Meeting 22nd May 2019

LOCATION

THE HUNTINGDON MARRIOTT HOTEL

TRINITY ROOM

WEDNESDAY 22^nd May 2019

7pm Arrival for 7-30pm Start

MINUTES

1. Attendees:

Jaco Craig - LDC Chairman

Mariana De Villiers - LDC Administrator

 Patrik Zachrisson - LDC Treasurer

 Amiras Chokshi

Marlise De Vos

Julia Hallam-Seagrave

Claire Jackman

Gawain King

Deepak Kumar

Peter Mullins

Meeraj Patel

Bharpur Sanghera

Francis Scriven

2. Apologies:

Maria Ross-Russell

3. Guests:

Tom Norfolk - LDN Chairman

Greg Kane - Anglia Orthodontics

Brundha Lloyd

4. Presentation: Greg Kane / Francis Scriven:

Orthodontic procurement remains a difficult issue. With the focus on Orthodontic Tendering the Cambridgeshire and Peterborough Local Orthodontic Society (LOC) undertook detailed population forecasts and looked in depth at the origins of orthodontic referrals that are currently present. From this research the LOC believes that the Units of Orthodontic Activity (UOA) provision allocated to cover Cambridge is not adequate to meet the needs of the population that require Orthodontic care in the city and surrounding wards. It is also believed that there are particular considerations concerning the lot allocation of Cambridge and that the underlying Orthodontic needs assessment and Service Review for East Anglia published in 2014, provided by Dental Public Health, underestimated the needs across the region at the time and therefore even more so now.

A Lot is the potential contract size and geographic area. The aim is to commission lots based on a minimum size of 6,500 UOAs which equates to about 250 to 350 starts on a 7 + 3 year contract: 7 years in the first instance with the option available to both parties to extend for up to a further 3 years by mutual agreement.

Data provided under the Freedom of Information (FOI) indicated that provision across the county as a whole for the next ten-year period is proposed to increase by 5.6% from levels set and contracted more than 10 years ago. There has been an explosion in population growth in Cambridge and surrounding areas with new residential areas already build and in the process of being developed. However, the data derived from FOI actually suggest a reduction in provision for Cambridge of 51% at a time when population figures for the city show significant current and forecast growth.

Orthodontic Providers currently have extensive patient waiting lists for assessment and treatment in excess of acceptable periods. Providers have no confidence that the orthodontic needs of the area will be met with the proposed reduction in provision in Cambridge. Whilst it is understood that new Lots have been created elsewhere across the county, this does not address the significant decrease in Cambridge UOAs. Some local providers have patient waiting lists that exceed 1 750 patients, one third of whom it is anticipated will require treatment. This equates to 583 cases/12 250 UOAs. These patients have not been seen or assessed.  In addition, those Providers reported a continuing steady flow of new orthodontic referral cases. The same have more than 1 050 cases assessed and requiring treatment at year end which they cannot progress due to shortage of UOAs.  This equates to approximately 22 575 UOAs.

This backlog has been building over recent years although Providers have tried their best to manage demand with limited UOAs. Failing to reflect the level of demand for existing cases which will also continue to grow in line with increase in population, the LOC believes that patient care will be seriously and adversely affected and as a consequence result in Providers failing to achieve the “18 week from referral to braces on” scenario.

The LOC believes that the UOA quota for Cambridge needs to be increased to reflect Population growth, Commuters into the city, both state and private School Student Numbers, Referral pathways, Patient choices and NHS Principle .  Although some major developments sited, such as Northstowe, are not yet build and will not be completed until the midpoint of the proposed contracts, the combined data show accelerated population growth.  The LOC believes it would be advisable not only to add more UOAs but possibly adding additional contracts to the Lot listings. 

5. LDN Chairman’s Report - Tom Norfolk:

Dental Strategy Group (DSG)

The DSG is presently focusing on increasing access and stabilizing high need patients who do not have access to routine dental care. A higher UDA value is being offered.  An engagement event was held in Peterborough on 21^st March 2019 but interest was not as high as was expected by Area Team (AT).

The is AT looking at areas of high need in which contracts have been given back. Most prevalent reason given is lack of retention of Associates and problems with recruiting. Looking into re-investing this money to increase access, commission new services or enlarge existing services.

LDN App is being developed to ensure quicker feedback/response to LDN proposals. This will be available to Providers and Performers.  Due to go live in July 2019.

LDN propose a scheme in Norfolk & Norwich + Kingslynn whereby associates can do ½ day/week of oral surgery/tuition with Max Fax and 4 ½ days in their GDP practice. The aim to offer more incentive for Associates to remain in the East of England area. This may lead to Level 2 accreditation.

Oral Health Steering Group (OHSG)

Suffolk is much more advanced than Peterborough pilot, mainly due to poor funding of Peterborough scheme by Public Health England.  Same model may be pushed out to other counties.  Need to look at increasing funding for Peterborough pilot.

Addenbrook’s is offering 1 Pediatric Dentistry training post.

Special Care Dentistry (SCD)

Procurement is imminent. Lot 2, which is Cambridgeshire  & Peterborough has been awarded to Cambridgeshire Community Services. It is likely that Level 2 accreditation will be rolled out for SCD as well, however no time frame established for this yet.

Orthodontics

Peterborough City Hospital is likely to lose secondary care Ortho contract as a replacement consultant cannot be recruited.  The AT is in discussion to try and retain the services in Peterborough City Hospital.

Ian Davies (Ipswich Ortho Consultant secondary Care reports that he normally has 2 x trainee posts. Will not be looking to fill post soon to be vacant as most work resolves around Orthognatic surgery.  Current Max Fax consultant 68 years of age, due to retire soon and no replacement has been found yet.

6. Chairman’s / Secretary’s Report - Jaco Craig:

Jaco attended the recent Secretary’s meeting held on 9^th May 2019.

• The Educator structure review for Foundation Dentists (FD) training particularly has been delayed until NHS England (NHSE) restructuring has been completed but parts of the country have seen an increase in FDs within some schemes from 12 to 16. Concerns were raised about the potential increased distances that FDs might have to travel for their weekly meetings and that the corporate meetings could be replaced by virtual meetings - seen as a retrograde step. Concerns were also raised about the difficulty in recruitment in those more rural parts of our region where large distances to the nearest post grad centre will be a disincentive when trying to recruit FDs.
• a new e portfolio is to be developed with an intended introduction in the 2020/2021 year.
• Health Education England (HEE) raised concerns about major inconsistencies over the quality of post grad courses and are looking at restructuring the Post grad centres once the NHSE restructuring has completed. Some centres, which were deemed to be vastly underused have already closed in Kings Lynn and Great Yarmouth. The same comments regarding FDs training days relating to the distances to attend post grad courses creating a disincentive for dentist's attendance were raised.
• the role of HEE in the PLVE process was discussed and concerns were raised over the ability of HEE to create a consistency of training 'contract' between the trainer and PLVE student. This was accepted as a problem and the PLVE pathway to obtain an NHS performer number for all overseas dentists might become greater with Brexit imminent so it essential to develop a consistent training contract for those undertaking PLVE.
• HEE were increasing the number of Clinical Fellows in the region to 7 next year across the region with placements in Colchester, Lincoln, Norwich, Derby and 2 in Northampton.
• Restoring Efficiency in Registrants (RERs) are under consultation currently but they have been very supportive for those colleagues going through the PASS and were seen as important support workers for those Dentists in Difficulty DiDs).
• Haptik centres. HEE's focus is on providing specialist centres for colleagues intending to re-enter the profession with Haptek machines. There are currently 3 in the region with 2 in Chesterfield. They are seen as the modern way of training!

1. Year End. Herts South Mids: It is reported that commissioners had shown little support for underperforming contractors with breach notices being issued in February of the following year. There was also very little time for contractors to address underperformance for the following year, given the late notice provided by commissioners. This was much the same in Essex and East with a similar robust approach to breach notices and late announcements of anticipated additional performance required for the following year. It was reported that if a contractor underperforms in the previous year then they are not allowed to over perform by 2% the following year, or if they do then they won't be remunerated for it. Evidence of fledgling 'flexible commissioning' schemes were reported from East Anglia with a scheme to address the difficulty that emergency patients in Cambridgeshire and Norfolk have with accessing a dentist. The AT were offering a 2 year PDS pilot for contractors to see patients as an emergency (1.2 UDAs) followed by a stabilisation phase (2 UDAs) with a UDA value of £60 to reflect the fact that these patients are high needs and often unreliable in attendance. Recruitment is the reason why these emergency patients can't get into a dentist and it is doubtful that this short term 'solution' is going to offer additional access unless the increased UDA values can be seen as a business model to attract another dentist to operate entirely within this pilot - certainly a UDA payment of £25 - £30 might attract a dentist.
2. Tier 2 accreditation. Essex and East Anglia have been piloting iMOS tier 2 accreditation and have recently reported. Concerns with the process have been

• the need for a consistent national accreditation framework for applicants from other parts of the country receiving the same assessment no matter where in the country they applied
• issues surrounding referees and references provided from referees deemed inappropriate
• lack of funding for those sitting on the Local Evaluation Panel
• lack of funding for admin staff
• difficulty in accessing appropriate training for those judged to have not achieved the level 2 competence - who delivers it, who funds the trainer and indemnity issues.
• in East Anglia, 44% of applicants were rejected as not competent compared with only 17% in London.

3. PAG/PLDP. The region had varying policies over whether an LRC observer could be present in a PAG meeting - HSMs have an opt in policy whilst Essex and East had an opt out policy. Essex and East had edited their letter sent to colleagues whose case was to be heard at PAG more fairly reflecting the advantages of LRC observers being present.

4. GDPC. A report was given of the recent GDPC meeting outlining the deliberations over the chair's position following his announcement of his intention to stand for the Brexit party in the forthcoming EU elections. GDPC accepted he could continue currently but would need to stand down in the event of him being elected. The BDA Indemnity offering was presented by Peter Ward, the current MD of the BDA. Concerns were raised over a potential conflict relating to the BDA/GDPC negotiations over State Indemnity, the introduction of which could adversely impact the competing BDA offering.

Contract reform was discussed with modest progress but there is a real likelihood that any rollout would       now be delayed till 2021. The NHSE Long Term Plan was discussed with the hope that the regulations around procurement would be repealed thus avoiding further examples of unnecessary procurement as seen with PDS ortho contracts. Essex reported the concerns they had over the lack of attendance at GDPC meetings of one of their reps. This person has been asked to stand down by GDPC and until a by election can be held an observer from Essex has been allowed to attend to cascade communications.

5. LDC Levy. Each LDC provided the meeting with the current position with their accounts and ability to undertake activities based on their income. Some smaller LDCs were really struggling due to a lack of levy (their countywide contract value being very small based on a small number of contracts) but an expectation to fund attendance at all the meetings that the larger LDCs attend.

6. LDC Conference 2019. Leah Farrell (chair elect) provided an update of the LDC Conference due to take place in June. All LDCs in the Eastern region are sending representatives. The emphasis will be on the motions presented with shorter presentations from 3 speakers.

7. NHSE restructuring. With the boundary changes planned over the restructuring of the NHS in England there is now a very real chance that Northamptonshire will become part of the Midlands and leave the Eastern region. This might impact on levy collection with the potential re coding of contractors working within Northants to align with the new cluster but also their attendance at these meetings in the future.

8. LDC issues. Some LDCs reported real problems with communicating with their commissioners coupled with an apparent lack of ambition on behalf of commissioners to address concerns raised by LDCs.

One LDC reported that they had had to resort to removing an elected LDC member from the committee due to inappropriate behaviour. A referral had been made by another source to the GDC about this individual's similar behaviour, not related to their GDC role. The GDC had however approached the LDC secretary requesting a report of the circumstances which led to the LDC's actions on the members removal. The LDC were concerned over whether they should have whistle blown and felt vulnerable over the GDC's approach.

9. Orthodontic and SCD procurement. All LDCs reported that both ortho and SCD were currently undergoing procurement. Concerns were raised over the methods used to arrive at ortho lot sizes and it was felt more elegant to use secondary schools as a proxy for identifying geographical placements for those lots than population centres of CCGs which had been shown to create anomalies. HSM had placed questions on the Proactis portal but these had been taken down before they were answered by the commissioners.

Starting well event – Basildon June 2019:

Another Starting Well Event will be held in Basildon in June 2019.

Starting Well is a new innovative programme to ensure children receive better dental advice, launched by the Government.

The programme will help dental teams go out into the community and teach children in high-risk areas about the importance of oral health and encourage parents to take their children to the dentist.

Dental teams will offer this through supporting children’s centres events, supporting tooth brushing clubs in early years settings and supporting health fairs and schools parents’ evenings where these are not already provided.

Currently around a quarter (24.7%) of five-year-olds in England experience tooth decay and 33% of under fives have visited a dentist.

Through Starting Well toothbrush and fluoride toothpaste packs will be given to children in the local community who are at risk of tooth decay.

Dental Check by One:

The campaign, by the British Society of Paediatric Dentistry (BSPD), aims to remind parents and guardians of the importance of children seeing a dentist by the age of one.

The BSPD believes the first visit to the dentist is an important opportunity for a child to start a life of positive dental care and for parents to get advice on how to keep their child’s teeth healthy and strong.

 Some children as young as two and three are being admitted to hospital for extractions under general anaesthetic.  Dental Check by One is intended to raise awareness of looking after children’s teeth from an early age.

Perio vs BPE Scoring:

Discussion was held on the guidelines (not statutory) of the new Perio pathway for NHS dentistry. It was concluded that it is too cumbersome and that the time spent on it is not reflected in NHS remuneration. It was deemed not to be appropriate for NHS dentistry and that the current BPE scoring system is an adequate screening system for periodontal disease in NHS Primary Care. 

Benevolent Fund:

It was agreed that the Cambridgeshire and Peterborough LDC would make a donation to the Benevolent Fund.

7. Treasurer’s Report – Patrik Zachrisson:

The Cambridgeshire and Peterborough LDC has sponsored part payment of the Professional Dentistry Midlands CPD Event on Saturday, 6^th April 2019 at The Kingsgate Conference Centre, Peterborough.

The Cambridgeshire and Peterborough LDC continues to be in a healthy financial state. 

8. Date of Next Meeting:

11^th September 2019