Dental Health Services: improvements.

STATES OF JERSEY

DENTAL HEALTH SERVICES: IMPROVEMENTS

Lodged au Greffe on 9th October 2013 by Deputy G.P. Southern of St. Helier

STATES GREFFE

2013   Price code: B  P.127 (re-issue)

PROPOSITION

THE STATES are asked to decide whether they are of opinion

to request the Minister for Health and Social Services and the Minister for Social Security to work together to improve the dental health of the Island by undertaking the following actions by the end of 2014 –

1. to transfer the funding of the Jersey Dental Fitness Scheme from the budgets  of  the  Health  and  Social  Services  and  Social  Security Departments to the Health Insurance Fund with the Fund also being used to fund the other measures below as required;
2. to uprate the monthly payment to dentists to bring children to, and then  maintain,  dental  fitness  and  to  ensure  that  the  value  of  the payment is index linked in future;
3. to raise the upper earnings limit for qualification for the Jersey Dental Fitness Scheme to the upper boundary of the 4th quintile of annual household income and to ensure that this is index linked in future;
4. to undertake a publicity campaign to promote dental health services provided in Jersey;
5. to ensure that that the need for upfront payments for dental treatment required by the Westfield scheme is eliminated;
6. to ensure that adequate training is provided by the States to all carers working in public or private residential care so that they are properly trained in the delivery of oral hygiene including training in relation to the benefits of the use of high-dose fluoride toothpaste for those in residential care;
7. to examine the potential of expanding the range of those eligible to partake in the Jersey Dental Fitness Scheme and to report back to the States with recommendations.

DEPUTY G.P. SOUTHERN OF ST. HELIER

REPORT

The following is taken directly from the introduction of S.R.12/2010, Dental Health Services Review, published in November 2010 –

"This report evidences that Ministers have neglected their remit in relation to dental  health.  The  Panel  identified  that  the  Health  Insurance  (Jersey) Law 1967 made provision for the introduction of a dental health scheme. It was obviously the intention of the States to introduce a dental provision as part of the Health Insurance Scheme which to date has been ignored.

The evidence received shows dental health care provision in Jersey to be outdated and insufficient. Problems also appear to exist in Ministers taking responsibility for dental health. This may be due to overlaps between the Minister for Health and Social Services and the Minister for Social Security."

Deputy D.J. de Sousa of St. Helier , the then Chairperson of the review, was shocked to witness the neglect of dental health –

"I  was  aware  that  the  Dental  Fitness  Scheme  had  not  been  updated for 18 years and that the existing provision of dental schemes offering financial assistance excluded a large proportion of the population between the ages of 18 and 65.

However, I was surprised to learn that neither of the Ministers with a remit for dental healthcare had looked at the difficulties people are facing when it comes to affording basic dentistry. More concerning was that those Ministers have not fulfilled their function in providing a modern dental health service as part of the primary health care system.

The evidence we have received suggests that Jersey residents are having a serious problem affording dental treatment. This is particularly frustrating because  the  Health  Insurance  (Jersey)  Law 1967  makes  provision  for assistance with dental costs. That provision in the law has simply not been enacted. The Health Insurance Fund does have an annual surplus, so there is absolutely some scope for this to be done.

I  am  pleased  to  present  this  report,  which  evidences  issues  in  service provision and cost of dental treatment that have been highlighted to us from a broad cross section of Jersey residents. The Ministers must now fulfil their remit  by  undertaking  the  eighteen  recommendations  made  by  the  Health, Social Security and Housing Scrutiny Panel."

After 3 years of inaction and false promises on the part of both Ministers this proposal concentrates on just 6 of the original 18 recommendations, each of which could make a significant improvement to the standard of dental health on the Island. I believe that all can be put in place in the short-term to deliver long-term benefits.

Recommendations (taken from SR.12/2010)

"1.  The Minister for Social Security should provide an incremental means

tested  system  within  the  Dental  Fitness  Scheme  to  accommodate families with more than one child. (Para 5.3)

2. The  Minister  for  Health  and  Social  Services  together  with  the Minister for Social Security must deliver an updated Dental Fitness Scheme before 8th July 2011. (Para 5.5)
3. The  Minister  for  Social  Security  must  remove  the  necessity  for (upfront payments at the point of treatment within the Westfield 65+ Plan by 8th July 2011. (Para 5.7)

7. The Minister for Health and Social Services must provide adequate oral hygiene training provision for all carers working in public or private residential care by 8th July 2010. (Para 5.17)
8. The  Ministers  for  Health  and  Social  Services  should  discuss  the introduction of fluoride toothpaste for those in residential care with the relevant professionals. (Para 5.18)

11.  The Ministers for Health and Social Services and the Minister for Social Security should immediately undertake a publicity campaign to promote dental health services provided in Jersey. (Para 5.29)

16.  The Minister for Social Security must consider the introduction of a dental  benefits  scheme  as  outlined  within  the  Health  Insurance (Jersey) Law 1967 by 8th July 2010.(Para 7.11)"

In their response to recommendations 1 and 2 in particular, delivered on the 8th December 2010, the Minister for Health and Social Services together with the Minister for Social Security had the following to say –

"The Minister for Health and Social Services is currently undertaking a major review of health strategy. It is recognised that all practitioners should be encouraged to provide appropriate preventative care. Until this review is complete, it would be a poor use of public resources to initiate separate reviews of parts of the health system.

However, it is accepted that a review of the JDFS should be undertaken at an appropriate time. This will be before the end of 2012.No additional funding is available for this scheme at present and any enhancements to the scheme will need to be achieved within the current funding envelope. The review will include the eligibility conditions for the benefit and investigate the reasons given for parents leaving the scheme."

What happened? Nothing.

Furthermore, one year on from this response, the Minister for Social Security made a statement in the Assembly as follows –

Senator F. du H. Le Gresley (The Minister for Social Security):

"I  have  recently  met  with  Senator  Breckon  to  discuss  his  proposition P.170/2011,  which  seeks  to  improve  access  to  dental  services  for  local residents.  After  a  positive  discussion,  Senator  Breckon  has  agreed  to withdraw his proposition on the basis that I will undertake to ensure that 2 issues identified by the Scrutiny Panel review of dental health services will be prioritised within my departmental business plan for 2012.

I am pleased that one of my first acts as Minister has been to make this agreement in the  spirit  of  co-operation  confirming the  importance  of  the Scrutiny function and that of independent back-benchers. The dental health services review was undertaken by the Health, Social Security and Housing Scrutiny Panel under the chairmanship of the former Deputy de Sousa.

The  report  S.R.12/2010  was  published  on  8th  November  2010.  A  joint response  from  the  Ministers  for  Health  and  Social  Services  and  Social Security  was  published  on  20th  December  2010.  The  review  noted  that support  with  dental  costs  was  available  to  teenagers  through  the  Dental Fitness  Scheme  and  to  pensioners  through  the  65-plus  Health  Scheme. However, neither of these schemes has been reviewed for a number of years.

I will undertake to review the provision of assistance with dental costs under both  these  schemes  during  2012.  The  reviews  will  also  consider  the administration of the 2 schemes. Senator Breckon has agreed to play an active part in the 2 reviews that will take place in 2012 and I look forward to working with him during the year."

I recently asked Senator A. Breckon what had happened. He replied "Nothing".

Eighteen years of neglect of the Dental Fitness Scheme has now turned into 21 years of neglect.

Proposals (a) and (g): Use of the Health Insurance Fund (HIF)

Recommendation 16 of the 2010 Review proposed that the Health Insurance Law be used to create a dental benefit scheme, pointing out that such a scheme could be created by regulation –

"Health Insurance (Jersey) Law 1967

5. In 1964, the States of Jersey adopted P69/1963 thereby creating the Health Insurance (Jersey) Law 1967.This legislation created a system whereby a percentage of earnings was taken from both employees and employers to fund certain health benefits for insured members of the scheme. The descriptions of the benefits are contained within article 7 of the Law:

The description of the benefit provided by this law is as follows –

1. medical benefit;
2. dental benefit;

3. ophthalmic benefit;
4. pharmaceutical benefit.

6. Dental  benefit  is  afforded  the  same  importance  as  medical  and pharmaceutical  benefits  throughout  the  Health  Insurance  (Jersey) Law 1967. It is clear that the intention of the law was to provide residents not only with medical and pharmaceutical benefits but also with dental and ophthalmic benefits.
7. The Health Insurance (Jersey) Law 1967 provides for the introduction of each of these benefits by regulation.
8. Subordinate  regulations  for  medical  and  pharmaceutical  benefits were  introduced,  however,  dental  and  ophthalmic  benefits  were omitted."

The report pointed out that the HIF was in a healthy financial state. It remains so today.

"7.9  Each  year  the  Health  Insurance  Fund  pays  out  in  benefits

approximately three quarters of the money it collects from Social Security  contributions.  The  balance  of that  fund,  as  at  December 2009, was £77,476,000. Medical Benefits paid for that year were in the amount of £5,785,000. The surplus of income over expenditure for that year was £5,378,000. The Panel believes that in view of those figures there is the potential to develop a dental benefit scheme of similar cost to the provision of medical benefits. As previously stated, this clearly was the original intention of the States."

The JDFS is funded from general tax revenues made up of £28,000 per year from HSS funds to bring children up to dental fitness and up to £140,000, held by the Social Security Department towards the monthly payments to maintain the dental fitness of those in the scheme.

Part (a) of this proposition suggests that this funding for JDFS be sourced from HIF.

Part (g) then goes further and requires the investigation of the potential for funding a wider scheme using HIF funding. Transfer of funding to HIF is designed in the first instance to avoid wrangling over health department funding priorities through the use of HIF which is in a healthy state despite the 2 large contributions to the funding of primary care in the past 2 years. In 2009 the HIF contained around £77 million of reserves and had a £5 million excess of income over expenditure.

(b): Uprating monthly payments Dental Fitness Scheme funded by health

When it was initiated in 1992, the JDFS was aimed at all 11 to 18 year olds and those 18 to 21 year olds in full-time education. Where a child is presented to the dentist, that dentist will examine the child's teeth and undertake any treatment required to bring

that child to Dental Fitness'. The £28,000 funding for this treatment comes from the Health and Social Services Department. It is a taxpayer funded benefit and there is no cost to the family, providing that they fall below the income bar of £43,197. Once the child reaches Dental Fitness' they become eligible for the Dental Fitness Treatment Scheme.

Dental Fitness Scheme funded by Social Security

At  this  point,  the  arrangements  change.  The  scheme  began  in  1992  when  the arrangement was that a dentist taking on a Dentally Fit' child would receive £6 per month for the maintained treatment of that child. If the work were expected to cost more than the monthly-accrued amount agreed with the parents, then a payment plan would be agreed with those parents for the outstanding amount. At that time, £6 per month was usually sufficient to cover the costs involved.

Although the Minister for Social Security asserted (to the Scrutiny panel) that the scheme has been reviewed over the years, the payment to dentists has remained at £6 per month since the inception of the scheme 18 (now 21) years ago. This was confirmed by the Consultant in Restorative Dentistry, stating that –

"£6 per month is what the States provides and that £6 per month comes from the £140,000 held by Social Security."

Worryingly, he went on to say –

"I think what is more noticed by the providing dentist is the £6 per capita which was introduced in 1992. The States pay the dentist £6 per month per child enrolled by that dentist and that has not gone up. That is the bit, I have to say, that there is a level of concern and disquiet by the providing dentists."

Obviously 21 years of inflation has eroded the value of the monthly £6 payment. In each of the last 2 decades the RPI has risen by approximately 50%, which means that to retain its value this monthly payment should be £13.50. Indexing the costs of the scheme would result in the initial work to get children dentally fit would raise the original £28,000 to £63,000. Index linking the sum of £140,000 for the maintenance of dental fitness would raise this cost to £315,000.

(d): Jersey Dental Fitness Scheme – scope and uptake

After 2 decades of neglect the JDFS has limited reach currently. It is interesting to note that some time the original sum for getting children to dental fitness was 335,00. This budget was reduced to the current £28,000 because of low numbers participating. Almost from the outset there was insufficient publicity given to the scheme. Further exploration of the numbers indicates the importance of part (d) of the proposition, the need for wide promotion of any scheme.

Examination of the Annual reports of the Social Security department show uptake of the scheme has been low, and that these low numbers have reduced over time –

Dental scheme members

This is reflected in the costs of the scheme over this decade –

As  can  be  seen,  the  nominal  £140,000  held  for  the  scheme  has  not  been  fully expended. This limited reach must be seen in the context of the total numbers who are eligible for membership. Covering the 8 years from 11–18 would encompass around 8,700 children. The cap I propose would reduce this by the number of 11–18 year olds in the upper quintile, 15% to 7,400. To this one has to add those aged under 21 in education, that is 1,250, giving a total of 8,600 children and young people eligible to join the scheme. If 100% coverage were achieved (which is highly unlikely) the total cost of the maintenance of dental fitness might add up to a total of £1.3 million.

(e), (f) and (g): Dental care for the elderly

Again, these parts come from the scrutiny report S.R.12 2010. The first deals with the need for  members  of the  Westfield  scheme  for over  65s  to  pay  for  their  dental treatment up front and then claim this back from the scheme. The sums available for dental treatment are as follows –

Dental

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

How do I make a claim?

• visit the dentist / optician / State registered chiropodist
• receive treatment
• pay for your treatment
• obtain a receipt (please note, credit card receipts are not acceptable)
• forward this receipt plus the completed claim form to Westfield.

It was reported that some members of the scheme found it difficult to pay the entire cost of their dental treatment up front. I do not know when the figures in the Westfield scheme were last uprated and whether they are realistic, but I am sure there are some who  would  have  difficulty  paying  out  £250  or  more  before  getting  reimbursed. Two hundred and fifty pounds is around the cost of an extraction, but far short of the cost of a cap, for example. It would, however, seem a simple step to obtain an estimate for treatment from the dentist and to have the £250 contribution towards the cost paid direct to the dentist.

Residential Care

Again I quote directly from the scrutiny report S.R.12/2010 –

"5.15  The Panel has found that there is a further vulnerable group who

require particular care within society. People in high risk groups who are  in  residential  care  require  particular  services.  During  the discussion  with  the  Minister  for  Health  and  Social  Services,  the following issues were raised:

1. The Minister has  given no thought to the people in these groups:

No, to be blunt. Until we had this review it had not been on my radar, so to speak. But it is interesting and full marks to the Consultant in Restorative Dentistry and his team too. I think it is those areas that perhaps Health and Social Service do not fly the flag saying this is what we do. But obviously we do it.'

2. The Consultant in Restorative Dentistry considered that large improvements could be achieved in residential care if patients mouths were cleaned with a fluoride toothpaste."

(Here the consultant is referring not to fluoride toothpaste that can be bought over the counter to special high strength (x3) toothpaste  which  can  make  significant  and  rapid improvements in oral health.)

"(iii)  Cleaning inside the mouth can be considered invasive, and as recognised by the Panel Members, carers are reluctant to

engage in this activity . The Consultant confirmed this saying:

Yes. I came into conflict with the manager of one of the homes over that precise issue. When a carer brought a patient in to see me at the hospital and I was frankly appalled at the poor oral hygiene. It was not the patient's fault, the patient does not know what to, they cannot do it, the patient has lost their  self-awareness  and  it  is  the  responsibility  of  the carer.'

16. It has not taken the Panel a great deal of effort to establish that the local guidelines on dental care within residential communities are not clear. The Consultant in Restorative Dentistry further stated:

They [persons in care] are not getting their teeth cleaned because people fear that it infringes their human rights; that really needs to be addressed.'

17. United Kingdom's Mental Capacity Act 2005 Code of Practice offers a best practice model for professional carers working in a residential care environment in the absence of any local legislation. The Code of Practice makes it clear that care should be in the interest of the

patient, not the interest of the  staff or  carer. Insufficient training appears to have created an environment of caution with regard to delivering oral hygiene which can be viewed as invasive."

Financial and manpower implications

As stated in the body of the Report, at best the scheme only achieved around 20% coverage in 2001, and was only funded to reach around 27% of those potentially eligible.  Simply  maintaining  this  level  of  coverage  and  uprating  the  funding  by inflation over the past 2 decades would result in the following costs, to be met from the HIF –

If we  were  to raise the  target above  the previous 27% coverage  to around 50% coverage, these costs would be increased to around £670,000.

In addition, to administer the scheme and in particular to deliver the improvements in residential and elderly dental health, this proposal would require additional staffing of a community dentist (grade 13) and a dental nurse (grade 6) at an annual cost of around £100,000, giving total costs of £770,000.

The  Health  Insurance  Fund  (HIF),  despite  2  years  when  a  £6 million  annual contribution was taken from the fund to deliver the costs of primary health care through the hospital, has seen its reserves rise from £77 million in 2009 to £80 million in 2011.

 _____________________________________________________________________ Re-issue Note

This Projet is re-issued because the financial and manpower statement was not the correct version.