NHS 111, snakes and ladders to get your emergency treated

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Almost every dental desert item in the news is illustrated with a personal story from someone unable to find NHS dental treatment for their emergency, and who was left in pain. The usual response from the minister of the day has been that patients with a dental emergency should use the NHS 111 service. In a number of areas there are specifically contracted NHS emergency dental services accessed via 111.

Having spoken with contractors in different areas, GDPUK has heard about the good, the bad, and the downright ugly, of different ICB approaches to managing NHS dental budgets.

Irrespective of ministerial pronouncements, the issue of whether or not a ring fence is applied to the dental budget remains a postcode lottery. Meanwhile, those ICBs that do seek to keep clawback money in dental care, are adopting a variety of different strategies.

The ICB’s covering the Midlands tend to act in concert and early signs from the West Midlands are not promising. Faced with a budget deficit they have made it clear that dental money will be re-routed elsewhere, to help balance the books. Relations between commissioners and GDP contractors are best described as cool.

In Greater Manchester it is a mixed picture. Above all, they should be credited with spending their entire dental budget. As reported in GDPUK last year’s initiative to put extra contract value on access sessions was generally reckoned to be a success, but it now removes eligibility for the new patient premium which can be worth as much as 4-10% of contract value. The ICB have also said that their financial circumstances leave them unable to fund delivery over 100%. This has left those practices willing and able to deliver extra NHS dentistry, unfunded.

In Mid and South Essex there have been a number of innovative schemes.  Liaison with the LDC has been a regular feature of them. This November will see the start of their Children and Young People dental pilot scheme. This sets out to link practices to schools in a programme designed to set up preventive patterns for life. It sees practices at the centre of a push to provide dental support to schools for not only pupils, but also teachers and parents and carers. In keeping with the recovery plan’s ambitions it will make extensive use of the whole dental team.

In the North East and Yorkshire, ICBs have used available money in their dental budget to support access, including care for asylum seekers, supervised brushing programmes, urgent access sessions and higher minimum UDA rates.

West Yorkshire ICB speak of ‘investing time in building strong relationships with our dentists, practice owners and providers’. They too engage regularly with LDCs who have shared their approach nationally as good practice, and have been invited us to speak at the BDA conference.

In practical terms this has meant that in 2023/24 they set out to use the full dental budget. They invested approximately an additional £8m through a £6.5m investment plan. A further £1.5m enabled practices that were delivering their full contract to go 10% further, so providing additional access to patients. The £6.5m included a range of initiatives, including urgent dental sessions, orthodontics, access for children living in the highest need areas, access for homeless groups, access for refugees and asylum seekers, access for domiciliary patients, and an innovative level 2 paediatric service.

One problem with the 2006 contract that has not only remained, but got worse, was the wide variation in UDA rates. Nearly two decades of reduced funding and rising costs, coupled with inflation, have made the disparities even more stark. Here too, imaginative ICBs have been able to ease the pressures. Apart from minimum UDA rates, those access projects that offer a fixed sessional rate for a certain number of patients, by pass the UDA rate differentials.

These local schemes, some of which predate the national recovery plan and Labours election promises, still matter. The manifesto pledge of 700,000 appointments nationwide sounds impressive, but is the equivalent of just six patients per practice, each month.

To quote West Yorkshire ICB: “We’ve established a pragmatic way of working with our practices, based on forming a shared understanding and finding agreeable conditions to ensure service continuity.” The reality is that ‘service continuity’ may simply not be as important to some ICB’s as it is to others.

This led to a series of series of questions: whether one had taken medicine prescribed to someone else, exceeded the dose, or combined more than two types. When answered as if one had followed current guidance on analgesic use, there were the same answers as when responding that no painkillers were taken, even though pain was an issue. Answering that one had taken someone else’s (unspecified) painkillers results in a request for your phone number and the promise of a callback from a nurse within 20 minutes.

This and some other questions would suggest that the designers of this part of 111 focussed on identifying and dealing with possible drug overdoses or life threatening conditions. This is perfectly reasonable, but as a consequence this type of triage is less able to support those with severe ongoing dental pain.

Some questions are quite specific, such as, is there swelling or a lump, or does pressing make it worse? Dental teams know that patients can be very vague on these, or simply so affected by severe pain that they can’t really tell.

Back at the original address, adding a swelling and keeping all other parameters didn’t alter the outcome – contact your dentist in the next few days.

Adding that there was a swelling and that the tooth was tender if tapped gently, got the advice to contact your dentist today or tomorrow, rather than in the next few days. A further change when using the original post code that had previously offered only one unsuitable practice, was that now there were two options offered. These were another local practice which has a larger contract that includes adults, but currently is at capacity, and the option of being called back by a dental nurse for remote assessment. The offer of a dental nurse call back, is something of a result. They are likely to be able to provide appointments, and will also be able to take a more comprehensive view of the presenting issues. It is doubtful that that a lay person in their third day of toothache, will realise this.

Ramping up the symptoms: the swelling is getting larger, swallowing is painful and there is some puffiness around the eye, led to the advice to contact your dentist today, though offered similar options.
Understandably, the available options will be different out of office hours and the exercise was repeated late at night. At 11 pm with an increasing swelling, the advice is to contact your dentist today and when checking for available services there was the offer of a call back from a dental nurse.

There is also a section on “what to do if things get worse.” Based on an enlarging swelling and difficulty swallowing the advice now was to: call 111, and to tell them 111 online said you needed to get help within 6 hours, and say that your symptoms have got worse and you need to speak to a nurse.

This would suggest that there is a lack of consistency within the telephone 111 staff, as well as limited training on dental issues.

There was one more anomaly, though possibly a life saver. When answering that where it had been painful or difficult before, but that one was now unable to swallow, the advice was to get help now, and directions to go to a specific A & E. This is also out of the immediate local government area by about 4 miles but somewhat closer than the nearest ‘in area’ A&E. This hospital is one that the local dental practices cannot refer to.

At a life and death level it is likely that 111 is usually giving the best advice. In its current form it is not best suited to dealing with dental emergencies. This may mean that urgent care sessions are not being used to the greatest benefit, and that some patients are struggling to get access to available care.

Dr Aaron’s advice was that if patients need an urgent appointment, they should ask 111 to put them through to dental nurse triage or ask for a callback from a dental nurse.