Agenda item

The Chairman welcomed those present to the meeting.  He advised that, under normal circumstances, there would have been a large number of witnesses attending the meeting.  However, with the ongoing pandemic and the legal requirement that Council meetings were now held in person, this had reduced the number of witnesses in attendance.  It was suggested that the Chairman and the Labour Lead meet with those organisations that were unable to attend in person to ask questions and gather information outside of formal Committee meetings which could then be reported back to the other Committee Members and used to inform the final report. 

The issue of children’s dental services had first been considered by the Committee in 2019 and had prompted the creation of a Select Panel to undertake a more in-depth review.  The pandemic had halted the review after only one evidence gathering session.  Rather than reinstating the Select Panel to complete the review, Members had hoped to scrutinise the subject in one Committee meeting with additional information gathered in informal meetings outside of the formal meetings. 

Some key lines of enquiry had been included in the report.  Members were advised that there was no requirement for them to use the questions in the report but that they might give them some ideas on scrutinising the issue. 

Dr Andrew Read, Clinical Director of Dental Services at Whittington Health NHS Trust and Deputy Chair of the Paediatric Dental Network (PDN) in North West London (NWL), joined the meeting via Microsoft Teams.  Dr Read advised that the Trust provided specialist community dental services in Hillingdon as well as promotional programmes.

The PDN comprised clinicians from the NHS with a focus on paediatric dentistry.  Work had been channelled towards addressing the huge backlog of children that had needed dental treatment under general anaesthetic (GA) by trying to increase capacity.  A network of dental practices was also being developed to help improve skills. 

It was suggested that there needed to be a greater focus on supporting upstream public health programmes as the driver for GA activity was tooth decay in children.  Although the level of tooth decay in children aged 3 and 5 in Hillingdon was one of the worst in London, it was not the worst in NWL.  There was no easy explanation for why levels of tooth decay were higher in NWL than elsewhere as it was a complex matter and drivers were not always easy to tease out. 

In terms of addressing levels of tooth decay in the Borough were concerned, it was suggested that strategies were needed to improve access to services but also to reduce the need for services.  A number of schemes had taken place to promote oral health in children and young people which had included: supervised brushing in schools; the distribution of toothbrush and toothpaste packs; and train the trainer sessions.  Unfortunately, the level and type of oral health promotional activity in Hillingdon was likely to fall short of that required to address the high level of tooth decay in the Borough.  What was required was more targeted programmes, such as fluoride varnish and toothbrushing programmes, which had evidence to show reduction in decay levels.

Concern was expressed that access to dental services had been negatively impacted by the pandemic with residents finding it difficult to schedule an appointment or to register with an NHS dentist.  In addition, dental related hospital admissions had been highest for those aged 5-9. 

Ms Shikha Sharma, Consultant in Public Health at the Council, advised that NWL had an issue with poor dental health amongst children which was significantly worse that the England and London averages.  It was suggested that the issue might be worse in NWL because of deprivation and population transience but that the reason would be multifaceted. 

With approximately 4,000 births each year, action needed to be taken to develop a sustainable programme of prevention for the long term rather than ad hoc initiatives.  It was agreed that access to dental services also needed to be improved which might be as a result of parental lack of awareness or parents being refused access.  It was noted that, since 2006, residents had not needed to be registered with a dentist to receive treatment from them. 

Ms Sharma noted that campaigns to raise awareness of the need for good oral health and to provide signposting had taken place in the Pavilions shopping centre in Uxbridge before the pandemic.  Action had also been taken to ensure that new dental practices were commissioned by NHS England / Improvement (NHSE/I) in Harefield and Yiewsley following the closure of the previous practices.  Promotional activity had also been taken with regard to weaning and healthy eating and staff and parents in early years settings had improved their understanding about the impact of things like sugary foods. 

A project had been undertaken working with dentists and schools to apply fluoride varnish in areas where issues of poor dental health amongst children had been identified.  It was noted that dental decay had been strongly linked to deprivation so these areas needed to be consistently targeted. 

It was thought important that maternity services raise awareness amongst expectant and new mothers that they were able to receive free NHS dental care until the baby was one year old and that the child would also receive free dental care.  These contacts could also be used as an opportunity to provide the mothers with information about how and when to brush their babies’ teeth/gums.

Other action that had been taken included targeting particular communities about the need for a healthy diet to maintain oral health and improvements to the food offered at schools.  A Children & Young People’s Dental Health steering group had been set up in Hillingdon to target specific areas so that the different organisations involved could collectively look at improving children’s oral health in that area.  This group included representation from NWL Clinical Commissioning Group, Whittington, London Borough of Hillingdon, Local Dental Committee and GPs.  The Democratic Services Manager would contact the Children & Young People’s Dental Health steering group to see if Councillors Denys and Money would be permitted to attend the meeting at 11am on Thursday 17 June 2021 as observers.

Dr Lalit Patel, Chairman of the Hillingdon Local Dental Committee (LDC), advised that the London Confederation was made up of 19 LDCs.  In 2006, dental practices had been issued with new contracts by NHSE/I which gave a figure for a practice in return for a specified number of UDAs (Units of Dental Activity).  The number of UDAs each practice was awarded varied and the value of each UDA varied for each practice but the number of UDAs needed for a particular procedure was the same for every practice.  Practices had not been given any guidance or direction on how many of their UDAs should be used on adults or how many on children.  If, at the end of the year, a practice had not used all of its UDAs, these (and the associated funding) would be clawed back by NHSE/I from the practice and put back into general funds.  This clawed back funding would not be ringfenced for reinvestment into dental services.  

In 2019, Hillingdon had a population of around 309,000.  The NHSE/I spend on dental services had been around £391m in London and Hillingdon had been 22^nd in terms of the amount of funding it had received.  The Borough had 33 dental practices with an NHS contract and 103 dentists.  However, given the current contract arrangements, there was no opportunity for practices to expand or develop insofar as NHS patients were concerned. 

It was noted that the current NHS contracts were coming to an end and were due for negotiation and reform in April 2022.  Dr Patel suggested that the new contracts should specify the proportions of UDAs that should be used by a practice on each age cohort.

Dr Patel stated that water fluoridisation would help reduce dental decay significantly.  Dr Read noted that a reorganisation of the NHS had been set out in a White Paper which would also make it easier to fluoridate the water.  Although this would reduce inequalities, there were significant challenges associated with fluoridating the water supply to 32 London boroughs.  As this was not possible, the next best thing would be fluoride varnishing.  Whittington had undertaken a programme of fluoride varnishing in schools elsewhere in London some time ago and, 10 years later, the level of dental caries had reduced significantly.  During the programme, the parents of those children who were found to have decay were being advised to take them to the dentist.  Although effective, this was the most expensive type of intervention.  Dr Read would provide the Democratic Services Manager with information about this programme and the long-term impact. 

Dr Patel acknowledged that access to dentists during the pandemic had been more difficult.  In his own practice, Dr Patel advised that there were around 250 people on a list waiting to join the practice but that the priority was to see existing patients first.  Dr Read advised that the pandemic had impacted on dental practice capacity but that recovery action was underway to address the backlog. 

Concern was expressed that access to NHS dental services appeared to be limited and Members queried how this was freed up.  Dr Patel advised that, once registered, a patient would stay with that dental practice and would not be removed until they left.  Often, if a patient did not attend for a number of years, when they did eventually attend, they required a lot of treatment and used a lot of UDAs.  As a practice would be limited on the number of UDAs that they were allocated in their contract, this meant that they would be unable to take on additional dentists unless it was for private practice. 

With a large number of dental practices in the Borough not taking on new NHS patients, Members queried what effect this would have on children’s oral health.  Concern was expressed that no organisation appeared to have responsibility of picking up those children that had been left without a routine NHS dental service available to them.

It was recognised that dental practices were under pressure.  They had had to close towards the end of March 2020 and did not reopen until June 2020.  Once reopened, the practices had had to build in fallow time between patients if an aerated procedure had been undertaken which had reduced the number of patients that could be seen each day.  As such, practices had been focussing on clearing the backlog of demand from their existing patients before they would be able to take on new patients.  It was noted that Healthwatch Hillingdon had produced a report on dental services which had highlighted this issue. 

In Hillingdon, four urgent care centres had been created which could be accessed by calling NHS 111.  However, these centres were for those residents that were in urgent need of dental treatment rather than routine dental care.  Dr Read advised that the Secretary of State for Health was responsible for securing access to dental treatment for residents. 

In addition to dental treatment, dentists provided patients with advice and guidance on things like when to start brushing your child’s teeth/gums and when to bring them into the surgery for a check-up.  Concern was expressed that there would be parents who were not registered with a dentist that would therefore not be getting this advice and guidance.  Dr Read advised that the highest need would be those families who accessed dental services the least.  Every now and then a campaign was run to improve access but this always seemed to fail.  Ideally preventative action was needed so that children had better oral health. 

It was noted that there were a number of factors which indicated that a child might be more susceptible to dental ill health.  These included: the child not being registered with a dentist; the parents not being registered with a dentist or not attending if they were registered; child being bottle fed; and living in a deprived area.  Dr Patel advised that bottle feeding had been the biggest cause of dental decay and that the promotion of breast feeding helped to reduce this.  Members queried whether these high-risk factors were mapped across the Borough so that areas for intervention could be targeted. 

Ms Sharma advised that a needs assessment had been undertaken some time ago and that work had been undertaken with maternity services and health visitors to identify families who needed additional support with regard to oral health.  There was an opportunity to look at how the mapping of high risk factors could be built in.  Although partners had an idea of where the target population was located, it would be important to listen to these families’ fears and address their barriers to access.  Further community involvement work would be needed to identify and overcome these barriers. 

It was suggested that health visitors got to know parents and would be able to identify those that had not registered with a dentist and those whose children were bottle fed.  Action could then be taken to get fluoride varnishing for these children.  In addition, consideration needed to be given to including information about dental health in the Personal Child Health Record (red book).  In the past, dental packs had been given to new mothers being discharged from the maternity ward.  This initiative had enabled reinforcement of the message that new mothers were eligible for free dental work until baby’s first birthday as well as pressing the need to maintain babies’ oral health from an early age and get them registered at a dentist.

Ms Sharma advised that, between March 2020 and March 2021, 3,180 brushing packs had been distributed in schools around Hillingdon.  600 packs had also been supplied to three special educational needs (SEN) schools who had engaged during lockdown.  Although annual dental screening was still undertaken in SEN schools, there was no further information available about whether or not a child subsequently sought further treatment from a dental practice.  Action was needed to ensure that this work was intelligence led so that resources were being directed to the children that were most in need. 

Providing new and expectant mothers with information about maintaining babies’ oral health was thought to be key.  It was suggested that information could be disseminated through antenatal classes (as pregnant women wanted what was best for their child) or through platforms such as Facebook, Mumsnet, etc.  A lot of activity had been undertaken on this by the Children & Young People’s Dental Health steering group with things like drawing competitions, Guinness world record attempt, campaigns and activities. 

Concern was expressed that dental health did not appear to be seen as a priority and had seemingly been forgotten.  Although thought did not have to be given to accessing primary medical care, consideration did need to be given to accessing good quality paediatric dental care.  The nature of the current contracts held by dental practices meant that children’s dental care was not seen as a priority.  With good networks already in place for physical and mental health, it was suggested that dental health be included as part of this existing system rather than working in isolation. 

Members were advised that data was available on the percentage of pregnant women who accessed NHS dental services during pregnancy.  However, NHSE figures were not routinely available to the Council so the maternity treatment update figures would need to be requested. 

It was agreed that further information would need to be sought from maternity services and Healthwatch Hillingdon.  Dr Read, Dr Patel and Ms Sharma all stated that they would be happy to provide further information if needed. 

RESOLVED:  That:

1.    Democratic Services Manager establish whether Councillors Denys and Money would be permitted to attend the Children and Young People’s Dental Health steering group meeting at 11am on Thursday 17 June 2021 as observers;

2.    Dr Read provide the Democratic Services Manager with information about the fluoride varnishing programme undertaken elsewhere in London the long-term impact of this intervention; and

3.    the discussion be noted.