Lord Colwyn

National Health Service dentists have been receiving their full funding with minor adjustments throughout the COVID-19 period. They are now open for face to face including routine care and are restarting services in line with the increased infection control required to minimise the risk of transmission. NHS England and NHS Improvement are carefully considering any impact this may have on the overall provision of primary care dental services.

In light of the current COVID-19 pandemic and associated economic climate a decision was made to freeze dental patient charges at 2019/20 levels. This is a temporary freeze being kept under review. No changes have been made to current dental exemption arrangements.

This information is not routinely collected centrally. However, the Department estimates that the total Government outlay is on average around £230,000 for the provision of a Bachelor of Dental Surgery, and around £110,000 for the provision of foundation training for a dental graduate.

The following table shows patient charge revenue for National Health Service dental services from 2015/16 to 2018/19.

Source: NHS England

The Dental Prescribing Dashboard developed by the NHS Business Services Authority and Public Health England, includes data for National Health Service local area teams. Latest available data show general dental practitioners issued 2,912,579 prescriptions for all antimicrobials including antibiotics during April 2017 to March 2018. There were 715,545 prescriptions between January and March 2018. The Dental Prescribing Dashboard will be refreshed in summer 2019.

Analysis is based on items prescribed by NHS dentists, but some patients may attend a general medical practice with a dental infection and receive a prescription from their general practitioner (GP). These prescriptions are not included, as we cannot determine the reason why a GP prescribed antibiotics.

The English Surveillance Programme for Antimicrobial Utilisation and Resistance (ESPAUR) Report 2018 provides information on NHS dental prescribing in dental practices and consultations. The ESPAUR report for 2019 scheduled for publication later this year will publish data for the 2018 calendar year. The ESPAUR 2018 report is attached.

In England, local authorities are responsible for assessing oral health needs and improving the oral health of their local population including those over the age of 65.

To support local authorities in this role Public Health England (PHE) published Commissioning better oral health for vulnerable older people: An evidence-informed toolkit for local authorities which gives an overview of the impact of oral diseases in vulnerable older people and presents the evidence of what works to improve their oral health. The toolkit for local authorities is attached. It is supported by an evidence review and a resource compendium to support oral health improvement of vulnerable older people in all settings.

NHS Digital publishes quarterly information on the number of adults who have seen a National Health Service dentist in the previous 24 months and children who have seen an NHS dentist in the previous 12 months.

There are no current plans to change the age breakdown of the data that is routinely published.

While we are currently unable to confirm exact details of the Green Paper, NHS England has a legal duty to commission National Health Service dental services to meet local need including people living in care homes.

The forthcoming Green Paper will be based on a number of principles including whole-person, integrated care with the NHS and social care systems operating as one.

The National Institute for Health and Care Excellence Oral health in care homes quality standard provides guidance to care home staff on assessing the oral health needs of patients on admission and advises on the need for residents to be helped to find a dentist if they do not already have one. A copy of the quality standard is attached.

Timing of the next Adult and Child Dental Health Survey has yet to be confirmed.

Information on the numbers of prescriptions for all antimicrobials, including antibiotics, issued by general dental practitioners is only available for the complete years of 2016 and 2017. In these years 3,198,411 and 2,977,302 National Health Service prescriptions were issued respectively.

From 2013 to 2017, the trend of antimicrobial prescriptions continued to decrease by 24.8%. The number of daily defined doses of antimicrobials per 1,000 inhabitants per day prescribed by dentists was 0.19 in 2013 and 0.16 in 2016; with an 8.3% decrease from 2016 to 2017. In the previous five years the proportions of daily defined doses of antibiotics issued by general dental practitioners out of all prescriptions, from hospital inpatients and outpatients, general medical practitioners and other community practitioners, were 4.8% in 2013, 4.8% in 2014, 4.5% in 2015, 4.6% in 2016, 5.2% in 2017.

Information on the numbers of prescriptions for all antimicrobials, including antibiotics, issued by general dental practitioners is only available for the complete years of 2016 and 2017. In these years 3,198,411 and 2,977,302 National Health Service prescriptions were issued respectively.

From 2013 to 2017, the trend of antimicrobial prescriptions continued to decrease by 24.8%. The number of daily defined doses of antimicrobials per 1,000 inhabitants per day prescribed by dentists was 0.19 in 2013 and 0.16 in 2016; with an 8.3% decrease from 2016 to 2017. In the previous five years the proportions of daily defined doses of antibiotics issued by general dental practitioners out of all prescriptions, from hospital inpatients and outpatients, general medical practitioners and other community practitioners, were 4.8% in 2013, 4.8% in 2014, 4.5% in 2015, 4.6% in 2016, 5.2% in 2017.

The English Surveillance Programme for Antimicrobial Utilisation and Resistance Report 2018 provides information on National Health Service dental prescribing in dental practices and consultations. From 2013 to 2017, the trend of antimicrobial prescriptions which includes antibiotics, continued to decrease by 24.8%. The number of daily defined doses of antimicrobials per 1,000 inhabitants per day prescribed by dentists was 0.19 in 2013 and 0.16 in 2016; with an 8.3% decrease from 2016 to 2017. The decline was largely attributed to less amoxicillin being prescribed between 2013 and 2017. A copy of the report is attached.

Information on how many children have been prescribed antibiotics or more than one course of antibiotics for dental problems in England over the last five years is not available as this data is not collected.

No assessment has been made of the potential impact of prescribing antibiotics to children who are waiting for tooth extractions due to tooth decay on their immune system and the levels of antimicrobial resistance.

The English Surveillance Programme for Antimicrobial Utilisation and Resistance Report 2018 provides information on National Health Service dental prescribing in dental practices and consultations. From 2013 to 2017, the trend of antimicrobial prescriptions which includes antibiotics, continued to decrease by 24.8%. The number of daily defined doses of antimicrobials per 1,000 inhabitants per day prescribed by dentists was 0.19 in 2013 and 0.16 in 2016; with an 8.3% decrease from 2016 to 2017. The decline was largely attributed to less amoxicillin being prescribed between 2013 and 2017. A copy of the report is attached.

Information on how many children have been prescribed antibiotics or more than one course of antibiotics for dental problems in England over the last five years is not available as this data is not collected.

No assessment has been made of the potential impact of prescribing antibiotics to children who are waiting for tooth extractions due to tooth decay on their immune system and the levels of antimicrobial resistance.

The English Surveillance Programme for Antimicrobial Utilisation and Resistance Report 2018 provides information on National Health Service dental prescribing in dental practices and consultations. From 2013 to 2017, the trend of antimicrobial prescriptions which includes antibiotics, continued to decrease by 24.8%. The number of daily defined doses of antimicrobials per 1,000 inhabitants per day prescribed by dentists was 0.19 in 2013 and 0.16 in 2016; with an 8.3% decrease from 2016 to 2017. The decline was largely attributed to less amoxicillin being prescribed between 2013 and 2017. A copy of the report is attached.

Information on how many children have been prescribed antibiotics or more than one course of antibiotics for dental problems in England over the last five years is not available as this data is not collected.

No assessment has been made of the potential impact of prescribing antibiotics to children who are waiting for tooth extractions due to tooth decay on their immune system and the levels of antimicrobial resistance.

We do not hold this information.

The Department does not hold information on whether patients have been prescribed antibiotics following an attendance at an accident and emergency department.

The English Surveillance Programme for Antimicrobial Utilisation and Resistance Report 2018 provides information on National Health Service dental prescribing in dental practices and consultations. From 2013 to 2017, the trend of antimicrobial prescriptions which includes antibiotics, continued to decrease by 24.8%. The number of daily defined doses of antimicrobials per 1,000 inhabitants per day prescribed by dentists was 0.19 in 2013 and 0.16 in 2016; with an 8.3% decrease from 2016 to 2017. The decline was largely attributed to less amoxicillin being prescribed between 2013 and 2017. A copy of the report is attached.

Information on how many children have been prescribed antibiotics or more than one course of antibiotics for dental problems in England over the last five years is not available as this data is not collected.

No assessment has been made of the potential impact of prescribing antibiotics to children who are waiting for tooth extractions due to tooth decay on their immune system and the levels of antimicrobial resistance.

The 2009 Adult Dental Health Survey contains information about the oral health of adults aged 65 and over including the proportion retaining one or more natural teeth, prevalence of tooth decay and the proportions reporting current dental pain. There has not been a subsequent national survey of this age group since then to assess whether oral health has improved or deteriorated. A copy of the Executive Summary: Adult Dental Health Survey 2009 is attached.

There has been no national assessment of the prevalence of oral health problems amongst care home residents.

In 2016, Public Health England (PHE) reported on oral health in older people in England and Wales using data from existing surveys.

The report found that older adults living in care homes were more likely to have no natural teeth and less likely to have a functional dentition; older adults living in care homes were more likely to have higher levels of tooth decay; care home managers experienced greater difficulty in accessing dental care for residents than household resident older adults did and; residents resisting oral care routines was the second most common oral health issue raised by care home managers. A copy of the report What is Known About the Oral Health of Older People in England and Wales: A review of oral health surveys of older people is attached.

In 2017, PHE reported on a nationally coordinated survey of the oral health of adults using domiciliary services in England undertaken between 2009-10 and 2010-11. Results showed that adult users of domiciliary care had fewer teeth present than their peers as reported in the 2009 Adult Dental Health Survey. A copy of the report Dental health among adults in contact with domiciliary care dental care services in England is attached.

In 2015/16, as part of the PHE National Dental Epidemiology Programme, a pilot dental survey was undertaken nationally of older people who have a mild level of dependency. The results are due to be published in summer 2018.

The 2009 Adult Dental Health Survey contains information about the oral health of adults aged 65 and over including the proportion retaining one or more natural teeth, prevalence of tooth decay and the proportions reporting current dental pain. There has not been a subsequent national survey of this age group since then to assess whether oral health has improved or deteriorated. A copy of the Executive Summary: Adult Dental Health Survey 2009 is attached.

There has been no national assessment of the prevalence of oral health problems amongst care home residents.

In 2016, Public Health England (PHE) reported on oral health in older people in England and Wales using data from existing surveys.

The report found that older adults living in care homes were more likely to have no natural teeth and less likely to have a functional dentition; older adults living in care homes were more likely to have higher levels of tooth decay; care home managers experienced greater difficulty in accessing dental care for residents than household resident older adults did and; residents resisting oral care routines was the second most common oral health issue raised by care home managers. A copy of the report What is Known About the Oral Health of Older People in England and Wales: A review of oral health surveys of older people is attached.

In 2017, PHE reported on a nationally coordinated survey of the oral health of adults using domiciliary services in England undertaken between 2009-10 and 2010-11. Results showed that adult users of domiciliary care had fewer teeth present than their peers as reported in the 2009 Adult Dental Health Survey. A copy of the report Dental health among adults in contact with domiciliary care dental care services in England is attached.

In 2015/16, as part of the PHE National Dental Epidemiology Programme, a pilot dental survey was undertaken nationally of older people who have a mild level of dependency. The results are due to be published in summer 2018.

No decisions have been taken yet on the timing of the next Adult Dental Health Survey.

The NHS Business Services Authority reports that a total of 217,539 fines were issued to patients on the grounds of incorrectly claiming an exemption from NHS Dental Patient Charges in the first six months of the financial year 2017–18.

The following table shows the total number of primary care courses of treatment that contained tooth extractions, and teeth extracted in primary care, in each year from 2010–11 to 2016–17, for children aged 0–17.

Source: NHS Digital

The following table shows the total number of primary care courses of treatment that contained tooth extractions, and teeth extracted in primary care, in each year from 2010–11 to 2016–17, for adults aged 18 and over.

Source: NHS Digital

The following table shows the total number of primary care courses of treatment that contained tooth extractions, and teeth extracted in primary care, in each year from 2010–11 to 2016–17, for children aged 0–17.

Source: NHS Digital

The following table shows the total number of primary care courses of treatment that contained tooth extractions, and teeth extracted in primary care, in each year from 2010–11 to 2016–17, for adults aged 18 and over.

Source: NHS Digital

The NHS Business Services Authority reports that a total of 217,539 fines were issued to patients on the grounds of incorrectly claiming an exemption from NHS Dental Patient Charges in the first six months of 2017–18.

In January 2017 the Department launched a consultation on proposals to fix or limit the costs recoverable by claimant lawyers in lower value clinical negligence cases. The Department published a holding response to the consultation on 25 July 2017, so as to allow the Department time to reflect the recommendations made by the Right Honourable Lord Justice Jackson following his review in to fixed costs, published on 31 July.

Lord Justice Jackson’s report includes a recommendation for the Civil Justice Council and the Government to set up a working party to develop a new process for clinical negligence initially up to £25,000 alongside new fixed costs.

Departmental Ministers have agreed with this recommendation, as referenced in the recent Public Accounts Committee on 29 November 2017 and the Department is now preparing the final response to the consultation for publication. The publication dates will be decided according to standard Government processes.

No such assessment has been made as the Department does not hold data on the causes of clinical negligence in National Health Service dental care.

Departmental Ministers and officials regularly meet with dental stakeholders to discuss expenses and other matters. Most recently, the Parliamentary under Secretary of State (Steve Brine MP) met with the British Dental Association (BDA), as the main representative body for the dental profession, on 28 November 2017 to discuss a range of issues, including professional indemnity insurance. Departmental officials also met with the BDA on 22 November 2017 to discuss professional indemnity insurance.

The following table shows the total number of fines issued for incorrectly claiming an exemption from National Health Service dental charges in each of the last ten years.

Source: NHS Business Services Authority

Note:

During the period covered in the table above, both the scope and volume of checking has increased significantly.

The table below shows the revenue raised from patient charges for National Health Service dental services in each of the last ten years.

Source: NHS Dental Statistics for England

Notes:

- Data on patient charge revenue are based on the amount calculated as recoverable from the contract payment based on the activity scheduled and patient charges recorded on the FP 17. It may not correspond exactly to the charge income reported in financial accounts for a number of reasons, including the fact that an estimate of charge income collected may have to be incorporated in the final phase of the financial year because accounts have to be prepared before the activity data for the full year becomes available.

- No account is taken in this report of refunds for patients who pay for their treatment and prove at a later date that they should not have paid charges, or penalties imposed on those who should have paid but did not.

- The patient charge total actually recovered into NHS funds during the year may also differ from the calculated amount, because of time-lags inherent in retrospectively deducting charges from monthly payments to dental contractors.

- 2006/07 data excludes revenue from Courses of Treatment (CoTs) which began before 1 April 2006 but were completed in 2006/07 due to the transition to the new contract system.

- The amount raised is dependent on the volume of banded COTs delivered and the charge for each banded COT levied.

The total contracted units of dental activity for England and by region can be found in the table, which is attached owing to the size of the data. We do not hold the average value of contracted unit of dental activity per capita in England or by region.

The total contracted units of dental activity for England and by region can be found in the table, which is attached owing to the size of the data. We do not hold the average value of contracted unit of dental activity per capita in England or by region.

The evaluation report on the first full year of prototyping is due to be published by the end of this year. Evaluation of the dental contract prototype scheme is led by Eric Rooney, Deputy Chief Dental Officer for England, with an evidence and learning reference group, which includes external members.

NHS England is responsible for the National Dental Performers list and currently do not hold information centrally on how many applications have been received from individuals wishing to join the National Dental Performers list. Information on the length of time to process applications is therefore currently not available.

Capita has made NHS England aware of a number of issues involving the National Dental Performers List process. Immediate action has been taken to put in place plans to recover the services, and NHS England has provided a team of experts to support Capita’s work, both in managing existing functions more effectively and improving the service for the future.

The actions Capita are taking to stabilise and recover the service include:

- Recruiting additional staff and developing staff knowledge through further training and development supported by external experts;

- Standardising the processes used and work tracking tools;

- More proactive communication to applicants regarding the progress of their application; and

- Developing the internal integrated work management system to enable Performers List work to be tracked and work-flowed through the process.

NHS England is meeting with Capita on a weekly basis to oversee the delivery of these plans and to ensure the right improvements are in place.

My hon. Friend, the Parliamentary Under Secretary of State (Nicola Blackwood), will continue to work with Capita and NHS England to ensure that services are restored to an acceptable and sustainable standard.

Capita has made NHS England aware of a number of issues involving the National Dental Performers List process. Immediate action has been taken to put in place plans to recover the services, and NHS England has provided a team of experts to support Capita’s work, both in managing existing functions more effectively and improving the service for the future.

The actions Capita are taking to stabilise and recover the service include:

- Recruiting additional staff and developing staff knowledge through further training and development supported by external experts;

- Standardising the processes used and work tracking tools;

- More proactive communication to applicants regarding the progress of their application; and

- Developing the internal integrated work management system to enable Performers List work to be tracked and work-flowed through the process.

NHS England is meeting with Capita on a weekly basis to oversee the delivery of these plans and to ensure the right improvements are in place.

My hon. Friend, the Parliamentary Under Secretary of State (Nicola Blackwood), will continue to work with Capita and NHS England to ensure that services are restored to an acceptable and sustainable standard.

Information on the average cost to Health Education England (HEE) of providing Bachelor of Dental Surgery (BDS) education and Dental Foundation Training (DFT) can be found in the tables A, B and C below.

Table A

Cost to HEE of BDS education

Notes:

1. Average Tariff is the placement fee to cover the placement.
2. Fee contribution is the tuition fee payable in year 5.
3. Maintenance is the Bursary cost.
4. These figures represent the best estimate of average cost to HEE, there may be other costs to the public purse, for example to provide student loans that are not included in these estimates.

Table B

Cost to HEE of providing dental foundation training in secondary care

Notes:

1. Training Placement Support cost is the cost of the dental practice providing training & facilities.

2. Trainee Salary/Maintenance cost is the contribution to the trainee salary and associated costs.

Table C

Cost to HEE of providing dental foundation training in primary care

Notes:

1. Training salary is the reimbursement of the salary paid to the dental trainee.

2. Trainer grant is the sum that represents the time spent in supervising a trainee.

3. Service costs is a sum that represents the service costs of employing a trainee.

Information on the average cost to Health Education England (HEE) of providing Bachelor of Dental Surgery (BDS) education and Dental Foundation Training (DFT) can be found in the tables A, B and C below.

Table A

Cost to HEE of BDS education

Notes:

1. Average Tariff is the placement fee to cover the placement.
2. Fee contribution is the tuition fee payable in year 5.
3. Maintenance is the Bursary cost.
4. These figures represent the best estimate of average cost to HEE, there may be other costs to the public purse, for example to provide student loans that are not included in these estimates.

Table B

Cost to HEE of providing dental foundation training in secondary care

Notes:

1. Training Placement Support cost is the cost of the dental practice providing training & facilities.

2. Trainee Salary/Maintenance cost is the contribution to the trainee salary and associated costs.

Table C

Cost to HEE of providing dental foundation training in primary care

Notes:

1. Training salary is the reimbursement of the salary paid to the dental trainee.

2. Trainer grant is the sum that represents the time spent in supervising a trainee.

3. Service costs is a sum that represents the service costs of employing a trainee.

The Government has already taken decisive action to support the National Health Service to be the most efficient health system in the world. That is why a series of tough financial controls were introduced last year to help the NHS tackle some of the extortionate rates charged and overspending on agency staff.

In November 2015, hourly price caps were introduced limiting the amount the NHS can pay to an agency for temporary staff. These were reduced gradually over a number of months and will apply to all ambulance trusts and ambulance foundation trusts from 1 July 2016.

The Department published an Impact Assessment which considered the impact of uplifting patient dental charges by 5% in 2016/17 and 2017/18, a copy of which is attached. We considered that the impact of increasing patient dental charges will mainly affect those of working age, for whom a proportionate increase to their charges is considered reasonable. Those on low incomes and other protected groups will remain exempt. Those not entitled to exemption but on low incomes may also be eligible to receive help with health costs. We do not consider that the uplifts to patient charges for National Health Service dental services in England will have any significant impact on people’s ability and inclination to regularly visit a dentist.

The Health and Social Care Information Centre (HSCIC) is able to provide data for patient charge revenue from 2006/07 to 2014/15. Data is not held by the HSCIC prior to this date. Data for 2015/16 will be published in August 2016.

NHS England is currently engaged in the process to appoint a new Chief Dental Officer and will make an announcement in due course.

NHS England intends to publish national guidance covering Orthodontics, Special Care Dentistry, Oral Surgery/Oral Medicine, and Restorative dentistry. NHS England’s intention is that this guidance will be published in 2015 and will supersede all local guidance.

The attached table provides a count of Finished Consultant Episodes (FCEs) by Strategic Health Authority from 2008-09 to 2012-13 for patients with a primary diagnosis of either head or neck cancer¹ or anodontia² with a main or secondary operative procedure of a dental implant.

Information on the cost to the National Health Service of dental implants for patients with head or neck cancer or hypodontia is not available in the format requested. The most relevant information is shown in the following table and is from reference costs, which are the average unit cost to NHS trusts and NHS foundation trusts of providing defined services in a given financial year to NHS patients.

These costs include dental implants and other similar procedures, but do not distinguish between procedures on patients with diagnoses of head or neck cancer or hypodontia.

Table: Estimated costs of dental implants and other clinically similar procedures

¹ It is unlikely that a dental implant would be carried out on the same episode as another treatment for cancer, so the count for head and neck cancer is likely to be a substantial undercount. This is because the implant is unlikely to occur until the cancer treatment was completed. If this is the case, the cancer code would not be recorded on the episode where the dental implant took place.

² The diagnosis of anodontia includes but is not exclusive to those diagnosed with hypodontia.

The attached table provides a count of Finished Consultant Episodes (FCEs) by Strategic Health Authority from 2008-09 to 2012-13 for patients with a primary diagnosis of either head or neck cancer¹ or anodontia² with a main or secondary operative procedure of a dental implant.

Information on the cost to the National Health Service of dental implants for patients with head or neck cancer or hypodontia is not available in the format requested. The most relevant information is shown in the following table and is from reference costs, which are the average unit cost to NHS trusts and NHS foundation trusts of providing defined services in a given financial year to NHS patients.

These costs include dental implants and other similar procedures, but do not distinguish between procedures on patients with diagnoses of head or neck cancer or hypodontia.

Table: Estimated costs of dental implants and other clinically similar procedures

¹ It is unlikely that a dental implant would be carried out on the same episode as another treatment for cancer, so the count for head and neck cancer is likely to be a substantial undercount. This is because the implant is unlikely to occur until the cancer treatment was completed. If this is the case, the cancer code would not be recorded on the episode where the dental implant took place.

² The diagnosis of anodontia includes but is not exclusive to those diagnosed with hypodontia.