Dental Health Services: Improvements (P.127/2013) - Comments

STATES OF JERSEY

DENTAL HEALTH SERVICES: IMPROVEMENTS (P.127/2013) – COMMENTS

Presented to the States on 18th November 2013 by the Minister for Social Security

STATES GREFFE

2013   Price code: B  P.127 Com.

COMMENTS

Although  these  comments  are  presented  in  the  name  of  the  Minister  for  Social Security,  they  are  joint  comments  prepared  and  agreed  between  the  Minister  for Health and Social Services and the Minister for Social Security.

Summary

This proposition is substantially based on selected recommendations from the 2010 Health,  Social  Security  and  Housing  Scrutiny  Panel's  Dental  Health  Services Review' (S.R.12/2010). It proposes –

• An extension of the existing Jersey Dental Fitness Scheme to higher income families, an uplift in the value of benefits payable and a possible further extension of the scheme;
• A change in the administration of the 65 plus Westfield Health Scheme;
• Improved publicity in respect of dental health services;
• Training in oral hygiene for care assistants;

with all actions to be complete by the end of 2014 and paid for from the Health Insurance Fund.

States Members are strongly urged to reject this proposition.

• The proposals in respect of children's dental health are poorly targeted and do not address the areas of greatest need in Jersey.
• There are significant legal implications in using the Health Insurance Fund to fund the proposed range of benefits and services.
• The financial impact of the proposals is not fully identified, and there is no justification for the prioritisation of these particular areas above other similar pressures.

However,  both  Ministers  acknowledge  that this  is  an  area  of genuine  public concern and that positive action needs to be taken. To that end, the Minister for Social Security and the Minister for Health and Social Services will incorporate the following actions into their 2014 business plans –

1. Commission  a  Dental  Health  in Schools'  Survey  to provide  up-to-date information on the current status of dental health among school and pre-school children.
2. Develop a Business Case for developing and implementing a dental health education programme to increase awareness of good oral hygiene and dental health among children and their parents/carers.

3. Undertake  a  review  of  current  States  spending  on  dental  health services/benefits and identify if and how existing spending could be utilised more effectively.
4. Prepare an implementation plan for the delivery of enhanced publicly funded dental health care services/benefits in Jersey.

1. Dental health for children and young people

The Health and Social Services (H&SS) Department provides an annual free dental screening programme for States primary-school children. Where a dental problem is identified, a letter is sent to the parent/carer advising them to contact the H&SS dental department or a private dentist. Routine dental treatment is provided free of charge by the General Hospital Community Dental Department for any child, irrespective of means, up to the age of 11.

Independent  surveys  of  the  dental  health  of  local  5 year-old  children  show  a significant improvement in dental health over the last 20 years, with dental fitness well above UK levels.

FIVE YEAR OLDS

AVERAGE NO. TEETH WITH ANY DECAY EXPERIENCE (dmft) JERSEY vs UK STUDIES

2 1.5 1 0.5 0

In the latest survey (2008) the average number of decayed, missing or filled teeth (dmft) was roughly half that noted in the UK. However, there is a significant variation in  dental  health  between  different  primary  schools –  analysed  by  school,  the percentage of children with decay experience (at least one decayed, missing, or filled tooth) varies from a high of 44% to a low of 8%. In general terms, non-fee-paying schools with higher proportions of low-income families have higher rates of dental problems.

Jersey Dental Fitness Scheme (JDFS) – children from 11 upwards

This  scheme  is  run  in  partnership  between  the  two  Departments  and  community dentists. When a child presents to a participating Private Dentist to join the scheme, they need to be dentally fit before they can be enrolled, and H&SS undertakes any necessary work to bring the child to dental fitness. Subsequently, the Social Security Department  (SSD)  provides  a  monthly  benefit  payment  towards  the  cost  of  a maintenance plan agreed between the community dentist and the child's parents to ensure  that  the  child  remains  dentally  fit.  The  Jersey  Dental  Fitness  Scheme  is promoted in schools and leaflets are available from dental surgeries.

At present, the JDFS scheme is available to families with incomes up to £46,000 per annum. There were 1,213 children included in the scheme in 2012. The dental health of children on the scheme was audited earlier in 2013, and the report noted that –

"It is very pleasing to note that the standard of dental health in the children audited was very good. In particular, the standard of restorative dentistry was high and the fitness scheme continues to meet its aims of provision of high quality dental care to children of lower income families."

Deputy G.P. Southern of St. Helier is proposing that the value of the benefit available under the JDFS should be increased and that the income bar should be increased from £46,000 to £59,8001 per annum.

The report within P.127/2013 and the associated Scrutiny Report, S.R.12/2010, do not provide any evidence to suggest the health improvements that would be achieved by extending the coverage of the scheme to higher-income families. Based on the survey of  5 year-olds  noted  above,  average  dental  health  levels  are  good  in  Jersey,  and children at fee-paying schools show the lowest level of dental problems.

However, the major variation in the dental health of 5 year-olds between schools suggests  that  there  are  issues  in  Jersey  that  need  to  be  addressed,  and  that consideration should be given to reviewing existing schemes and/or providing more targeted support for low-income families. For example –

• Should the existing primary school screening programme be reviewed with a view to introducing a more pro-active, preventive approach to dental health in schools along the lines of the "Child Smile" programmes being rolled out in Scotland, which seem to be establishing an effective new model of promoting child dental health and reducing inequalities?
• Local epidemiological surveys have recommended that action should be taken to deliver preventative activity, and that this should be aimed at pre-school children, targeted  geographically  at the  catchment areas  of schools  where dental health was poor. Should a strategy be developed aimed at a reduction in the decay experience of the parents of those pre-school children who are most at risk of developing disease?

1 Upper bound of 4th quintile household income (HIDS 2009/10) adjusted for average earnings

index to 2013.

• Is the structure of the JDFS scheme appropriate for families in "hard to reach" communities?
• Should  we  provide  a  two-tier  JDFS,  including  a  fully  funded  option  for children in the lowest-income families?

A commitment to undertake the actions set out in P.127/2013 before the end of 2014 will not address these issues and will not improve the dental health of the poorest children in Jersey.

As  confirmed  in  a  written  answer  dated  8th  October  2013,  the  JDFS  scheme  is currently  under review, and  the Minister  for  Social  Security  has  already  given  a commitment  to  announce  changes  to  the  scheme  when  they  are  complete.  Both Ministers acknowledge that work needs to be undertaken to improve the dental health of low-income children in Jersey, and they are committed to working together to identify  a  pro-active  way  forward.  In  particular,  the  Ministers  will  include  the following specific actions in their 2014 departmental business plans –

• Commission a Dental Health in Schools' Survey to provide up-to-date information on the current status of dental health among school and pre- school children.
• Develop a Business Case for developing and implementing a dental health education programme to increase awareness of good oral hygiene and dental health among children and their parents/carers.

2. Dental health for older people

The Social Security Department provides support for dental costs of low- to middle- income pensioners through the 65+ Westfield Health Scheme and through income support.

In general, assistance with dental costs is provided for adults on Income Support in the form of grants to a maximum of £500 every 2 years. Costs in excess of this may be met by a loan. In 2012, 409 people received grants at a cost of £165,000. A further 82 people received loans which totalled £35,000. For those aged 65 and above, grants can be provided in excess of £500. At the end of 2012, the 65+ Westfield Health scheme  included  2,266 members  at  a  total  cost  (including  optical  and  chiropody services as well as dental services) of £251,000.

Adults receiving income support are encouraged to join the Westfield scheme when they  reach  the  age  of  65.  An  Income  Support  pensioner  making  a  claim  from Westfield does not need to make any upfront payment in respect of their treatment. The initial cost of the bill is met through the Income Support special payment system, and then up to £500 can be recouped from the Westfield scheme.

In  response  to  S.R.12/2010,  the  Department  undertook  to  review  the  information distributed to pensioners. In 2011, a flyer was created which gave information on all pensioner benefits, including the 65+ Westfield Scheme, and was sent to all local pensioners with their pension uprating notice. This exercise has been repeated in 2012 and 2013. The distribution exceeds 16,600 local people. In addition, all new local pensioners are given this information when they first draw their pension. This has

proved  an  effective  means  of  encouraging  additional  claims  across  the  range  of pensioner benefits. For example, 63 applications for the 65+ Westfield Health Scheme were received following the 2013 notice, bringing the current number of claimants to 2,354.

An independent study Dental Epidemiology in Jersey 1987 – 2003', reported on the dental health of people aged over 65. The report noted that people over 65 in Jersey retain more natural teeth than their counterparts in the UK, but three-quarters (75%) of the over-65s did not attend a dentist regularly. At that time, barriers to attendance were described as physical, practical, economic and attitudinal constraints'.

More  recently  in  the  UK,  the  British  Dental  Association  has  presented recommendations  to  address  the  needs  of  older  people,  these  include  looking creatively' to align dentistry with other provision, including voluntary organisations and day centres, a free screening check-up, guidelines for care homes and contracts between care homes and dentist surgeries.2

P.127/2013 proposes that the need for upfront payments for dental treatment required by the 65+ Westfield health scheme should be eliminated. As noted above, upfront payments are not required by Income Support claimants. However, it is acknowledged that the requirement for the individual to meet the costs of treatment in full may act as a barrier to some claimants who do not receive income support.

The  written  answer  dated  8th  October  2013  confirmed  that  the  Social  Security Department has already commenced a review of SSD pensioner benefits for Income Support claimants in line with existing Business Plan commitments, and this will be extended in the 2014 Business Plan to include a review of the operation of the 65+ Westfield Health scheme for those above the Income Support limit. This review will extend beyond the payment method used for the scheme and will examine other barriers, which can also include a perceived lack of need, access and mobility or social isolation and depression, all preventing some pensioners from seeking dental check- ups and treatment.

P.127/2013 also requires a publicity campaign to be undertaken during 2014. The Social Security Department has already established a cost-effective route to provide information to all local pensioners once a year. In addition, all benefits are publicised on the States of Jersey government website, at – http://www.gov.je/Government/Departments/SocialSecurity/Pages/index.aspx  

and are explained on the Citizens Advice Bureau website (http://www.cab.org.je/).

Earlier this year, 3 dental teams (Dentist and Nurse) visited H&SS-run care homes at The Limes, Sandybrook and Overdale's Samarès Ward to undertake inspections of patients' teeth and to give staff instructions on how to care for both natural and false teeth.

H&SS  has  run  semi-formal  training  sessions  previously  for  carers  from  nursing/ residential homes to instruct them on how to care for clients' teeth, both natural and false. A further session is set to run in the early part of 2014.

2 http://www.bda.org/dentists/policy-campaigns/research/patient-care/older-people.aspx  

3. Funding

All the services referred to in P.127/2013 are currently funded through the tax-funded budgets  of  the  Social  Security  Department  and  the  Health  and  Social  Services Department. Part (a) of the proposition suggests that all the additional benefits and activities should be funded through the Health Insurance Fund. Whereas it is correct that the Health Insurance Law includes Regulation-making powers to create a dental benefit, this power could not be used directly to provide the range of benefits and services proposed in P.127/2013.

Benefits currently paid from the Health Insurance Fund are "universal" benefits – i.e. they are not subject to any means test or income bar. Both the Jersey Dental Fitness scheme and the Westfield scheme include an income bar, and States Members would need to agree that the Health Insurance Fund should be extended to provide income-related benefits as well as the existing universal benefits.

More  fundamentally,  the  Health  Insurance  Fund  is  only  currently  set  up  to  pay benefits to local residents when receiving treatment covered by the Fund (e.g. G.P. consultation, prescribed drugs). The scope of the Fund would need to be extended by primary legislation to support the direct cost of healthcare professionals and publicity campaigns. This work would need to be prioritised over other urgent improvements already  planned  to  the  legal  framework  governing  primary  care  to  achieve implementation by the end of next year.

The report accompanying P.127/2013 explains that –

"  transfer  of  funding  to  HIF  is  designed in the  first  instance  to avoid wrangling over health department funding priorities "

Many Members will be aware of the enormous volume of work undertaken by health professionals over the last few years to build up the business cases that formed the basis of P.82/2012 – Health and Social Services: A New Way Forward, and the many difficult decisions that needed to be taken to identify the relatively small number of new projects that could be funded from available resources. This proposition does not put forward any argument to suggest why these particular areas of dental spending should be prioritised above many other, equally valid, areas.

Proposals for additional public spending should be supported by relevant evidence and a full understanding of the costs of the proposals and the anticipated benefits. The financial  information  given  in  P.127/2013  is  vague  and  does  not  provide  a  full explanation of the financial implication of each proposal.

Both Ministers acknowledge that existing spending on dental services/benefits has built up over a number of years across the two Departments, and that there is merit in co-ordinating  a  review  to  ensure  that  resources  are  allocated  appropriately.  The following actions will be included in 2014 departmental business plans –

• Undertake  a  review  of  current  States  spending  on  dental  health services/benefits  and  identify  if  and  how  existing  spending  could  be utilised more effectively.

• Prepare an implementation plan for the delivery of enhanced publicly- funded dental health care services/benefits in Jersey.

4. Timetable

The Scrutiny Report S.R.12/2010 was published in November 2010. The Ministerial Response  drew  attention to  the  major review  of  health  strategy  that  was already underway at that time, and noted that it would be inappropriate to commit significant funds to a specific area until the review was complete.

Since then Caring for each other, Caring for ourselves' has been delivered. The Green Paper consultation was conducted between May and August 2011, and the White  Paper  consultation  during  May  and  July  2012;  and  these  culminated  in P.82/2012 – Health and Social Services: A New Way Forward, which firmly places dentists  alongside  general  medical  practitioners,  high  street  optometrists  and pharmacists  as  frontline  providers  in  the  new  primary  care  model.  The  States Assembly overwhelmingly supported the proposal that the –

"  Council  of  Ministers  should  co-ordinate  the  necessary  steps  by  all relevant Ministers to bring forward for approval ... proposals to develop a new  model  of  Primary  Care  (including  General  Medical  Practitioners, Dentists,  high  street  Optometrists  and  Pharmacists)  before  the  end  of September 2014."

In the course of the P.82/2013 debate, Deputy Southern made the following comment in respect of an amendment to reduce the time available to develop the new model of primary care –

"It is very, very rare for me to stand up and support the Chief Minister especially when he talks about doing something over a longer time period than a shorter, but I believe that what he had to say was absolutely correct. Senator Ferguson made a good case for starting with primary health care and getting it right. What she did not make a case for was doing it quickly because the risk is that we do not get it right. On that particular amendment I cannot see the reason to hurry up. Certainly in talking with G.P.s in my previous life as head of H.S.S. (Health and Social Services) Scrutiny, getting it right was very much the emphasis of what was needed. A major reform of how we fund our primary health care; but let us get it right because the risk is otherwise we will have increasingly a number of people on our Island who cannot afford that primary health care and that is to be avoided, I would say, at all cost. I believe we are already in that position and in order to get out of that position we have to get it right. If that takes 2 years then it takes 2 years."

Deputy   Southern 's  comment  last  year  acknowledged  that  health  care  issues  are complicated and new projects need to be carefully thought through. In this light, the requirement to implement all of the P.127/2013 proposals within 13 months seems unreasonable.

On 8th October this year, Deputy Southern submitted a written question and an oral question addressed to the Minister for Social Security, in respect of progress against the Scrutiny recommendations on the review of the Jersey Dental Fitness Scheme and the 65+ Westfield Health scheme. In the written response provided at that time, the

Minister for Social Security confirmed that work was underway in a number of areas in respect of both schemes, and that specific changes would be announced when that work was complete. A few weeks later, this situation has not changed.

Despite  the  problems  identified  above  in  respect  of   Deputy   Southern 's  specific proposals,  both  Ministers  are  committed  to  improving  existing  dental  services. Inevitably, the Primary Care Review will have a part to play. But, with that Review proving  to  be  a  considerably  more  complex  and  difficult  project  than  originally anticipated, both Ministers recognise that immediate steps can be taken in advance of the completion of the new model of primary care, to improve dental health in key areas. To that end, and as set out above, specific actions will be included in 2014 departmental Business Plans.

Conclusion

The two Ministers will work individually and together to deliver the specific actions included in this comment. In particular, departmental business plans for 2014 will include the commissioning of a dental health survey among school and pre-school children, and the preparation of a business case for developing and delivering a dental health awareness and education programme. In addition, a review of current spending on dental services and benefits will ensure that available funding is targeted to best effect. However, it must be accepted that, dependent on what is to be delivered, audited and evaluated, the implementation of additional services will, inevitably, place extra demand and pressures on existing departmental budgets and capacity.