British Dental Association Response to The Health Select Committee Inquiry into Public Health

British Dental Association Response to The Health Select Committee Inquiry into Public Health Introduction 1. The British Dental Association (BDA) is the professional association and trade union for dentists practising in the UK. Its 23,000-strong membership is engaged in all aspects of dentistry including general practice, community/salaried services, Dental Public Health, the armed forces, hospitals, academia and research and includes students. 2. The BDA strongly welcomes the objective of improving public health. We support the vision of a shift from treatment towards prevention of ill-health and the recognition of Professor Sir Michael Marmot s view that the wider social determinants of health must be addressed in order to tackle inequalities. The change in focus must also be underpinned by specific measures to prevent avoidable illness, and supported by an appropriatelystaffed NHS-based public health workforce. 3. We welcome the specific recognition of dental public health in the White Paper. This must translate into inclusion in local priority and strategy setting in all areas of the country, requiring full integration of dental public health with other health and social care structures and continuing dialogue between professionals. 4. The strengthening of public health outlined in the White Paper is supported. As Dental Public Health is a small specialty, it is important that Consultants in Dental Public Health are able to work in the most effective way across the three public health principles of health protection, health improvement and health services. Whilst it is essential there is Dental Public Health input into Local Authority Joint Strategic Needs Assessments (JSNA), the majority of dental commissioning will be with the NHS Commissioning Board, where it is even more important to give advice. We feel that this can only be carried out from within the NHS and so support the model of a public health agency. 1

5. The BDA responded to the three government public health consultation exercises in early 2011 1. 6. The BDA, along with a reference group of Consultants in Dental Public Health, has produced a document outlining our vision for the future of dental public health which is attached at Annex A. 7. We note that a sound strategy already exists for developing the Dental Public Health workforce in England, and we urge the Government to draw on this in consolidating its plans for the new arrangements 2. The creation of Public Health England within the Department of Health 8. Both the BDA and the BMA support a model which would see a single NHS public health agency assume responsibility for all public health specialist staff. This organisation would cover the three domains of public health practice health protection, health improvement and public health support for commissioning. 9. It is essential that the Committee considers the impact of the creation of Public Health England alongside the NHS Commissioning Board, GP consortia, the transfer of budgets to local authorities and how this impacts on the public health workforce. It is likely that the creation of new NHS and civil service branches will result in unnecessary complication and the potential fragmentation of public health services, which must be avoided. It is essential that a robust strategy for the design, commissioning and delivery of all public health services is developed in collaboration with Consultants in Dental Public Health. 10. There is a lack of clarity on how dental public health will be integrated with other areas of public health and social care, particularly in view of the stated aim to adopt a life-course approach. We would welcome opportunities to work with the Department of Health on this. Proper integration of dental public health will require expert input on all Health and Wellbeing Boards, to ensure that local oral health issues are represented in every JSNA and therefore in the joint health and wellbeing strategies. We advocate the inclusion of Consultants in Dental Public Health on Health and Wellbeing Boards to provide this. In cases where direct membership might not be possible, Health and Wellbeing Boards must be required to seek expert input from Dental Public Health specialists in identifying strategic priorities. The abolition of the Health Protection Agency and the National Treatment Agency for Substance Misuse 1 http://www.bda.org/dentists/policy-campaigns/research/government/leg-regs/pub-health-reform/ 2 Improving oral health and dental outcomes: developing the public health workforce in England http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh _115512.pdf 2

11. The transfer of the Health Protection Agency (HPA) to the Department of Health would render its function significantly reduced, to the detriment of the existing public health workforce. Approximately half of HPA s income is self-generated through research grants and commercial activity, and becoming part of the civil service will bring an end to these essential income-generating activities. This will inevitably result in a reduction in staff numbers, capacity and capability. 12. It is essential that relationships between HPA and the public health workforce are maintained, and this should be a core consideration when functions are transferred. We have significant concerns that we have already lost considerable expertise since changes to local structures began in 2010. It is imperative that structures are developed that facilitate the delivery of the public health strategy, rather than further fragmenting it. The public health role of the Secretary of State 13. It is vital that the Secretary of State maintains statutory responsibility for protecting the health of the population. The new public health strategy forms a fundamental part of the Government s ambition for the modernisation of the health service, and we have reservations about the separation of health and public health, and the consequent division of accountability of the Secretary of State, and how this then relates to commissioning and funding. 14. Alongside the role of the Secretary of State, it is essential that healthcare Chief Officers are given a public health role. We were disappointed that Healthy Lives, Healthy People did not include a specified role for the Chief Dental Officer in the design and delivery of the public health strategy, despite making mention of the role of the Chief Medical Officer. It is essential that the Secretary of State maintains a strategic role across the healthcare professions in relation to the three domains of health protection, health improvement and health services, and how they fit into the wider NHS strategy. The future role of local government in public health (including arrangements for the appointment of Directors of Public Health; and the role of Health and Wellbeing Boards, Joint Strategic Needs Assessments and Wellbeing Strategies) Arrangements for public health involvement in the commissioning of NHS services 15. Local government will play an important role in the delivery of the public health strategy, and this must be underpinned by the advice and guidance of an expert public health team. There must be a duty for local authorities to work with Consultants in Dental Public Health when developing the JSNA and Wellbeing Strategies to ensure that local needs are identified and addressed. Oral health must be a mandatory component of the JSNA. 16. It is essential that Directors of Public Health have a primary duty to their populations, and we support the BMA s view that this would require that they: prepare an independent annual professional report on the health of the population; act as an advocate for public health within all areas of the local authority; undertake health impact assessments of local 3

authority policies, programmes and services; provide professional public health advice (rather than the corporate local government view) to other public bodies active within the area. 17. As at paragraph ten, we advocate the inclusion of Consultants in Dental Public Health on Health and Wellbeing Boards to provide expertise on oral health issues. 18. Most importantly, it is essential that a legislative framework is developed in collaboration with consultants in all areas of public health to avoid the need for local authorities to make ad hoc arrangements. Protected budgets and a clear strategy are required to ensure that consultants in dental and healthcare public health are able to best serve the needs of their local populations. Arrangements for commissioning public health services 19. As all dental services (this includes primary, secondary and specialist) will be commissioned by the NHS Commissioning Board, it is essential that the commissioning of these services is supported by a dentally qualified team, and not passed to any other healthcare specialty. These teams should be led by Consultants in Dental Public Health and would further support commissioning. The future of Public Health Observatories 20. We support the BMA s view that Public Health Observatories (PHOs) must be supported if the Government is to achieve its vision of assessing and improving the performance of local public health programmes. The dental observatory in the North West provides important information for the specialty, and it is essential that this work continues. The structure and purpose of the Public Health Outcomes Framework 21. Overall, the BDA is satisfied with the structure and purpose of the Public Health Outcomes Framework, but made recommendations to include further outcomes for Dental Public Health in our response to the consultation exercise earlier in 2011. 22. The proposed oral health indicator for five-year-old children will promote collaborative working between health and social care professionals locally, and between family members. Sound oral health at age five is dependent on the prior establishment of good diet and effective oral hygiene routines, requiring engagement of all the child s carers. (This should also produce secondary benefits for family members, who are likely to lead by example when teaching the child good oral hygiene practice.) Consistent messages and support from midwives, health visitors and any other professionals coming into contact with children and their carers prenatally and during infancy are also essential. A further oral health indicator relating to older age groups would also encourage local partnerships across health and social care. 23. The BDA commends the Government s aspiration to reduce the incidence of dental decay in children aged five years, with the caveat that there will not be a significant change in outcomes unless interventions occur from a much earlier age. Dental decay is strongly 4

linked to social deprivation, and the BDA advocates that the Scottish ChildSmile 3 programme be rolled out across England, if this aspiration is to be achieved. 24. The scheme has achieved its target of 60 per cent of children aged seven showing no signs of dental decay, and the programme is currently under review to establish firmly its effectiveness. Early indications show that the results will be positive, and the BDA recommends that Government monitor these outcomes and consider the impact of implementing the scheme in England. Arrangements for the funding of public health services (including the Health Premium) 25. We cautiously approve the basic principle of a ring-fenced public health budget, although we would like more information on how the dental public health budget will be calculated and allocated. We have concerns, however, about whether the ring-fenced money will be spent only on public health activity or will also cover salaries for local authority staff employed in public health teams. The financial situation of local authorities was not addressed in the consultation on funding and commissioning routes for public health as part of the Healthy Lives, Healthy People white paper consultation exercise, although they are facing real term cuts in Government funding of 26 per cent between 2010-11 and 2014-15. This translates, on average, to a reduction of 7.25 per cent per year. We are concerned that this will have severe implications for the delivery of public health. The impact assessment for the proposals indicates that any funding will be transferred from PCTs to local authorities for the transference of function from the NHS, and we need assurance that the service will not suffer as a consequence of a reduction in resourcing. 26. Whilst we strongly support the commitment to a reduction of inequalities and advocate a focus on vulnerable groups in society, we do not agree with the proposed health premium as a means to achieve this goal. A health premium should not be required if funding is correctly allocated in the first instance, with appropriate weightings that take account of inequalities. 27. We have concerns about how the ring fenced budget will be calculated and how the Department has formed early estimates that the spend on public health could be over 4bn. We ask the Government to publish the evidence base that supports this figure. Our concerns arise because not all public health money is easily identifiable for example, funding for training of epidemiologists is found locally, but we believe it is important in the new system that it should be funded centrally. We seek clarity on the total budget for dental public health to ensure that it is adequate to provide the required functions and can be safeguarded. The future of the public health workforce (including the regulation of public health professionals) 3 http://www.child-smile.org.uk/ 5

28. We recommend that a commitment be made to ensure that there is adequate consultant advice available to the news structures and boards. One third of PCTs are currently without access to consultant advice in dental public health, and around one fifth have no input from a Dental Practice Adviser, meaning that dental public health is already considerably under-resourced. The average whole time equivalent in PCTs that have access to a Consultant in Dental Public Health is two days per week, with average Dental Practice Adviser input of only one day per week. 29. We recommend that all Dental Public Health posts that were in existence in 2010 be retrospectively protected to ensure that dental public health expertise is preserved, which should include recruiting to any posts that were vacant during that year. The budget for Consultants in Dental Public Health and Dental Practice Advisers who retire or move on during the transition period must be protected, and not diverted elsewhere. Dental public health is already underfunded, and the loss of any of its budget or roles will have a negative impact on the oral health and health services of local populations. 30. Consultants in Dental Public Health are and must remain NHS employees. That some are already being transferred into the local authority structure and are losing touch with dental commissioning is a worrying development. We support the BMA s proposal that public health staff should sit within a single public health organisation that would be part of the NHS. The development of guidance on where Consultants in Dental Public Health will sit and their accountability and reporting structure is required. This should be led by the Department of Health with input from the NHS Commissioning Board when it takes up its shadow responsibility. 31. We welcome the Government s commitment to develop a detailed strategy document to be published in autumn 2011, but caution against the duplication of existing work. The Department of Health s Improving oral health and dental outcomes: Developing the public health workforce in England provides a comprehensive analysis of the requirements of the Dental Public Health workforce, and should be used as the starting point for the forthcoming strategy. It is essential to recognise that the Dental Public Health workforce does not simply mirror the medical model. Consultants in Dental Public Health cover a much wider range of functions than their medical counterparts, with no separate workforce dedicated to dental epidemiological surveys or oral health promotion and in addition we have a particular focus on commissioning, service redesign and service evaluations across all areas of dentistry, primary and secondary care. 32. Healthy Lives, Healthy People outlines a budget of 4bn for public health spending, and the BDA would be interested to see how that figure has been calculated. We support the idea of a ring-fenced budget in principle, but we have concerns about the lack of clarity on how this budget will be divided across the healthcare professions. Given that the Dental Public Health workforce is currently insufficient to deliver a nationwide strategy effectively, we are concerned that a reduction in funding will heighten this challenge, resulting in a detrimental impact on oral health. We understand the current financial challenges facing the NHS, but advise that, if there is a commitment to improving the public health of the nation, appropriate investment must be made to support this aim. The 2008 workforce 6

summary for Dental Public Health estimated a target of one whole-time Consultant in Dental Public Health per 600,000 population and Dental Public Health teams should be developed to meet this target. 33. Alongside the commitment to improve the oral health of five-year-old children, we urge the Government to consider a similar target for the heavy metal 4 generation, who will have significant restorative needs as they approach older age. As set out in our response to the public health Outcomes Framework consultation, we believe that an indicator is required for the maintenance of functional dentition into older age. In order to meet this increasing demand, it is vital that careful workforce planning is undertaken to ensure that we have sufficient staff numbers to carry out the volume of restorative work that will be required over the next 20 years. 34. The BDA responded to the Developing the healthcare workforce consultation, and we urge the Department to make use of all available data on the dental workforce and the future challenges it faces. We note that many members of the Dental Public Health workforce are approaching retirement, and clear succession planning is required. Dentistry also has a number of small specialties, including periodontics, endodontics and prosthodontics, with just under 30 per cent of practising staff below the age of 55, and with limited training opportunities. Similarly, a lack of clinical academic places has the potential to destabilise training in these specialist areas, and this situation should be carefully monitored to ensure that the supply of specialist dentists meets the demand for their services. 35. Academic Dental Public Health must also be supported. Funding is required to promote excellence in research and teaching, in order to develop sound, evidence based practice. 36. We support the proposal in the Scally Report that the professional regulation for Consultants in Dental Public Health remain with the General Dental Council. How the government is responding to the Marmot Review on health inequalities 37. The BDA welcomes the focus on reducing health inequalities. Oral health is an area in which inequalities are rife, as set out in our recent paper Oral health inequalities 5. Vulnerable groups in society, including those with disabilities, prisoners, older people and children, are particularly affected and there is a strong correlation between oral health and socioeconomic status. We agree with the stated need to share responsibility across society for reducing these unacceptable disparities, with co-ordinated involvement of all sectors and health and social care agencies. Many of the factors underlying oral health inequalities, including diet, smoking and alcohol abuse, are common to poor general 4 Defined in Professor Jimmy Steele s Review of NHS dental services in England as The younger generation of 1978 (16 34-year-olds) who had high levels of decay and many fillings, mostly of dental amalgam. As this cohort ages, they will require significant restorative work to maintain their oral health. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_101180.pdf 5 http://www.bda.org/images/oral_health_inequalities_policy.pdf 7

health. Close partnership working between all health and social care professionals is essential to deliver consistent and appropriately targeted messages across society. 38. People with disabilities must be considered specifically within local needs assessments, as their particular requirements can be overlooked in the absence of positive measures to include them. As recommended in the 2007 report Valuing People s Oral Health, oral health should be included in every care plan; co-ordination between all relevant health and social care professionals is required in planning, commissioning and delivering services. Robust local data must be the foundation of the needs assessment. 39. We welcome the emphasis on tackling the underlying social factors affecting inequalities in health and wellbeing, including environment, housing, education, as identified in the Marmot Review. Budgets for specific oral and general health interventions must be protected, and must not be subsumed into funding targeted to the underlying social determinants of health. This must be a statutory undertaking for local authorities. 8

Annex A - Dental Public Health Futures 1. We support the sound strategy for Dental Public Health which already exists 6, and should underpin the development of the Government s public health strategy, which we understand will be published in autumn 2011. This strategy was developed with broad professional input. 2. We recommend that a commitment be made to ensure that there is adequate consultant advice available to the new structures and boards. One third of PCTs are currently without access to consultant advice, and around one fifth have no input from a Dental Practice Adviser, meaning that Dental Public Health is already considerably underresourced. The average whole-time equivalent (WTE) in PCTs that do have access to a consultant is two days per week, with average Dental Practice Adviser input of only one day per week. 3. The budget allocations must match the range of required activities to deliver the Dental Public Health strategy. Alongside this, we seek clarification of how the proposed public health budget of 4 billion 7 has been determined, and urge the Government to consider ring-fencing amounts for each area of healthcare, including dental public health. A defined budget is the only way to ensure that each of the healthcare professions can effectively plan and deliver their services. We would welcome the opportunity to work with the Department of Health and the NHSCB to calculate the public health budget and numbers of staff required to achieve the Dental Public Health aims, including epidemiology, oral health promotion, health services and oral health strategy. 4. We recommend that all Dental Public Health posts that were in existence in 2010 be retrospectively protected to ensure that dental public health expertise is preserved, which should include recruiting to any posts that were vacant at that time. The budget for Consultants in Dental Public Health and Dental Practice Advisers who retire or move on during the transition period must be protected, and not diverted elsewhere. Dental Public Health is already underfunded, and the loss of any of its budget or roles will have a negative impact on the oral health and health services of local populations. 5. Consultants in Dental Public Health are and must remain NHS employees. That some are already being transferred into the local authority structure and losing touch with dental commissioning is worrying. We support the BMA s proposal that public health staff should sit within a single public health organisation that would be part of the NHS. The development of guidance on where Dental Public Health consultants will sit and their accountability and reporting structure is required. This should be led by the Department of Health with input from the NHS Commissioning Board (NHSCB) when it takes up its shadow responsibilities. 6 Improving oral health and dental outcomes, http://www.dh.gov.uk/en/publicationsandstatistics/publications/publicationspolicyandguidance/dh_114488 7 Healthy Lives, Health People: our strategy for public health in England 9

6. In order to be in a position to give this advice, it was recommended in the Dental Public Health strategy that Consultants in Dental Public Health should work as part of a network. The model described by the BMA 8 - of a single public health agency with secondments to other organisations or with whatever sub-national arrangements of the NHS Commissioning Board - appear to be the favoured and most sensible models. High level input into these structures as they are developed is important. It will also ensure that dental public health continues to offer best value for money and contributes to the Department of Health s QIPP agenda by supporting service redesign and quality management. 7. As all dental services, both primary, secondary and specialist will be commissioned by the NHS Commissioning Board, it is essential that the commissioning of these services must be supported by a dentally qualified team, and not passed to any other healthcare specialty. These teams should be led by consultants in Dental Public Health and would further support commissioning. 8. It is imperative that Consultants in Dental Public Health maintain their responsibilities regarding quality, access, probity and performance in the new NHS structures. They must also continue to be involved in the Joint Strategic Needs Assessment (JSNA) and health improvement programmes to ensure that identified needs are addressed at population level, and must have a role in quality oversight alongside the Care Quality Commission (CQC). 9. Although the oral health of the population continues to improve, there are still significant public health challenges to address, spanning the entire population. Issues such as access to quality, effective dental services, poor diet and nutrition, smoking and alcohol consumption, and the restorative needs of the heavy metal generation as described in the Steele Review 9 will all play a part in ensuring that there will continue to be a significant long- term role for consultants in improving health and addressing inequalities. 10. During the transition period, a new dental contract will be piloted by the Department of Health, which is due to be implemented in 2014. To support general dental practitioners, commissioners and the Department of Health in piloting the new contract, it is vital that there is continuity in the provision and availability of dental public health services within the NHS, to ensure the process has expert clinical involvement. 11. The specialty of dental public health must be safeguarded through the protection of academic careers, education and training, the availability of sufficient consultant and training posts, thereby ensuring opportunities for career progression. Salaries and terms and conditions must continue to reflect the level of expertise currently provided by Consultants in Dental Public Health to ensure that the specialty can attract and retain the best people for the role. Terms and Conditions and Salaries must remain as core NHS. 8 BMA response to Healthy Lives, Healthy People 9 http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_101180.pdf 10

Clinical commissioning expertise must be safeguarded to ensure that Dental Public Health is not overlooked by non-clinical commissioners who are sometimes unaware of the importance of the specialty. We believe that this is best achieved by ensuring that public health, including dental public health remains the responsibility of the NHS. 12. The continuum of education and training in dental public health must be closely monitored and safeguarded. Trainees will continue to require both NHS and local authority-based experience to build the required competencies to become a Consultant in Dental Public Health. We must ensure that Consultants in Dental Public Health are able to work effectively across organisations and populations within new structures. 11