Mobile dental service funded from the Health Insurance Fund

STATES OF JERSEY

MOBILE DENTAL SERVICE FUNDED FROM THE HEALTH INSURANCE FUND

Lodged au Greffe on 13th October 2011 by Senator A. Breckon

STATES GREFFE

2011   Price code: C  P.170

PROPOSITION

THE STATES are asked to decide whether they are of opinion

1. to request the Minister for Health and Social Services to establish a new mobile dental service in Jersey with 2 fully-equipped mobile dental  surgeries  providing  dental  care  to  primary  schoolchildren, children of pre-school age attending nurseries and senior citizens who are in receipt of an old age pension with the initial capital cost of the mobile surgeries and the annual operating costs being met from the Health Insurance Fund for an initial period of 5 years;
2. to request the Ministers for Health and Social Services and Social Security,  in  consultation  with  the  Minister  for  Treasury  and Resources, to bring forward for approval the necessary measures to enable funding to be made available from the Health Insurance Fund and, subject to that approval, to take the necessary steps to establish the service.

SENATOR A. BRECKON

REPORT

In August 2011 I came across a snippet of information about "Dental Visits" in the UK which said that –

"Some 26,000 fewer children are now seen by an NHS dentist than in 2004/06, despite a rise in the overall number of people paying a visit. Data for England reveal 29.2 million people (56.3% of the entire population) were seen by an NHS dentist in the two years to June 2011, a rise of one million on the two years to March 2006 (55.8%). But while the number of children seen has risen over the past three years, there are still fewer child visits than before a new dental contract was introduced in 2006."

I know that Jersey has no equivalent NHS dental services so this raised the question about who is going without dental treatment. I am also aware from what people have told me in Jersey over many years that the cost of dental treatment is a very real issue. Therefore, many do without or seek treatment only as a last resort for emergency treatment. I believe while we have money in a "Health Fund", it should be targeted at a definite community health need dental treatment.

I believe there are some positive health benefits from getting the population "dentally fit" while there are schemes for young and old and do not believe they are effective enough and more direct action is required.

Background

I viewed with some concern and voted against P.125/2010 by which the Minister for Social Security has obtained over £6.1 million in 2011 and will seek a similar amount in 2012 to give to the Minister for Health and Social Services, in what can be loosely described as "health funding". This will be overseen by the Minister for Treasury and Resources.

I am not amused by this "gang of three" having a sort of "kitchen cabinet", accessing funds that have been obtained from each employer/employee contributions to use to prop up the health budget. Furthermore, I've no doubt that senior officers will become all too aware that this is a nice little fund for them to raid when the need arises.

However,  I  take  a  slightly  different  view;  contributions  have  been  paid  in  by employers and employees and should be ring-fenced for defined health benefits, as happens with assistance with services of a GP or towards prescription costs.

Therefore, I am proposing that a comprehensive dental system should be set up from the Draft Health Insurance Fund. Firstly, this should serve children at the Island's Primary Schools, which at September 2011 have 6,940 pupils and a further 500 are in States schools nurseries. Also there are about 460 children in private nurseries or catered for elsewhere (Figures attached, see Appendix 1). So there is a considerable workload for a team of dentists to get their teeth into!

At the time of writing this Report, the information for 2010 is not available from Social Security.

5 Year Summary of Health Insurance Fund

2005 2006 2007 2008 2009 £000 £000 £000 £000 £000

Income

Contributions-

Contributors  22,312 23,610 25,507 27,549 28,912 Taxation  1,171 1,218 1,276 125 – Bank Interest  1,751 1,997 2,986 3,138 294 Discounts Received  59 121 149 158 85

Total Income  25,293 26,946 29,918 30,970 29,291

Expenditure

Benefits  17,318 17,534 18,210 21,154 22,424 Administration  1,084 929 1,051 1,153 1,489

I believe it will be a good "health investment" for the future to offer a comprehensive dental provision for young children. However, I do not believe it should stop there and the service and facilitation should also be used for those in the receipt of a Jersey old age pension.

One of the ways that I believe this could be achieved is by targeting school-children by citing a mobile unit within the school premises. There are just under 7,000 children in education 11 and under, who could benefit from this scheme (at September 2011).

Mobile medical accommodation is the future of accessible healthcare. Single or a specialist fleet of trailers can be configured to any sophisticated clinical environment required, creating a high-quality, patient-friendly facility that can be easily transported to any location. Whether for temporary accommodation at a fixed site or to take treatments  on  the  road'  to  various  locations,  mobile  medical  clinics  are  a  cost- effective  and  convenient  solution.  Quick  to  deliver  and  simple  to  install,  highly sophisticated  mobile  clinics  can  be  tailored  precisely  to  medical  and  community needs.

Taking treatment into the community – taking healthcare services direct to the patient, can attend to patient needs with speed and efficiency away from a busy town centre, it can also be beneficial and cost effective at Parish Hall s and more rural sites, cutting out people travelling in all directions.

I believe that this is an ideal vehicle' for Jersey to do some catching up with dental treatment for young and old alike.

Below  are  some  extracts  from  P.125/2010,  Draft  Health  Insurance  Fund (Miscellaneous Provisions) (Jersey) Law 201-

"The Health Insurance Fund (the "Fund") was established when the Health Insurance (Jersey) Law 1967 (the "Law") came into force on 4th December 1967. The Fund receives a set percentage allocation of all social security contributions collected under the Social Security Law, which is currently 2% (made up of a 0.8% contribution from employees and a 1.2% contribution from employers) of the 12.5% total contributions collected.

The Law specifies that the Fund is to use the contributions received to meet primary  health  care  costs,  which  are  currently  limited  to  medical  and pharmaceutical benefits."

My Comment

I believe this should be extended to include dental treatment – beginning with the young and the old. A 10 year plan will bring considerable health benefits and is just the type of scheme that should be funded from the Health Insurance Fund – it is targeted at a specific area of need as opposed to allowing the Ministers for Health and Social Services and Treasury and Resources to use it as a piggy bank to be raided to support the health budget.

"Since  1967,  the  scope  of  primary  care  has  expanded  greatly  and  many different healthcare professions are now involved in first-line medical and healthcare  treatment  and  care.  Typically,  primary  care  is  provided  in  a community setting, such as a G.P. surgery or a health centre. In Jersey, some primary care services are delivered from the General Hospital.

The  Health  and  Social  Services  Department  (HSSD)  funds  a  number  of primary care services, some of which are provided directly and some through third-party organisations, in particular Family Nursing and Home Care.

Transfer of funds

This proposition would bring into effect the funding arrangement set out in the 2011 Business Plan, to be debated in September 2010. In order to provide the Health and Social Services Department with the full value of its proposed budget for 2011, it is necessary to bring a proposition to draw on funds currently held in the Health Insurance Fund.

The Draft Business Plan 2011 identifies a £4.9 million contribution from the Health  Insurance  Fund  to  fund  growth  in  Health  and  Social  Services expenditure and a further £930,000 primary care service costs transfer from the  Fund  as  part  of  the  Health  and  Social  Services  2%  Comprehensive Spending Review (CSR) proposals. It is further proposed that an additional £301,000 should be met by a transfer from the Health Insurance Fund to partially fund diabetic supplies and dietary, oxygen and continence products. This  would  remove  these  "user  pays"  elements  from  within  CSR  2011 proposals (Ref HSS-UP 1/2 in the 2011 Business Plan P99/2010).

The draft Law provides for a transfer of funds in 2011 in the total sum of £6.131 million. Article 2 of the draft Law allows the Minister to return to the

States and seek a similar transfer in 2012. The value of this transfer will be determined during 2011 and will need to be approved by the States before it can take place.

There is no provision made for any further transfers; and the Minister for Health and Social Services has made a clear commitment to address the issue of primary care health services within this 2 year period. Legislation to replace or  substantially  revise  the  current  Health  Insurance  Law  will  be  brought forward before 2013. Given the continuing pressures on health services, this is likely to include the requirement for increased contributions to fund a modern primary care health service.

The  ring-fencing  of  Social  Security  and  Health  Insurance  Funds  is  of paramount importance, and the agreement with the Minister for Health and Social Services to propose this draft Law has not been undertaken lightly. However,  given  the  ongoing  requirement  for  additional  funding  across primary and secondary health care, the transfer of agreed sums to be allocated to the funding of specific primary health care services, currently funded by HSSD, is considered to be reasonable in the circumstances. It will allow funds to be released from existing HSSD budgets to meet the cost of essential growth in HSSD funded areas, as set out in the 2011 Business Plan.

The  release  of  the  £6.131  million  to  the  Health  and  Social  Services Department in 2011 will be tightly controlled by the Minister for Treasury and Resources. The Minister for Treasury and Resources will only sanction the release  of  funding  upon  receipt  of  evidence  from  the  Health  and  Social Services  Department  confirming  expenditure  in  respect  of  primary  care services.  The  balance  of  the  cost  of  primary  care  services  administered through HSSD will continue to be funded directly from the HSSD revenue budget." (P.125/2010)

My Comment

I really have some concerns about this, or any other Treasury Minister getting their hands on the Social Security Funding. When these funds were modernised in the 1960's and 1970's they were deliberately set up for Social Security purposes – that is to say in general terms "health related and benefits". Cheques and payments are made to "Social Security", not the treasurer of the States. I believe it is important –vital- to maintain this process and keep the Treasury Minister and the Treasury at arms length and not let them raid the funds.

"Primary Care Services

Whilst the intent of the 1967 Law has generally served the Island well, it is increasingly recognised that there is now a need, some 43 years later, to review and revise aspects of the Law. New primary care legislation needs to support a contemporary range of primary care services and to establish a rigorous  local  governance  framework  as  required  by  U.K.  primary  care regulators.  The  attached  draft  Law  (Article  3)  provides  funding  for  the

introduction of new arrangements for the delivery and regulation of primary care.

Primary care services are the first point of contact that individuals and their families have with health and social care services. Currently in Jersey, many different health professionals working for a range of private and public sector organisations are involved in providing these services.

The Minster for Health and Social Services is responsible for the development of primary health care policy in Jersey; and the Minster for Health and Social Services is aiming to achieve primary health care services that include –

• universal basic health care and the first point of contact that individuals and families normally have with health services;
• services delivered to individuals and families in non-hospital settings, for example, health visiting services from Family Nursing and Home Care;
• preventative services to help people before they get ill, for example,  breast  and  cervical  cancer  screening  and  the avoidance of heart disease;
• programmes of care for the improved management of chronic diseases  such  as  diabetes,  chronic  obstructive  pulmonary disease and depression.

In the U.K., longstanding policy has been to strengthen the role of primary care services through a strategy of shifting the balance of care away from hospitals. To date, this trend has not been seen in Jersey. This must, at least in part, be due to the inflexibility of the 1967 Health Insurance Law in which medical benefit is linked exclusively to services provided personally by G.P.s. There has been a tendency to develop and fund separate primary care services from within the Health and Social Services Department.

Review

In the longer term, and in the interests of delivering more fully-integrated services,  there  will  need  to  be  significant  structural  changes  to  the  way primary care services are funded and delivered. This is to be the subject of a detailed review that will form part of the Comprehensive Spending Review and parallel work in relation to implementing the Fiscal Strategy.

The review will consider how those services are best delivered in the future to achieve the maximum health benefit for the population whilst delivering value for money.

Hence  the  options  of  continuing  to  deliver  them  through  the  hospital  or through primary care providers will form a key part of the review. Revised legislation will substantially amend or replace the current 1967 Law.

Financial and manpower implications

There are no permanent additional manpower implications arising directly from this proposition; any short-term manpower implications arising from Article 3 will be managed from within existing manpower budgets.

The financial implications are for the years 2011 and 2012 only and will be met from within the accumulated surplus within the Health Insurance Fund, which amounted to £77 million as at 31st December 2009.

The accumulated surplus within the Health Insurance Fund is designed to provide for the increasing cost of current medical and pharmaceutical benefits as the proportion of elderly people increases significantly over the next 20 to 30 years. Drawing funds down now and extending the scope of the Law to fund  a  modern  primary  care  health  service  will  require  additional contributions to be levied in coming years.

The effect of these proposals will be to place the Fund into "in-year" deficits for 2011 and 2012. If funding for the proposed initiatives was to continue on this  basis  in  the  medium  term,  then  the  accumulated  surplus  would  very quickly be exhausted.

The primary Health Care strategy, when presented, will include proposals for the sustainability of funding." (P.125/2010)

Appendix 1 – Pupil Numbers for each of the Island's schools at September 2011. Appendix 2 – Jersey Dental Fitness Scheme 11–21 year olds.

Appendix 3 – Qualifying for the 65+ health plan.

Appendix 4 – Cost/Project Estimate.

Appendix 5 – Unique Mobile Healthcare Solutions

Conclusion

Over the years many people have expressed concern about the cost of dental treatment and I believe this proposal gives an opportunity to provide some long-term health benefits, however, a degree of catch-up is required to get lots of people dentally fit. The money is available languishing in a fund which I believe should be targeted at a specific health need.

Financial and Manpower Implications

The scheme would be funded from the Health Insurance Fund not from the States of Jersey budgeting process. I have looked at a number of recruitment agencies for dental staff and I have set out below some outline figures for guidance – which are at best an annual estimate.

5 x Dentists

4 x Dental Staff 2 x Admin Staff Incidental Costs

£600,000 £200,000

£60,000 £140,000

Total: £1,000,000

Start-up Costs

To purchase and equip 2 mobile dental units each with capacity for 2 dentists and support staff and make some site modifications in Jersey to accommodate the units is estimated at £1 million.

Therefore, the initial request from the fund would be £2 million in the first year and £1 million per year thereafter for at least the next 5 years and then subject to review.

The Staff would be contract staff and not employed by the States of Jersey.

At September 2011

  Secondary School  Total

  Haute Vallee  700   Grainville  567   Le Rocquier  891   Les Quennevais  777   Hautlieu  676   d'Hautree House  17   Mont a l'Abbe  41   J.C.G.  716   V.C.  737   Beaulieu  561   De La Salle  542   St. Michael's  60 6285

There  are  approximately  a  further  460  pupils  either  in  private  nurseries  or  catered  for elsewhere

The Jersey Dental Fitness Scheme can help towards the cost of dental treatment for young people between the ages of 11 and 21.

You may be eligible to join the Jersey Dental Scheme if:

• you are between 11 and 18, or 21 if you remain in full-time education
• the total annual family income (that of parents or guardians) is below a certain limit
• you have lived in Jersey for a continuous period of at least 5 years, or have been in full-time education in Jersey for at least 2 years
• a dentist is willing to have you as a patient in the scheme

Please note: if you are between 16 and 18, are working, and are living in the family home, it is your own income which is considered.

How do I join the scheme?

You should choose a dentist and make an appointment mentioning the Jersey Dental Scheme. At the appointment, the dentist will examine your teeth to see if you are dentally fit. There may be a charge for this initial appointment.

If you are dentally fit, and your dentist agrees to treat you under the scheme, then you will need to complete an application form. Your dentist must complete part 2 of the form.

As soon as you receive details of your membership of the scheme, all you have to do is make regular appointments to see your dentist.

You will be charged monthly once you have joined the scheme. The States will pay part of the monthly fee and you will pay the rest. This monthly fee covers all routine treatment while you are in the scheme.

How do I pay the monthly fee?

There are 3 ways to pay the monthly fee:

• by direct debit. Fill in the 'instructions to your bank' section on your application form, and the payment will automatically be paid from your bank account each month
• by cheque, if paying for 6 months or a year in advance. Cheques should be made payable to the Jersey Dental Scheme
• by cash, which can be paid into any branch of HSBC Bank using the paying-in slips we will give you

Please note: if you make your cash payment at any bank other than HSBC, you may be charged. You cannot claim this back from the scheme.

If you fall behind in your monthly payments by 2 months you will no longer be a member of the scheme.

You will have to pay the full price for all further treatment.

What dental care is covered under the scheme?

The  scheme  covers  all  routine  dental  care.  This  includes  all  of  the  following treatments (if given in normal surgery hours):

• examination and report (including all necessary scaling and polishing of teeth and treatment of sensitive dentine)
• routine x-rays taken inside the mouth
• emergency first aid treatment of a dying tooth
• treatment of acute infection or pain
• re-cementing a crown or inlay
• re-cementing a bridge
• construction and fitting of a temporary crown
• stopping  abnormal  bleeding  (including  aftercare  and  removing stitches)
• easing of dentures (not including laboratory fees)
• removing stitches put in by another dentist
• routine extractions under local anaesthetic
• routine preventative dentistry
• routine fillings

What dental care is not covered?

The following treatments are not covered under the scheme:

• crowns or bridges
• dentures (making or adding to)
• surgical removal of impacted wisdom teeth
• general anaesthesia
• root fillings
• straightening of teeth
• minor oral surgery
• cosmetic surgery

If you receive any of these treatments you will have to pay the full cost of the treatment.

Are all dentists involved in the scheme?

Most dentists are involved in the scheme. Please contact the Jersey Dental Scheme for a list of dentists taking part in the scheme.

Can I change dentists once I've joined the scheme?

You can change your dentist once you've joined the scheme.

You need to send us a new application form filled in by yourself and your new dentist, and tell us that you will no longer be seeing your old dentist.

What if I want to leave the scheme?

If you want to leave the scheme, write to us. We will let your dentist know and you will be charged for all further treatment in the usual way.

Qualifying for the 65+ health plan

How do I know if I qualify for the plan?

You are likely to qualify if you meet each of the following:

• you are 65 or over at the time of application
• you do not pay income tax because your income level is below the relevant tax limits
• you have been resident in Jersey for 5 years
• if you are single your capital assets are less than £20,000 or
• if you are married your capital assets are less than £30,000

Please note: capital assets do not include your own home but do include items such as other properties you own, savings and investments, pension bonds and other items of value such as jewellery and paintings.

How much can I get towards optical, dental and chiropody costs? Optical

• every 2 years, up to £15 towards an eye test
• every 2 years, up to £90 towards new prescription spectacles, lenses or contact lenses

Dental

• every year, up to £22 towards a dental check-up
• every year, up to £250 towards dental treatments or dentures

Chiropody

every year, up to £90 towards the cost of chiropody treatment from a State registered chiropodist (a list of State registered chiropodists can be found in the advertising section of the Jersey Telephone Directory)

Cost Project Estimate

Description   Quest 2  Liberty Purchase of existing unit  £250,500  £246,000 Modification of the existing  £45,500.00  £42,000 Dental Furniture  £28,700  £28,700

Dental Sterilisation

Equipment  £12,775  £12,775 Vehicle Delivery  TBC  TBC

Per Vehicle   £337,475  £329,475 2 x Vehicle Total (4 dental surgeries total)  £674,950  £658,950

Purchase of new build unit)  £920,000  £920,000 Notes

Costs exclude VAT

Site preparation & Connections at clients cost

30% Payment Terms  Deposit

Balance Monthly in advance