P127/2013 Dental Health Services: Improvements
COMMENT
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 HSSH Scrutiny Panel Dental Health Services Review (SR.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 are 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:
- 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
- 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
1. Dental health for children and young people
The HSS 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 HSS 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 five-year-old children show a significant improvement in dental health over the last 20 years with dental fitness well above UK levels.
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 HSS undertakes any necessary work to bring the child to dental fitness. Subsequently, 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 pa. 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 Southern 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 £59,800[1] pa.
The report of P.127 and the associated Scrutiny Report SR.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 five 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 five 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 ?
- 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 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 8 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 proactive 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 two 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 SR.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 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 8 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 checkups and treatment.
P.127 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 web pages and explained on the Citizen Advice Bureau pages.
Earlier this year three dental teams (Dentist and Nurse) visited HSS run care homes at The Limes, Sandybrook and Samares Ward to undertake inspections of patients’ teeth and to give staff instructions on how to care for both natural and false teeth.
HSS 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.
3. Funding
All the services referred to in P.127 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.
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. GP 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 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 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 SR.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 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 front line 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 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 proposals within 13 months seems unreasonable.
On 8 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 under way 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.
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