundation

make it clear that shisha is just as addictive and harmful as cigarette smoking and, since the social aspect

of shisha smoking is different, it is possible that people can inhale the same amount of smoke as 100

cigarettes in one shisha session30. Shisha is often flavoured and this can make people assume that it is

less dangerous than other tobacco products.

LDC Recommendation 11. We recommend a Mayor of London led campaign informing different

community groups about the dangers of shisha, smokeless tobacco, areca nut, betel nut and other

carcinogenic products use in a pan-London campaign in conjunction with local authorities.

14. What can you do to help all Londoners to develop healthy habits? What is preventing you from

doing more and what would help you?

The LDCs work closely with local Cancer Research UK facilitators to promote healthy living campaign

initiatives such as Dryathlon and other stop drinking and stop smoking initiatives.

Cancer Research UK facilitators have been attending Local Dental Committee meetings in south

London to gather feedback about referral services and training requirements. Croydon Local Dental

Committee is in discussions with their local Cancer Research UK faci litator to arrange training event on

oral cancers for dentists and practice staff. We hope to see more collaboration like this in the future.

28 https://www.food.gov.uk/sites/default/files/betel -nut%20usage.pdf retrieved 06.11.17 This report also

noted that the Bagladeshi community in London has higher rates of oral cancer because of the higher rates of use of tobacco, smokeless tobacco and betel nut use and the misconception that betel nut is

good for health. 29 We are aware that the Stop Smoking services in Ealing run a targeted smokeless tobacco programme

and believe that Tower Hamlets does too, but we would welcome a coordinated and consistent approach which engages local dental practices. 30 https://www.bhf.org.uk/heart-health/risk-factors/smoking/shisha retrieved 02.11.17

http://www.cancerresearchuk.org/about -cancer/causes-of-cancer/smoking-and-cancer/shisha-and-other-

types-of-tobacco retrieved 02.11.17

https://www.food.gov.uk/sites/default/files/betel-nut%20usage.pdfhttps://www.bhf.org.uk/heart-health/risk-factors/smoking/shishahttp://www.cancerresearchuk.org/about-cancer/causes-of-cancer/smoking-and-cancer/shisha-and-other-types-of-tobaccohttp://www.cancerresearchuk.org/about-cancer/causes-of-cancer/smoking-and-cancer/shisha-and-other-types-of-tobacco

20

As the local representative voice of dentists the Local Dental Committees will engage with stakeholders

in their strategies to promote healthy living and promote relevant communications. We will work with

the London Dental Network, Health Education England, NHS England (London Region) and Public Health

England (London Region) on the development of strategies and implementation of campaigns and

learning designed to raise awareness of the risks to oral and overall health of poor lifestyle choices.

15. What should be our measures of success and level of ambition for helping more Londoners to

develop healthy habits?

The success of this ambition can be measured by a commensurate reduction on treatments in hospital

and primary care for conditions related to poor lifestyle habits, as well as a drop in smoking rates. This

will only occur, however, after an increase in attendance at primary care and pharmacies while people

respond to positive messaging and seek advice. If the Mayor follows our recommendation for a targeted

information campaign for specific groups of users of smokeless tobacco and areca nut then a measure

can be put in place for local authorities to assess engagement and reaction to the messaging.

21

GENERAL COMMENTS

As noted in our introduction we believe that maintaining good oral health can make a real difference to

improving the quality of life of some of London’s most vulnerable residents. The LDCs will work with the

Mayor, NHS England (London Region), the London Dental Network and other stakeholders to ensure

that dentistry is embedded in the healthcare system of the capital. Below we set out some general

considerations and wider issues that we would like to bring to the Mayor’s attention. We include more

detailed information on some points that we have already made in the main response and have

attached an annex explaining how the dental contract works. We hope that this information is helpful

and are confident that by raising the profile of oral health we can, together, have a positive impact on

the wider determinants of health and reduce inequalities. Poor oral health is associated with

deprivation, and while addressing poor oral health will not solve all problems it may help improve

people’s life chances, happiness and reduce inequality for those in the greatest need. Joining oral health

up with strategies tackling obesity, smoking, diabetes and other conditions will have a dramatic effect

on ensuring mutually supportive messaging designed to reduce inequalities.

The final paragraph of our introduction mentioned the wide ranging contribution that we feel dentists

make to their community from setting up a local business and employing local people to providing

quality and life enhancing care. We feel that this contribution would, as with other col leagues who make

similar investments, benefit from some central recognition. We are also aware that there is a paucity of

good news about dental services and are concerned that repeated negative reporting can have an

impact on care. It is time for more to be made of the great success that is NHS general dental practice in

England. We therefore recommend that the Mayor institutes a system of recognition for dental teams to

raise the profile of high performance care.

LDC Recommendation 12. The Mayor to initiate a system of recognition for providers and teams who

have made significant contributions to their local community in improving oral health

There are many misconceptions around general dental practice which we are concerned have an impact

on patients’ decisions to access care. We have written to the Department of Health to make it clear that

messages about the NHS being free at the point of use are not true for many people accessing NHS

dental care and that this is extremely confusing31. There is significant confusion among the public about

NHS dental charges. This has been shown by the British Dental Association in their report A Tax on Teeth

and in various Healthwatch reports, including by Healthwatch Camden. Not only would the removal of

dental charges from dental practices reduce confusion and complaints but it may well increase

likelihood of attendance. The profession firmly believes in the importance of the service they provide

and those of us who work for the NHS firmly believe in its principles and support the removal of any and

all barriers to accessing care. Data shows that nationally more Band 3 courses of treatment are carried

out on patients exempt from patient charges with 49.1 per cent of Band 3 courses of treatment being

31 A copy of our correspondence with the Department of Health is available from https://ldc.org.uk/ldcs-

write-department-health-reminding-nhs-dentistry-not-free/

https://ldc.org.uk/ldcs-write-department-health-reminding-nhs-dentistry-not-free/https://ldc.org.uk/ldcs-write-department-health-reminding-nhs-dentistry-not-free/

22

delivered to this group showing the clear link between deprivation and oral health need. The dental

budget must be made more responsive to patient need and support dentists to deliver care to where it

is most needed. The current contracting arrangement makes this unsustainable and unaffordable.

It is unsurprising to us that confusion over NHS dental care exists. There are persistent public facing

messages from the NHS, Department of Health and government that the NHS is free at the point of use.

It is not for NHS dentistry. This mixed messaging along with other damaging messages serves only to

confuse and undermine public confidence32. Confusing information over the frequency of attendance

was highlighted by Healthwatch as a “common issue”33. Rather than publicising confusing messages we

consider that the NHS and Department of Health should be doing more to ensure that dentists are

supported in their clinical judgements. Similarly those who know they must pay a charge for NHS

dentistry may think that the practice sets or keeps the payment, which is not the case and can cause

difficulties in relationships. Many reports from different bodies refer to patients being registered with a

dental practice and a fear from patients that they will be de-registered. This is not the case as patient

registration ended in 2006. A patient is under the care of a practice only while they are in a course of

treatment. They can then make another appointment, but they are not registered to the practice. While

this may seem unimportant it is extremely frustrating to the profession that such inaccurate information

is propagated by bodies which should inform patients correctly. Current guidance which the NHS

expects practices to follow undermine years of public health messaging. Many peopl e grew up with the

message that they should visit a dentist every six months. Current guidelines extend recalls to two years

for those who are dentally healthy and likely to remain so.

In 2016 the British Dental Association commissioned YouGov to find out more about the public’s

perception of the impact of oral health on life chances34. The results showed that those with poor oral

health will be on the receiving end of discrimination and stigma, severely affecting their life chances.

There has long been an association between those from lower socio-economic groups having poorer

oral health into adulthood in the UK35, and a presumption that early years intervention will mitigate

against this36. Reports show that there is a correlation between oral health status and self-esteem,

particularly for those from lower socio-economic backgrounds37.

32 “Going to the dentist every six months is unnecessary, says UK's top dentist” Daily Telegraph 07

September 2016. Retrieved 27 March 2017: http://www.telegraph.co.uk/news/2016/09/07/going-tothe-

dentist-every-six-months-is-unnecessary-says-uks-to/ “Dentists clogged up by ‘worried well’ insisting on unnecessary check-ups” The Sun 08 September 2016. Retrieved 27 March 2017: https://www.thesun.co.uk/news/1746566/dentists-clogged-up-byworried-well-insisting-on-unnecessary-

check-ups/ 33 Healthwatch op. Cit. page 28. 34 British Dental Association 2016: https://www.bda.org/news-centre/press-releases/bad-teeth-hurting-

career-prospects retrieved 21 July 2017 35 ‘Self-Esteem and Socioeconomic Disparities in Self-Perceived Oral Health’ D Locker. Journal of Public

Health Dentistry 2009 Volume 69, Issue 1, pages 1-8. 36 ‘Association between children's experience of socioeconomic disadvantage and adult health: a life-

course study’ R Poulton et. al. in The Lancet Volume 360, Issue 9346, 23 November 2002, Pages 1640-

1645 37 Locker op. Cit.

http://www.telegraph.co.uk/news/2016/09/07/going-tothe-dentist-every-six-months-is-unnecessary-says-uks-to/http://www.telegraph.co.uk/news/2016/09/07/going-tothe-dentist-every-six-months-is-unnecessary-says-uks-to/https://www.thesun.co.uk/news/1746566/dentists-clogged-up-byworried-well-insisting-on-unnecessary-check-ups/https://www.thesun.co.uk/news/1746566/dentists-clogged-up-byworried-well-insisting-on-unnecessary-check-ups/https://www.bda.org/news-centre/press-releases/bad-teeth-hurting-career-prospectshttps://www.bda.org/news-centre/press-releases/bad-teeth-hurting-career-prospects

23

We are keen to work with the Mayor to ensure that Londoners have access to dental services. On the

one hand data clearly shows that access to NHS care in London is the lowest in the country at 45.2

compared to the national average of 51.538. Within London 15 boroughs have access below 44.5 per

cent for adults, with a further six boroughs reporting access at between 44.5-49.7 per cent for adults.

Treatment data shows that those in London have significantly greater need than outside of London 39:

Figures from the HSCIC show that in the third quarter of 2016/17 39.8 per cent of UDAs claimed in

London were for Band 3 treatments, compared to the national average of 29.8 per cent40. The picture

continues to deteriorate for children’s access with 23 boroughs showing access at lower than 52 per

cent for children in the 12 month period ending March 2017. The total access figure for children in

London is 48.9 per cent compared to the national average of 58.2 per cent.

On the one hand it may appear that there is no significant access problem as contracts underperform

and unperformed funding which has not been used on patient care is recouped annually. While it is true

to say that there is contractual underperformance the conclusion that there is too much resource

allocated to NHS dentistry in London is false, however. As explained in the annex the current contract

works on blocks of activity called Units of Dental Activity (UDAs). These UDAs are not responsive to

patient need as they treat a low needs patient as the same as a high needs patient; there is no

distinction made in the payments according to level of need, differentiated within a treatment category,

i.e. a person who requires a single filling is treated the same as someone who needs four fillings. While

the LDCs in London support the patient not being penalised financially for poorer oral health, the impact

is felt in the practice overheads and this is not sustainable. The result is a contract which effectively

punishes a practice for encouraging access for those with the greatest need. This cannot be compatible

with a universal health service and the Mayor’s drive to reduce health inequalities. We therefore call on

the national bodies, the British Dental Association, Department of Health and NHS England, to work

together on reforming the regulations to allow practitioners to split a course of treatment for those with

severe dental treatment need, until a permanent contractual arrangement is reached. It is correct to

claim that there is clawback and undelivered care but the reason is not that there is too much care or

money in the system, but that the system is so perverse that it does not release the money in the UDAs

in a way which is responsive to patient need. It is for this reason that the profession has been so vocal in

its calls for a reformed contract.

The “sugar tax” to be introduced from April 2018 should be used to fund children’s oral health

programmes as these will also have an impact on obesity. Currently, we understand, revenue generated

from this source is to be used to fund exercise programmes and other initiatives to help tackle childhood

obesity. We support the objective of reducing childhood obesity and increasing physical activity but feel

38 HSCIC NHS Dental Statistics for England - 2016-17, Third Quarterly Report May 25, 2017 available

from

http://content.digital.nhs.uk/searchcatalogue?productid=25121&topics=1%2fPrimary+care+services%2fDental+services&sort=Most+recent&size=10&page=1#top retrieved 29/09/17 39 HSCIC op. Cit. footnote 2. 40 For an explanation of the NHS Banding system please see annex below.

http://content.digital.nhs.uk/searchcatalogue?productid=25121&topics=1%2fPrimary+care+services%2fDental+services&sort=Most+recent&size=10&page=1#tophttp://content.digital.nhs.uk/searchcatalogue?productid=25121&topics=1%2fPrimary+care+services%2fDental+services&sort=Most+recent&size=10&page=1#top

24

that oral health initiatives for children would address two issues. Educating children and parents about

sugar intake and its effect on the mouth will reduce the number of avoidable hospital admissions, and

also serve to instill good messages around eating and overall health. Instilling good oral health habits at

a young age will pay dividends and propel the oral health of London’s children from national disgrace to

shining example.

It must, therefore, be a priority of the NHS and politicians to ensure that those with the greatest need

have access to NHS dental care to not only improve oral health but to safeguard self -esteem and help

safeguard life chances.

Health and Wellbeing Strategies A quick assessment of current Health and Wellbeing Strategies in London shows that oral health does

not feature with any prominence. Given the opportunity that dentistry represents for engagement with

the public this is extremely disappointing. Of the 22 strategies current in boroughs with Federation Local

Dental Committees only three contain oral health as a specific workstream or case study. In total nine

strategies mention oral health in some sense, though six of these are simple statements about visiting

the dentist. This is surprising given the number of times and frequent occurrences in the strategies of

diabetes, obesity, smoking, alcohol and cancer. NICE guidance for local authorities makes it clear that

they should have regard for oral health and engage with professionals to de liver oral health

improvement strategies in conjunction with these other issues. We would expect that, if councils want

to make the greatest impact on these issues that dentists would be key stakeholders as whatever goes

in the stomach goes through the mouth first. We anticipate that the Mayor’s Health Inequalities

Strategy will affect how future Health and Wellbeing Strategies in London are focused and suggest that

the Mayor supports borough engagement with their LDCs to ensure that they have a rounded vie w and

opinion on how to meet the needs of their populations.

Healthwatch reports Healthwatch is the national patient champion for health and social care in England. Each London

borough has a Healthwatch which works with their community to identify and address issues in the

provision and delivery of service. Some of these Local Healthwatches in London have published reports

or undertaken other activity in relation to primary dental care. It is the hope of the Federation LDCs that

every Healthwatch will engage with its community to create a robust picture of the patient perspective

on dentistry in the capital which can be used to generate improvements. We will engage with

Healthwatch at their Pan-London level to share information about access rates and locally issues from

general dental practitioners to help the individual Healthwatches determine whether they wish to run

specific programmes on dentistry.

A. Camden: Camden Healthwatch launched an investigation into BAME groups’ experiences of accessing

25

dental care in Camden in early 201741. They engaged with the Local Dental Committee to gather

information about how the dental contract works and where patient and practitioner expectations

differ. The report highlighted many of the concerns that the profession has about dental services,

including high patient charges, lack of information available in a suitable format and lack of clarity over

what is available on the NHS. Camden and Islington LDC has met with Camden and Islington Health and

Wellbeing Board, the Community Dental Services provider and Camden Healthwatch to discuss how the

report’s recommendations can be taken forward and recommendations are now being taken forward

together. One major issue highlighted in this report and that we have seen reported by dentists across

London is that lack of effective translation provision. There is no consistency or clarity on cost and

appropriateness.

B. Barnet: From 2015-16 Barnet Healthwatch published three reports on dentistry. The latest, from

November 2016, assessed family attitudes and experiences of dental care in the Borough 42. They found

that over 20 per cent of respondents did not have access to a dentist within walking distance of their

home, which was felt to be a major issue for those with mobility issues and those with young families.

As with other reports cost was a major factor deterring visits to the dentist.

C. Bexley: In early 2016 Bexley Healthwatch published the findings from a series of Enter and View visits

to dental practices43. The report found that the vast majority of residents (87 per cent) were satisfied

with their care. Cost was once again cited as an important factor for people when deciding whether to

access care or treatment.

D. Enfield: Healthwatch Enfield has a page on its site allowing patients to review their dental practice.

E. Lambeth: Healthwatch in Lambeth was focussing on care provided to those with learning disabilities.

As part of their review of services Lewisham Healthwatch visited eight dental practices, including two

run by the Community Dental Services44. They found that overall the quality of care was high but felt

that primary care dentists may benefit from more support from the community dental service

colleagues. Concerns were raised that some information provided by the NHS was not accessible, but it

was recognised that this was not the fault of the practice. This pragmatic and constructive engagement

was welcomed by the LDC.

F. Waltham Forest: Healthwatch Waltham Forest conducted a patient experience report based on data

from 2013-2015. This report was based primarily on feedback collected from NHS Choices with the

majority of feedback being positive.

While it is positive that some local Healthwatches have chosen to engage with dentistry it is a

disappointingly small minority. In addition, some have not engaged in the most robust way. As the local

41 Available from: http://www.healthwatchcamden.co.uk/resources/accessing -dental-services-camden-

experiences-local-people retrieved 25 July 2017 42 Dental Care in Barnet A Report on Family Attitudes and Experience, Barnet Healthwatch 2016,

http://www.healthwatchbarnet.co.uk/sites/default/files/uploads/Dental%20Report%20HSB-HW%20Final%20Version%20Nov%202016.pdf retrieved 24 July 2017 43 http://www.healthwatchbexley.co.uk/sites/default/files/report_ -_dentist_enter_and_view_bexley_0.pdf

retrieved 24 July 2017 44 Enter and View: Right for Everyone: Dental Practices Visits Report Healthwatch Lambeth June 2017

http://www.healthwatchlambeth.org.uk/wp-content/uploads/2017/07/HWL-R4E-dentist-enter-and-view-

report-FINAL.pdf retrieved 25 July 2017

http://www.healthwatchcamden.co.uk/resources/accessing-dental-services-camden-experiences-local-peoplehttp://www.healthwatchcamden.co.uk/resources/accessing-dental-services-camden-experiences-local-peoplehttp://www.healthwatchbarnet.co.uk/sites/default/files/uploads/Dental%20Report%20HSB-HW%20Final%20Version%20Nov%202016.pdfhttp://www.healthwatchbarnet.co.uk/sites/default/files/uploads/Dental%20Report%20HSB-HW%20Final%20Version%20Nov%202016.pdfhttp://www.healthwatchbexley.co.uk/sites/default/files/report_-_dentist_enter_and_view_bexley_0.pdfhttp://www.healthwatchlambeth.org.uk/wp-content/uploads/2017/07/HWL-R4E-dentist-enter-and-view-report-FINAL.pdfhttp://www.healthwatchlambeth.org.uk/wp-content/uploads/2017/07/HWL-R4E-dentist-enter-and-view-report-FINAL.pdf

26

patient voice we think it is extremely important for Healthwatch to work with dental practices to ensure

that the local population has access to high quality dental care. Where the LDCs have been contacted

they have supported the work of their local Healthwatch by providing input and responses to the

reports and we are confident that by working together improvements to services can be made. It cannot

be forgotten, however, that many recommendations and mechanisms for improving services are not for

dental practices or LDCs to implement but rely on the NHS either providing greater resources or

increased support for the provision of services. It is the hope of the LDCs within the Federation that

increasing engagement with a wide range of stakeholders will improve the chance of NHS dentistry

receiving the support from the central NHS that it so desperately requires, and nowhere requires this

support more than London.

Healthwatch Camden approached the Camden and Islington Local Dental Committee at the

development stage of their report into access to dental care in Camden. The LDC welcomed the early

engagement and provided information and background to Healthwatch Camden. Following the

submission of a response to the report the LDC identified a lead to work with Healthwatch and other

local partners to implement some of the recommendations made.

Healthwatch Lambeth conducted enter and view inspections of eight dental practices in the borough

as part of their series investigating how those with learning disabilities access primary care services.

They approached the Lambeth, Southwark and Lewisham LDC for their support and presented the

final findings. The LDC responded to the report and has offered to provide speakers at Healthwatch

events to answer questions about NHS dental services. We are pleased that after this report the LDC,

Healthwatch Lambeth, the Community Dental Services provider and Lambeth Early Action Partnership

all in close communication to ensure consistency of message and mutual support.

These are just two examples of LDC engagement with local Healthwatch, and examples we would like

to see replicated across London.

The LDCs in London are grateful for this opportunity to raise the issue of oral health in the Capital with

the Mayor and are committed to working with partners to achieve the recommendations and actions we

have listed above. As well as our response we urge the Mayor to consider the recommendations and

evidence presented by other dental stakeholders, particularly the Bri tish Dental Association and the

London Local Dental Network. The Federation of London Local Dental Committees

Waterhouse Square 138 Holborn

London EC1N 2SW

Contact@ldc.org.uk

mailto:Contact@ldc.org.uk

27

ANNEX:

How do NHS dentists get paid?

NHS England pays for dental practices to look after the oral health of people. NHS England works out

how much to pay NHS dentists for doing this by using Units of Dental Activity (UDAs). These UDAs are

like tokens that NHS England give to local dentists. When a dentist sees a patient at their practice the

dentist uses up a number of these tokens. The dentist has to use up between 96 and 102 per cent of the

UDAs allocated each year.

How many UDA tokens does a dentist use to see a patient?

The dentist uses a different number of UDAs depending on which treatment Band their patient needs.

Band 1 treatments use one UDA. Band 1 treatments include simple things like a check-up and a teeth

clean (for clinical reasons).

Band 2 treatments use thee UDA. Band 2 treatments are more complicated and include things like

fillings.

Band 3 treatments use 12 UDA. Band 3 treatments are the most complicated treatments, like dentures

and crowns45.

The dentists only submits a notice on the use of tokens for each course of treatment, not for each

treatment itself. So, if a dentist sees a patient who needs one crown they report the use of 12 UDA

tokens. And if a dentist sees a patient who needs three crowns and needs to come back over several

visits, they still only report the use of 12 UDA tokens. This means that dentists don’t get credited for

doing extra or more complicated work.

What is a UDA worth?

The average value of a UDA in London is £28.88. However, the amount that the UDA is worth is not fixed

across the country or even across London so NHS dentists get paid different amounts from place to

place. The total amount of money a practice receives from the NHS is the value of the UDAs times the

number of UDAs allocated to the practice, minus any UDAs not used at the end of the financial year. The

money paid by the patient, the patient charge, does not contribute to the practice’s income.

How many UDA tokens do dentists get?

Local dentists are given a set number of UDAs each year. The number of UDAs they get depends on how

many people they treat, the number of people living in their area and the expected treatment need. This

information, however, is based on data from before 2006 (when the current contractual system for

dental services was introduced) so the number of UDAs may no longer be reflective of need or worth an

amount reflective of providing that care.

A typical dental practice may have about 4000 UDAs to last a year. The dentist has to make sure that

they use their UDA tokens in a steady way and don’t use up all their tokens at once or save them all up

until the end of the year. Dental practices have to make sure that they do not run out of UDAs.

45 There are additional UDAs credited for other activity, such as emergency appointments

28

Patient Charges

● For each of the three bands of course of treatment there is a mandatory charge f or the patient46.

● The charge is set by the government and has been increasing by five per cent a year for the last

two years.

● Overall, patient charge revenue has grown by 66% in last decade.

● Contrary to common belief the patient charge does not go to the dental practice as additional

income – it is collected by the practice and given back to the NHS.

● In some cases the UDA value is actually lower than the NHS dental charge, resulting in