Spotlight: dentistry ‘in crisis’

NHS dentistry in Northern Ireland has reached crisis point, according to the BDA NI, writes Stewart McRobert.

In a recent submission to the Northern Ireland Affairs Select Committee Inquiry on Funding for 2018/19, the organisation outlined a litany of deficiencies, from an “abject failure to invest in the people who deliver Health Service dentistry” to strategic inadequacy and abdication of responsibility.

It sets out a case for increased investment and development of co-ordinated plans that can bring better oral health for all.

The Northern Ireland Dental Practice Committee believes action is needed urgently to improve the low morale that permeates the profession and endangers health service provision.

Its chair, Richard Graham, said: “First of all we need the immediate implementation of the Doctors’ and Dentists’ Review Body (DDRB) recommendations for 2018/19. Because Northern Ireland doesn’t have a government, we don’t know if we are getting any award and, if we are getting anything, how much it will be or whether it will be backdated to 1 April.”

He added that it took 18 months for the previous pay award to be implemented and “that simply is not good enough. Practitioners are business people and they need certainty”.

Speaking on behalf of the committee, Richard also called for the reinstatement of commitment payments. “They removed payments a couple of years ago because of a projected overspend in the dental budget that didn’t actually happen. Reinstatement would go some way to address the low motivation of dentists committed to the health service.”

He argued that the quality improvement scheme that allows practices to invest in patient care must be confirmed as an annual programme, and he called for a relaxation of the regulatory regime.

“I believe that even some within the Regulation and Quality Improvement Authority (RQIA) have admitted that the regulation is not fit for practice.

“We would ask for a move to a two-year inspection schedule. In England, practices are likely to receive an inspection once every ten years.

“However, in Northern Ireland, practices are classified as a ‘small independent hospital’ and inspected every single year – that is totally inappropriate.”

Underspend

The Health and Social Care Board recently released the figures for first quarter expenditure in 2018/19. “At the end of month four, there was already a £1.4m underspend,” said Richard, “and there’s a projected year-end underspend of £3.7m.”

He is frustrated that, according to the report, this underspend will be allocated elsewhere.

“It seems they are removing money from dentistry to address a pharmaceutical services overspend.”

Dentistry underspend is not a new phenomenon in Northern Ireland. In the three years to 2017-18, the total underspent was £7.5m.

Richard emphasised: “We have a service that is experiencing unprecedented pressure, and money is available, yet it is not being spent. It’s not rocket science. We need investment in practices now.”

“In Northern Ireland, practices are classified as a ‘small independent hospital’ and are inspected every single year – that is totally inappropriate”

Richard Graham

The committee is unimpressed by the argument that the lack of an executive necessarily means a lack of action. “These problems exist, and they can’t just keep saying there’s no minister to make a decision. Somebody has to make a decision over the implementation of the DDRB recommendation. It’s not contentious.”

Another frustration is the refusal of those in charge to discuss dentists’ concerns. “[Permanent Secretary at the Department of Health] Richard Pengelly has refused to meet with dentistry on a number of occasions. We don’t know why, but we are simply told to speak to the chief dental officer.

“Sadly, he simply fobs us off, though to be fair I don’t think he is being listened to by the Department of Health. If they are prepared to raid the dental budget to pay off the pharmaceutical services it shows dental health is not a priority.”

Many people believe the current state of play in the profession is unprecedented, and BDA NI is concerned about the potential impact of the situation. Richard cited examples of practices where turnover has been so low in some months that the practice owner has had to pay staff from their personal account.

“The goodwill of dentists has always been there to put their patients first. However, practice owners are running a business. They have bank loans to pay and children to feed. It’s getting to crisis point. If decisions aren’t made now practices will close their doors or go private.”

 

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A treatment plan for Northern Ireland dentistry

Here is the full set of recommendations submitted by BDA NI to the Northern Ireland Select Committee:

• HM Treasury to allocate additional funding to health to put services on a sustainable footing and create headroom for transformation.
• UK Government to announce an end to the pay cap in Northern Ireland for dentists and other public sector workers/contractors. Pay uplifts should be announced immediately in accordance with the recommendations of the Doctors and Dentists Review Body.
• In lieu of a NI Executive, UK Government to authorise immediate implementation of “new” Community Dental Services Contract.
• UK Government to instruct Department of Health and HSCB to engage with BDA Northern Ireland towards compensating GDPs for increased expenses incurred in delivering NHS dentistry.
• In the absence of an Executive, UK Government to mandate Department of Health to develop a new oral health strategy to be co-produced with the dental profession.
• In the absence of a NI Executive, UK Government to sign-off “spend to save” initiatives in dentistry, including universal nursery toothbrushing initiatives, and HPV vaccine to be extended to boys as “cost effective”.
• UK Government to intervene to ring-fence sugar levy monies to be spent on improving child public health, including a significant proportion on
  improving oral health.
• Additional investment in addressing gaps in provision of oral care of the growing elderly population, particularly those living in care homes, with input from dental profession.
• A ‘Health-in-all policies’ approach to be taken forward across all Northern Ireland Government departments, under an approved programme for government.
• Increased funding to Public Health Agency, and a clear remit established for improving oral health.
• Additional investment to address long waiting lists for hospital dental service referrals, including oral maxillofacial surgery and paediatric dental departments.
• ‘Government’ to guarantee the long-term sustainability of NHS  dentistry by investing adequately in provision of services and dental professionals who deliver these.

 

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Official Response

Department of Health says pay is a local issue and policy still to be set

The Department of Health has responded to the issues raised by Richard Graham and BDA NI.

On the need for immediate implementation of the DDRB recommendations, a spokesperson said: “Public sector pay is a devolved matter that is determined locally and pay policy has yet to be set for 2018/19. This is a matter the Department of Finance is currently considering, and once it is set, it is for departments and other public sector employers to bring pay proposals forward to be considered for approval as and when appropriate.”

There is recognition that the removal of commitment payments was unpopular. However, the spokesperson added: “The potential for savings was focused on this allowance in order to protect the practice allowance (which plays a greater role in maintaining practices). It is the one element of the savings proposals that could be guaranteed, made up a significant proportion of the overall savings and would not be affected by any changes in dentists’ clinical activity.”

The department also said, that from its point of view, commitment payments did not directly impact on the provision of dental treatments, so there would be no oral health impact from amending or withdrawing these.

Recognising that there is broad support to reduce the minimum number of inspections for dental practices from once every year to once every two years, the department pointed out that legislation has been finalised in draft but could not be progressed without a minister/assembly.

On a projected dental budget underspend being used to offset pharmaceutical overspend, the spokesperson noted: “The General Dental Service budget is demand led, so it may happen to offset another overspend within the wider family health service budget at year end, but this is
not planned.”

There was also a reiteration of the stance that decision-making is limited without ministers.

Meanwhile, on the refusal of Richard Pengelly to discuss dentists’ concerns directly with BDA NI, it was explained that diary commitments made a meeting in March 2018 difficult, but: “There is now a meeting planned in early December between Department and Health and Social Care Board colleagues with BDA NI to discuss concerns regarding non contract issues such as dental pay uplifts and the general financial situation plus the sustainability of Health Service dentistry among independent contractors.”

 

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In Brief

RCSI meeting focuses on medical problems

The Annual Scientific Meeting of the Faculty of Dentistry RCSI held in October, titled ‘Is It Safe? Understanding & Managing Dental Patients With Medical Problems’, presented a focused medical update and dental implications for the busy GDP.

This year, the lectures were held for the first time in RCSI’s new facilities at 26 York Street, Dublin. More than 300 delegates enjoyed lectures from medical specialists in cardio/cerebro vascular, pulmonary, metabolic, anaesthetic and pharmacological medicine, as well as dental specialists. The programme ended with the Edward Leo Sheridan Lecture 2018, presented by Professor Michael Glick.

The OSI Seamus Keating Award

The Orthodontic Society of Ireland (OSI) has issued a call for entries for The OSI Seamus Keating Award. This new award, established in 2018, offers an opportunity to postgraduate students in orthodontic specialist programmes in Ireland or internationally, to present clinical science or basic science-based projects in orthodontics as part of a presentation at the OSI annual session, which will be held on 12-13 April 2019 at Hayfield Manor Hotel, Cork City, Ireland. The closing date for entries is 1 March.

Tags: crisis, Dentistry, funding, Invesment, November 2018