SAFEGUARDING DENTAL HEALTH IN CRAVEN

EQUAL ACCESS, EQUAL OPPORTUNITES

A REVIEW OF DENTISTRY PROVISION IN CRAVEN

Overview and Scrutiny – Dentistry Working GroupJune 2010

CONTENTS PAGE

Page Number(s) Topic

3 - 4 Chairman’s Foreword

5 - 7 Executive Summary of Recommendations

8 Dentistry – Issues, Terms of Reference and Methodology

Views and Evidence Section

9 - 14 NHS North Yorkshire and York (Primary Care Trust)

15 - 17 Dentists

18 - 19 The Public

Appendices

20 NHS (and average private) dental treatment charges

21 List of NHS dentists in Craven (and how to register)

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CHAIRMAN’S FOREWORD

Often we’re all guilty of taking life - especially our health - for granted. We usually put off going to the doctor’s or hospital until there’s something wrong. In the cases of dentists it’s more often when there’s an emergency, you’re in agony with toothache….and then you wish you had been registered with a dentist!

This sounds melodramatic but dental healthcare is critical and can even prevent cancer. This is why we decided to tackle this serious issue which potentially affects everyone – young or old – we all need to go to the dentist at some time or other. Although the Council is not responsible for dentistry provision, one of the Council’s key priorities relates to ‘Promoting the Well-Being of Craven’s Communities’ which includes helping to safeguard the health of its citizens. People are often put off registering with a dentist as there appears to be no spare capacity or the nearest dentist is some distance away. There may be a variety of reasons – some are valid, some are myths – including people perhaps not realising how simple it is to be added to a waiting list or lack of public information.

The key focus of this review was to ensure that Craven residents have decent access to a dentist for good dental health through establishing whether the ratio of dentists (and services) to patients was about right, that waiting times (including registering) to access a dentist were satisfactory. We also considered if the distance and travelling time to a dentist was reasonable. The focus was on NHS provision but also looked at the private sector to establish any differences in provision/service and also any gaps that could possibly be filled through improved working.

Various key elements of dentistry provision were considered including: Identifying dentistry services that exist across Craven and by geographical

spread; Identifying NHS and private dentistry providers; Quantifying the size of waiting lists, waiting times and geographical

differences; Identifying what is an acceptable average waiting time to be registered; Marrying this information with data from NHS North Yorkshire and York

(Primary Care Trust) to better understand the level of provision and investment and any other innovations/issues; and

Also scanning neighbouring areas such as West Yorkshire.

For this review we sought feedback from dentists, other healthcare professionals and patients/residents concerning their experiences. We advertised details of the review widely with an article in newspapers such as the Craven Herald and Yorkshire Post, sent public notices to dentists and doctors for displaying in their practises. We also wrote to a sample of representative (NHS and private) dentists inviting their input through informal interviews with Members of the Working Group and also NHS North Yorkshire and York (Primary Care Trust) who are the main organisation responsible for overseeing provision of dental services.

As well as the above views, we sought statistical evidence and details of policies and investment plans from the PCT. They provided detailed information on: levels of provision; formulae used to calculate ‘units of dental activity’ (averages for frequency of visits to dentists and quantity of treatment etc); costs of treatment; contracts with dentists and service expectations; investment in dentistry services; and opportunities.

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Our meeting with the PCT was valuable, we found their attitude very positive and planned approach to dentistry provision well structured. They were keen to ‘tap-in’ to our local knowledge so we look forward to developing a fruitful partnership.

Our findings have been interesting, for example: There are clearly views and evidence from different sources that are correct

in themselves but provide a conflicting picture ‘on the ground’ of provision of dental services;

Whilst across Craven – as a whole – there’s reasonable dental coverage it could be better matched in terms of where it’s most needed – local ‘hot-spots’;

Not all available dental resources are fully used by people – greater awareness needs to be increased;

Next steps - we plan to present this report and recommendations to the PCT (and other interested parties). We expect a response from the PCT which will hopefully lead to a structured action plan with target deadlines for implementing proposed improvements which we shall monitor. The PCT have already committed to updating us with progress concerning dental contract tendering and awards in the summer.

Concluding remarks - last but most importantly – patients need to be supported through good access to dental healthcare and that the Council also needs to be proactive through communications and promoting awareness of local dental services.

Councillor Helen Firth, Councillor Helen Firth, Chairman,Dentistry Working Group and Overview and Scrutiny Committee, April 2010

Members of Dentistry Working Group Councillors Helen Firth (Chairman), Lin Barrington, Stephen Butcher, Robert Mason and John Roberts.

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EXECUTIVE SUMMARY OF RECOMMENDATIONS

The majority of recommendations are for the PCT to consider and it is anticipated that – agreed recommendations – will form an action plan for implementation which Overview and Scrutiny (O&S) will be able to monitor. Some recommendations are for the Council (or other parties). Some recommendations are of general interest.

Recommendations for NHS North Yorkshire and York (Primary Care Trust)

R1 That the level of dentistry provision across Craven – as a whole – needs to be raised to the Primary Care Trust’s 66% access target. However, this should follow careful investigation, including evidence of low take-up of dental opportunities in any area, with an aim to spreading access – as appropriate - across Craven to achieve the ‘best fit’. Provision of dentists in North Craven needs to be particularly improved to reduce existing inequalities compared with Skipton and South Craven.

R2. That significantly greater awareness needs to be achieved concerning the under-used community facilities at Skipton Hospital and the Settle Health Centre which provide emergency treatment and services for vulnerable people. These services should be promoted in dentists’ surgeries and through NHS Direct. Alongside this (or in place of) the PCT should consider the option of investing in a mobile dentistry service (like mobile libraries) offering a regular ‘outreach’ service to more remote, rural areas that have do not have easy access to a local practise.

R3. The PCT should continue to publicise widely to make people aware of the procedure to register onto waiting lists

R4. That the oral health needs assessment for Craven be reviewed regularly (e.g. every three years).

R5. The PCT should provide regular dentistry updates (provision/service) to the Council highlighting any significant issues/improvements affecting Craven.

R6. An update be provided on progress securing the ambitious target of a further 156,000 units of dental activity in 2010 (Note – the PCT have committed to providing an update on dental contract awards in the summer)

R7. The PCT should work closely with neighbouring PCT’s to develop opportunities for providing capacity in areas with poor access to dental services, develop awareness (for dentists) that such opportunities can be pursued and also streamline/simplify the admin process for dentists.

R8. That the PCT considers greater flexibility with dental contracts, e.g. relating to quotas and order of payment (reduce risk to dentist of patient not paying), and that the PCT be requested to consider the benefits of a long-term capital programme to build new dental facilities in well populated remote areas without any facilities such as Bentham / North Craven (estimated costs for a new build are a minimum of £60,000 which is prohibitive for dentists) and helping with set-up costs where there is demand.

R9. Some facilities are innovative e.g. Grassington where a ‘one stop-shop’ exists of a dental and medical centre with an adjacent chemist. The PCT should aim to promote and invest in this approach.

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R10. The Primary Care Trust should ensure they work closely with local NHS dentists.

R11. The PCT should raise awareness of dentists who conduct home visits to patients and ensure that the provision of this service is set at an effective level (note – the PCT are reviewing provision of this later in 2010).

Recommendations for the Council

R12. The Council should support the PCT by providing local knowledge of dental health issues. Elected Members should be proactive identifying ward issues, and officers may be aware of issues through day-to-day work.

R13. The Council led by the Stronger Communities Team (and other services with a frontline role working with residents) should support the PCT promoting awareness of dental services in Craven using a variety of means such as flyers (agricultural shows, area forums etc) notices in prominent places (town halls, tourist information centres, libraries etc), website and ‘Your Craven’ newsletter.

R14. That the Council should ensure that the PCT are consulted on large scale residential developments, e.g. over 25 new properties, and opportunities are sought through section 106 agreements for creating new dental facilities especially in well populated remote areas without any facilities.

R15. That the Council should also ensure that the PCT are consulted through the Local Development Framework to balance changes in population and dental provision in areas.

Recommendations for the Yorkshire Dales National Park Authority Note – these are repeat recommendations (see above) relating to planning issues.

R16. That the National Park Authority should ensure that the PCT are consulted on applications for large scale residential developments, e.g. over 25 new properties, and opportunities are sought through section 106 agreements for creating new dental facilities especially in well populated remote areas without any facilities.

R17. That the National Park Authority should also ensure that the PCT are consulted through their Local Development Framework to balance changes in population and dental provision in areas.

Recommendations for North Yorkshire County Council

R18. North Yorkshire County Council should be requested to help promote dentistry services and awareness through their newsletters and other media.

Recommendations for Dentists in Craven

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R19. Local dentists (NHS and private) should be encouraged to display prominent notices in surgeries to inform patients of any spare capacity, how to register and also the consequences of failing to keep appointments without good reason.

R20. Local dentists (NHS and private) should be encouraged to operate more flexible opening times.

R21. Local dentists (NHS and private) should seize opportunities to work more closely sharing information such as spare capacity allowing them to refer patients to other practises. The Council (or PCT) could facilitate an annual networking meeting of local dentists.

R22. Patients should be encouraged to consider dental health plans for good preventative care and be made aware of the consequences of missed appointments.

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DENTISTRY – ISSUES, TERMS OF REFERENCE AND METHODOLOGY

IssuesThe review of dentistry had been initiated primarily to investigate the ease of access to a dentist for treatment. Ease of access could incorporate a number of issues such as cost of treatment.

There were a range of wider issues that were potential considerations including: Identifying the communities in Craven experiencing the poorest dental health The availability of NHS dentists in those communities and the quality of

service offered to patients How problems of access and service are being addressed by the NHS

Dentistry Service, particularly in the context of tackling health inequalities

Whilst it was appreciated that quality of care issues needed to be noted it was not viable to consider them in-depth. Members learnt that there was no simple remedy, e.g. a national standards monitoring body that inspected dental quality or investigated dental patients’ complaints. Patients needed to initially try to resolve issues with their dentist before trying the PCT (for NHS patients) or the Dental Complaints Service (for private patients). Given the circumstances it was felt appropriate to refine the terms of reference.

Terms of ReferenceAfter the first meeting - which included a discussion with a local dentist and a background guidance paper for patients from the Department for Health ‘Guide to NHS Dental Services in England’ - the terms of reference were refined as:To consider the access to dental services in Craven and level of service.

Members felt that this provided the right level of focus with room for influencing dental healthcare provision.

MethodologyThe review was well publicised initially through a press release leading to articles in papers such as the Craven Herald and Yorkshire Post and also public notices in dental and medical surgeries inviting the public to give their views and details of any (good or bad) experiences. More direct communications were made with a cross-section of dentists and the PCT inviting them to informal discussions with Members.

As well as NHS dentistry provision, which was the main focus, consideration was also given to the private sector which forms a sizeable element of the overall provision.

Evidence was collected through public feedback received and views of dentists to get a feel for the situation ‘on the ground’ and data from the PCT.

Statistical evidence included numbers of dentists in Craven, their geographical spread against estimated demand (including waiting lists and waiting time), costs of treatment and investment. Members needed to ‘iron’ out apparent differences that emerged during the review to develop coherent and realistic improvement recommendations.

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NHS NORTH YORKSHIRE AND YORK (PRIMARY CARE TRUST)

Members met Lorraine Naylor (Assistant Director – Primary Care) and Jacqui Higo (Senior Commissioning Manager) from NHS North Yorkshire and York (Primary Care Trust) who are the main organisation responsible for overseeing provision of dental services. The PCT had been invited to give evidence including statistical analysis of the picture overall, any specific local issues and discuss areas that require improvement. Members were presented with a paper which gave a picture of dental health needs in Craven and the provision provided as well as details of any issues.

Background to the role of primary careThe PCT are responsible for commissioning oral health (dental) services in North Yorkshire and York. NHS North Yorkshire and York is the current organisational name with the ‘primary care trust’ reference being eased out. The organisation is also currently being re-structured.

Work undertakenAn Oral Health Strategic Commissioning Group (including dental professionals, patient representatives, communications staff etc) had been set up to produce an oral health needs assessment resulting in procurement plans being developed to refine the ratio of dentists (and services) to patient need and demand. The needs assessment was conducted over 2.5 years ago and would need reviewing in due course. Issues included movement of NHS dentists to private practise and geographical areas of poor dental health. Assessments are undertaken in line with service reviews and dental procurement exercises. An ‘out-of-hours’ needs assessment was also undertaken 18 months ago.

Units of Dental Activity Units of dental activity (UDA’s) were numerical measures of treatment activity. The formula equated to more than just simply a trip to the dentist. One UDA roughly equated to a course of treatment although numbers of UDA’s also depended on the treatment cost band. Band 1 (simplest treatment) equated to around 1 UDA, Band 2 (most common treatment) to 3 UDA’s, and Band 3 (complex treatment) to 12 UDA’s. On average 3 UDA’s were allocated to an individual annually.

Sustainable Services and Dental ContractsDental services needed to be sustainable taking into account remoteness of rural areas – balancing need, demand, travelling time with economically viable prospects for dentists.

The PCT agreed dental contracts which included elements of service delivery. Annual UDA targets were set which a dentist might exceed but could bid for more including from other PCT’s – generally dentists secured the right level of UDA’s.

To encourage sustainable services - with more assurance for the PCT, patients and dentists – dental contracts were usually awarded for five years. Dentists were not employees of the NHS so were ‘independent’ although bound by any contract requirements. They had to invest in their own properties and equipment.

Investment and Dental ContractsThere was a continuous drive to buy-in (commission) UDA’s through contracts with dentists and there had been significant investment of 120,000 UDA’s since 2006 and another 156,000 aimed for in 2010. Investment in the region of £2,300,000 was planned for dental services in North Yorkshire and York of which around £2,000,000 was for general dental services. This equates to around 5,000 UDA’s in Craven

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which will cover over 1,700 new patients. The proportion for Craven depends on local access requirements against competing demand from other areas.

Contract tendering is taking place from April with awards expected to be made in July. Members would be informed of progress allowing them to inform local residents and other interested parties.

Quality of Care / Value for MoneyContracts were awarded fairly based on the service being offered such as flexibleopening times and value for money.

Dental Treatment PlansA more holistic approach is encouraged by the National Institute for Clinical Excellence (NICE) who advocate that ‘pathway to care’ plans are developed between dentists and patients whereby an appropriate level of treatment is agreed which could result in not needing a dentist for 24 months in some cases unless an emergency occurred. Members learnt at another meeting that one dentist in Craven only dealt with patients on a dental treatment plan – this was an interesting approach.

Demand, Need and Waiting ListsThere is a distinction between demand and actual need which needs to be managed and matched against waiting lists to ensure that waiting times to access a dentist is satisfactory.

Waiting Lists/Times and Patient ChoiceMost recent waiting list occupants were aged 17-59 (90 out of 148) or over 60 (34). Most waited up to one month to become registered (64 out of 148) or 1-2 months (63). 16 people had had to wait for over 6 months although this was probably due to patient preference for a particular dentist. The same choice theory applied to people travelling some distance. Far more people had been assigned to a dentist in recent years although there was always an active turnover of people on the waiting list with people moving home etc.

Demand, Need and Capacity in CravenHowever, the demand in Craven appeared to be quite low although actual need based on UDA data suggested people were using services on an ad-hoc (possibly emergency) basis. Dentists were required to provide a minimum of two daily slots for ‘walk-in’ emergencies. Services were available to visitors too. Table 1 demonstrates quite a small demand for NHS dental services across Craven.

Table 1: CHRD patients added to the NHS NYY dental waiting list Oct 09-Mar 2010

Locality Oct Nov Dec Jan Feb TOTAL Craven Harrogate and Rural District (CHRD) – Craven

37 80 101 77 74 369

Table 2: Patients assigned to an NHS dental practice Oct 09 – March 2010

Locality Oct Nov Dec Jan Feb TOTALCraven Harrogate and Rural District – Craven

476 0 0 275 0 751

TOTAL (8,185)

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Dental health centres also exist at Skipton Hospital and Settle (Townhead) that are for emergencies and vulnerable people. These generally require a referral but are under-subscribed. These are community bases employing a few salaried dentists. If they were not well utilised then it was possible that the service would be decommissioned with ‘independent’ dentists assuming the role.

Table 3: Access to Community Dentistry facilities provided at Skipton and Settle

Total Contacts(number of appt’s)

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Clinic Total

Skipton Hospital

0 0 79 92 55 100 114 112 85 85 0 0 722

Settle Health Centre

0 0 62 28 13 44 48 58 38 56 0 0 347

Month Total

0 0 141 120 68 144 162 170 123 141 0 0 1069

Did Not Attend (missed appt’s)

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Clinic Total

Skipton Hospital

0 0 7 (9%)

9 3 5 0 0 0 0 0 0 24

Settle Health Centre

0 0 3 (5%)

1 2 6 0 0 0 0 0 0 12

Month Total

0 0 10 10 5 11 0 0 0 0 0 0 36

Access (patients not registered elsewhere)

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Clinic Total

Skipton Hospital

0 0 28 29 16 43 45 38 38 26 0 0 263

Settle Health Centre

0 0 34 18 8 16 22 13 15 29 0 0 155

Month Total

0 0 62 47 24 59 67 51 53 55 0 0 418

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Continuing Care (vulnerable people)

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Clinic Total

Skipton Hospital

0 0 44 41 35 53 58 61 44 36 0 0 372

Settle Health Centre

0 0 25 9 2 16 26 34 15 18 0 0 145

Month Total

0 0 69 50 37 69 84 95 59 54 0 0 517

Treatment following referral(from GP, usual dentist)

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Clinic Total

Skipton Hospital

0 0 7 22 4 4 11 13 3 23 0 0 87

Settle Health Centre

0 0 3 1 3 12 0 11 8 9 0 0 47

Month Total

0 0 10 23 7 16 11 24 11 32 0 0 134

NHS communications needed to be developed so that people were aware some spare capacity existed. The Council could also assist with promotions raising awareness, e.g. at tourist information centres, local schools.

Access to Dental Healthcare in CravenThe basis used for levels of access to dentistry services was the number of patients visiting a dentist in the last 24 months. The target measure was 66% of patients able to secure NHS services assuming a number of people opted for private dentistry. The average access rate (2009) for Craven is 62.9%. On average Craven residents travelled 8-13 miles for treatment. Currently most practices offer a limited number of home visits. Later in 2010 the PCT are planning to undertake an assessment of the need for home visits and based on this formulate an appropriate level of service. Some more populated areas such as Grassington, Settle and Skipton were reasonably well served. Conversely some wards including most of Skipton, Barden Fell and West Craven were over 10% short of the 66% access target.

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Table 4: Access to NHS dental care across Craven wards 2007-9.Note – all access rates under 66% are highlighted Note – all names of wards that are around or under 60% are also highlightedNote – Hellifield and Long Preston is at the overall average of 62.9% for Craven

Ward NameNote – wards under 60% access are highlighted Pop

Apr 07 to Mar 08 Total Patients

Apr 07 to Mar 08 Access %

Jan 08 to Dec 09 Total Patients

Jan 08 to Dec 09 Access %

Change in Access rate

Aire Valley with Lothersdale 3573 2147 60.1 2193 61.4 1.3Barden Fell 1707 963 56.4 967 56.6 0.2Bentham 3727 2584 69.3 2489 66.8 -2.5Cowling 2272 1492 65.7 1507 66.3 0.7Embsay-with-Eastby 1790 1026 57.3 1056 59.0 1.7Gargrave and Malhamdale 3069 2004 65.3 1994 65.0 -0.3Glusburn 4036 2621 64.9 2662 66.0 1.0Grassington 1645 1143 69.5 1131 68.8 -0.7Hellifield and Long Preston 2274 1417 62.3 1430 62.9 0.6Ingleton and Clapham 3906 2772 71.0 2768 70.9 -0.1Penyghent 2101 1484 70.6 1446 68.8 -1.8Settle and Ribblebanks 3763 2410 64.0 2374 63.1 -1.0Skipton East 3439 1630 47.4 1636 47.6 0.2Skipton North 3379 1824 54.0 1819 53.8 -0.1Skipton South 3787 2106 55.6 2133 56.3 0.7Skipton West 3957 2392 60.4 2388 60.3 -0.1Sutton-in-Craven 3708 2806 75.7 2838 76.5 0.9Upper Wharfedale 1930 1375 71.2 1348 69.8 -1.4West Craven 1892 1046 55.3 1067 56.4 1.1

Access to services in neighbouring areasNeighbouring PCT’s did work together to allow movement of dental credits across boundaries – it was up to dentists to bid for contracts across borders although this was not significant and not all dentists were aware of this option.

Other areas of potential supportInnovative mobile dentistry services are being developed in Leicestershire County and Rutland, County Durham jointly with Darlington, and other parts of the country including Tower Hamlets, operating on similar lines to a mobile library. Effectively an ‘outreach’ service whereby a travelling dentist (in an appropriately ‘kitted-out’ vehicle offering standard services and facilities ‘on-site’) visits remote areas going to different villages on different days. Some emergencies may need to be referred.

It is understood that a few years ago the PCT did offer some form of mobile service in the Yorkshire Dales although this ceased due to limited usage. Nevertheless the PCT should reconsider the option of investing in a mobile dentistry service offering a potentially valuable service to rural areas that have do not have easy access to a local practise. This would have real community benefit for vulnerable or elderly people especially with limited public transport. Such a scheme could prove cost-effective by not requiring the expense of a ‘traditional’ premises and also be well used. There may also be potential for grants from government bodies for innovation,

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supporting rural communities etc. The service could run alongside the community dental services (Skipton Hospital and Settle Health Centre) or in place of them.

Other potential benefits of the service include providing wider health screening and wider health advice as well as raising general awareness of services.

‘Hard to reach’ groups are also been targeted in some parts of the country by working with supermarkets in publicising information and in some cases providing some simple services, e.g. for children.

The PCT do not directly help with funding should a dentist plan to build a new practise. For ‘major’ new residential developments of over around 25 properties there was potential for a section 106 agreement whereby developers might agree towards helping increase dentistry facilities or develop new facilities.

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VIEWS FROM DENTISTS

Members requested informal interviews with a sample of representative dentists (NHS and private) from across Craven. Interviews were conducted with 4 experienced dentists including one from a neighbouring PCT area, a recently retired dentist and hospital experience. Two of the dentists were primarily NHS with some private treatment and two were primarily private with some NHS for children and/or vulnerable people.

Practises naturally wished to understand the purpose of the review before providing views. Disappointingly some practises mainly belonging to larger corporate groups were refused permission to take part by their head offices. The Whitecross Dental Centre in Skipton declined to take part on this basis although they did indicate they may do so on a later basis. We would still very much welcome their views as they are a significant provider of NHS treatment.

NHS focus

Balance of work NHS treatment primarily including one practise with 2,000 registered patients.

Dental Contracts Concerns that annual NHS quotas can’t be exceeded otherwise further work

would effectively be ‘free’ and at cost to the dentist, risk patient doesn’t pay Need greater contract flexibility including cross-border working

Investment (funding) Numerous unsuccessful funding bids (to PCT) to secure extra dentists

Quality of Care v Value for Money Needs to be more preventative focus for better quality There are examples of people’s dental health declining due to being unable to

secure access to a dentist There are corporate groups overly interesting in purchasing other practises

Local Access Most practises not currently accepting new patients or no longer do. Access is an issue in Craven (rural parts) Access an issue in neighbouring PCT areas with no waiting lists database –

can mean dropping waiting lists and simply operating ‘first-come, first-served’. One busy well-staffed practise in a neighbouring PCT area recently had to turn away 30 patients – demand/need exceeding supply.

One month is a reasonable amount of time to wait to be registered. Each dentist allows for emergency slots (24hrs maximum should be a target

to treat emergencies and is an example of good practise), one practise allowed for emergencies within a 10 miles radius of the practise.

Serious issues of 20% (1 in 5) appointments not kept by patients without good reason – wasted resources and appointments may have been filled by others.

Cross-Border Working Believe there is no real communications between the PCT’s. Needs to be more cross-bordering working.

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Private focus

Balance of work Some NHS treatment for children or vulnerable people.

Reasons for Private Practise Private practise primarily for financial reasons. .

o NHS dental contracts equated to a relatively poor return or even a loss – based on units of work and also risk of patient not paying for completed work.

o Limited range of NHS work allowed to be charged for and level of charges

o Market economy approach allowing competition worked more effectively than a subsidised approach

o NHS counterparts effectively had a different target market so there was no conflict.

Private practise allows more personal freedom.

Quality of Care v Value for Money There was still an underlying principle of trying to provide quality treatment. Government was more focused on quantity (high numbers of patients

securing NHS treatment cheaply with a high turnover for appointments) rather than quality (low numbers using private treatment with sufficient time allowed for appointments).

NHS treatment may be quite involved but only amounts to a fixed number of units falling within a set charges band thereby discouraging NHS work.

Generally NHS appointments took less time than a private appointment so a high quantity of NHS work was achieved. This was in the context of a NHS check-up costing a fraction of a private check-up. There had been improvements in terms of numbers of (NHS) dentists and time spent on appointments.

Quality care at a price did in fact provide value for money by virtue of taking time to safeguard dental health. Dental advances also meant that generally more and better services could be offered.

Investment Private service also required a great deal of investment such as in

infrastructure and equipment. Healthcare standards required disposing of gloves, sterilisation equipment etc and – as only set amounts could be claimed for NHS work – this created financial pressures to manage.

Local Access (Private/NHS) One practise felt there had been no notable departure of patients upon

turning private although another experienced a departure in the region of 50%.

Private practise tended to register all new patients. In urban areas such as Keighley (Bradford PCT) practises were very busy but

the community services at Skipton Hospital and Settle Dental Centre were under-used. Nevertheless they were valuable community assets that needed to stay although being used more effectively.

There are enough dentists overall in Craven but there are some local ‘hot-spots’ with a shortage.

NHS should focus on children and vulnerable adults – with the remainder of adults adopting dental treatment plans.

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Cross-Border Working There were mixed views as to how the system of accepting patients from

neighbouring PCT’s worked. o One dentist felt that it was difficult to get recompense from the other

PCT while another believed that it was possible requiring a dentist to bid for separate contracts although different NHS identity numbers needed to be used causing potential administrative confusion.

One dentist believed that cross-border work was a generally accepted practise across the country although not high profile.

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VIEWS FROM PATIENTS

Some feedback was received from local residents based on their experiences as patients or trying to register with a dentist. A summary of views is provided below:

Problems with securing a dentist A retired couple on pension credits and registered blind recently moved to

Craven. One of them recently had emergency treatment successfully although this didn’t lead to them being registered

They are registered on the NHS website and have been looking for a dentist since November 2009. Phoned NHS – given list of 100 dentists within 25 miles radius to phone. Accept inevitably that there’s some waiting time to be registered and feel that up to 12 months waiting time is acceptable although obviously much sooner is better.

Prepared to travel outside County but mobility issues (age, registered blind) and significant transport required (risk of missing appointments) so need a local dentist. Personal circumstances will allow NHS exemptions but meaningless if not registered.

Years of being unable to access a NHS dentist A retired person during his working life had used a private dentist for

convenience (close proximity) which outweighed the expense. However, upon retiring that became no longer affordable but he has been unable to secure a NHS dentist in over 10 years. Therefore use of the private dentist has continued but frequency of visits has declined – his check-ups are now not as frequent as they should be.

Need for more NHS dentists A person having worked in Craven for over 15 years had been unable to find

a local dentist. Registered with a dentist in Lancashire so over years, lot of travelling time and expenditure consumed and negative environmental impact.

Ironically a former colleague now living in Lancashire is registered with original dentist from Craven. People are loath to risk changing dentists to wherever they now live or work as there’s no guarantee of being able to find one.

Another person also expressed the need for more NHS dentists to help ensure local availability.

 No dentist in Bentham (North Craven)

One person referred to a NHS Dentist being needed in Bentham, most people had to travel to Lancaster or Kendal to access one, which was some distance and also can be difficult for anyone reliant on public transport, She felt that the private dentist in Bentham was expensive and not everyone could afford private treatment.

Note - geographically Settle’s the furthest ‘north-east’ NHS surgery and Grassington’s furthest ‘north-west’ but nothing further north.

Customer service and succession planning. One person had been a NHS patient with the same practice for decades. This loyalty had been encouraged by quality customer service (both the

dentist and staff always being helpful and friendly) Current dentist due to retire – aware of another practice which did not

immediately fill vacancies. Need to ensure proper succession planning.

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Problems with quality of work and staff turnover One person required a course of treatment but time lags between

appointments resulted in more serious emergency problems beyond just dental issues.

There seemed to be little flexibility to match appointments with treatment need.

The problems also seem to relate to a high turnover of dentists with locums filling vacancies.

Another person expressed concerns about turnover of dentists (same practice) as well as more rushed work. All this followed a change of ownership.

Problems with quality of work and complaints procedure A retired person with little income had had years of experience using

dentures with a new set required every ten years. New dentures had been fitted – the top set was fine but bottom too small. Told to reuse old bottom set until corrected. Interim – difficulty eating and embarrassing going out (stressful). After three weeks – pink ‘filling’ added to increase set but still not a good fit. From experience – simpler to provide a larger set and file/chip away until right

Complaints procedure ref quality of work – partner went on NHS website, required to complain to dentist first. Wary of doing this – would have preferred a neutral third party. Also whole family used the practise – concerned that there might have been a service ‘back-lash’.

Problems with quality of work, complaints procedure and appointments A carer with dental problems and difficulty accessing a dentist with an elderly

mother had experienced severe issues. He felt that access to a good dentist allows proper dental planning (effectively better dental care and more cost-effective).

However, it can be very difficult to resolve unsuccessful work (simply redoing the work at no extra cost not guaranteed; not a simple complaints process; and failure to resolve quickly can lead to prolonged difficulties).

The time taken to get actual appointments can be significant too (transport to rural locations can be difficult).

Unable to pay for private treatment. The prolonged catalogue of unresolved difficulties has led to a severe decline

in dental health and no prospect of seeing a dentist even though numerous attempts have been made to resolve this with the PCT and other bodies.

Note – given contact details for Skipton Hospital’s emergency/vulnerable people’s service.

Privacy One person noted that in a certain practise, patient/dentist discussions in the

surgery could be overheard in the waiting room which was not helpful. 

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Appendix ANHS Dental Charges (from NHS website)

The three NHS charge bands are as follows:

Band 1: £16.50. This charge includes an examination, diagnosis and preventive advice. If necessary, it also includes X-rays, scale and polish and planning for further treatment.

Band 2: £45.60. This charge includes all the necessary treatment covered by the £16.50 charge, plus additional treatment, such as fillings, root canal treatment or extractions.

Band 3: £198. This charge includes all the necessary treatment that is covered by the £16.50 and £45.60 charges, plus more complex procedures, such as crowns, dentures and bridges.

Note – below table taken from ‘what price’ website, lists national average prices for indicative comparative purposes. The accuracy of private practise figures should be treated with caution – prices across the country will vary and some regions such as in the north may be substantially lower than in the south.

Dental Work Required Private Prices NHS PricesApiectomy £376 £198Braces-Metal £1090 £198Bridge £568 N/ACancellation fee £34 N/ADental Crown-Gold £405 £198Dental Examination £43 £16.2Dentures-Full £561 £198First Consultation £53 £16.2Hygiene Clean £63 N/AImplants £1172 N/ALarge Tooth Filling-Non-white

£101 £44.6

Root canal £365 £198Sedated tooth removal £141 £44.6Small tooth filling-Non-white

£79 £44.6

Tooth Extraction £94 N/ATooth Scale and Polish £46 £16.2Veneer £343 N/AWhitening £307 N/AWisdom tooth extraction £178 N/AX-ray £28 £16.2

Source: http://www.whatprice.co.uk

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Appendix BList of NHS Dentists in Craven (by broad geographical spread)(North Yorkshire and York Primary Care Trust’s website)Note – the listed dentists may provide the full range of NHS dental services to adults and children or may be predominantly a private service providing a limited range of NHS services. Note – this list is based on website searches.

Craven – population (2001) approximately 54,000

Skipton Town (radius of 1 mile) Main population base – approximately 14,500

1. A.J. Bates [Note – not on NHS website]33, Gargrave Rd, Skipton,

2. Belle Vue Dental Practice 32 Belle Vue Terrace, Skipton, N Yorkshire, BD23 1RU

3. Mr P G Bode 33 Otley Street, Skipton, N Yorkshire, BD23 1EL

4. Muirhead & Associates 52-54 Otley Street, Skipton, N Yorkshire, BD23 1ET

5. Whitecross Dental Centre Unit 4, Acorn Business Park, Keighley Road, Skipton, BD23 2UE

Central Craven 6. Grassington Dental Care

9 Station Road, Grassington, Skipton, N Yorkshire, BD23 5LS

7. Mr D A Jackson 18 East Street, Gargrave, Skipton, N Yorkshire, BD23 3RS

North Craven

8. Oasis Dental Care Station Road, Settle, N Yorkshire, BD24 9AA

Note – there are no dentists listed north of Settle.

South Craven

9. Mr R F Buckley 46 Main Street, Cross Hills, Keighley, W Yorkshire, BD20 8TQ

10. The Brace Place 2 Albert Road, Cross Hills, Keighley, W Yorkshire, BD20 7LE

Details of How to Register with a NHS DentistPatients are encouraged by all dental practices to contact either:The NHS NYY dental waiting list team on; 0300 303 8010;Website; http://www.nyypct.nhs.uk/adviceinformation/dentalregister; Email: nyy-pct.dentalregistration@nhs.netWrite to: NHS Dental Waiting List, FREEPOST RSHB–UTRR–LZUA,NHS North Yorkshire and York, Harrogate, HG2 8RE

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