Response to Public Health England Centres consultation

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1 Response to Public Health England Centres consultation The British Dental Association (BDA) is the professional association and trade union for dentists practising in the UK. BDA members are engaged in all aspects of dentistry including general practice, salaried primary care dental services, dental public health, the armed forces, hospitals, academia and research, and include dental students. This paper sets out the response of the BDA to the Public Health England (PHE) Centres consultation. It outlines how the structures proposed in the consultation documents could impact on the Dental Public Health resource and the delivery of work and suggests some key considerations for further discussion with PHE and other stakeholders. We present the collective view from all areas of the dental profession as represented by the BDA, supported by the BDA s Principal Executive Committee. 1. Introduction 1.1 The specialty of Dental Public Health is a dental specialty recognised by the GDC and works across all three key domains of Public Health. in England, the responsibility for each domain lies with a number of different organisations, including: local authorities health improvement NHS England healthcare public health Public Health England health protection. Dental Public Health s role is to advise and support these and other organisations across the health and social care system to carry out their functions and responsibilities collaboratively and effectively to improve oral health. Consultants in Dental Public Health provide systems leadership as the authority on both clinical matters and public health in relation to oral health. 1.2 PHE is the sole employer of non-academic Consultants in Dental Public Health, which constitute the only public health group that has its workforce entirely based within PHE; the consequences of any reductions in staff numbers cannot be mitigated by compensatory changes in other parts of the system, i.e. NHS England or local authorities. Therefore, these organisations are entirely reliant on the Dental Public Health specialist support provided by PHE. 1.3 Dental Public Health Consultants have a unique role in protecting the public and providing specialist advice, professional leadership and support to frontline clinicians. In order to carry out our role effectively, we need to be able to work with a number of key 1

2 stakeholders, thereby ensuring that key PHE priorities and evidence-based interventions are embedded in wider health and social care services and clinical dental practice. 1.4 Oral disease remains a significant public health problem in England, with persistent variation in levels of disease between populations with the best and worst oral health. These unacceptable and preventable inequalities are highlighted by the recent PHE survey of oral health in three-year-olds and the Children s Dental Health Survey. Inequalities in adult oral health, as demonstrated by the Adult Dental Health Survey, are also an issue, particularly in the context of an aging population. Consultants in Dental Public Health have a crucial role in supporting PHE and other organisations in tackling these issues. 2. Resources for Dental Public Health Through a combination of recurrent and non-recurrent funding, the budgeted establishment of consultant posts for 2014/15 was whole time equivalents (WTE). A need to cut the budget by at least 20 per cent resulted in a pre-consultation suggestion by PHE to reduce this to 29 WTE (including London) over two years; this represents a reduction of 28 per cent. The BDA is concerned that a Dental Public Health workforce reduced to this extent would not be able to meet the need to support the NHS England commissioning agenda and local authorities statutory responsibilities to assess and improve the oral health of their populations. The BDA urges PHE to undertake an independent workforce review in consultation with its key partners to obtain an evidence-based assessment of the Dental Public Health workforce required. It should also be noted that any requirement for the workforce, determined on this basis, to devote time to generic public health duties would leave Dental Public Health with insufficient resources. 2.1 There are currently WTE consultants in post in England, based in PHE Centres across the country. In the past 12 months there has been no recruitment to substantive vacant consultant posts. Posts that have become vacant due to retirement or relocation have not been advertised. 3. Equitable geographic distribution 3.1 In 2013, Consultants in Dental Public health were transferred from the NHS to PHE. At this point in time there was no attempt to move to an equitable distribution of the workforce, although a few consultants did take the opportunity to relocate at the time of transition. Recruitment at the end of 2013 also led to the appointment of a limited number of consultants to some regions that had previously not had Dental Public Health capacity. The current geographical distribution of the Dental Public Health Consultant workforce, therefore, is largely based on the historic NHS distribution, i.e. those areas where Primary Care Trusts chose to invest in Dental Public Health have a greater number of consultants than those areas that did not invest. 3.2 The proposed Centre organograms seek to address this inequity by broadly following the principle of a minimum of two consultants per NHS sub-regional team, as outlined preconsultation. The organograms account for 23.4 WTE excluding the London 2

3 Centre/Region, which is not included in the consultation. There are currently two WTE in London, which indicates that there are a further 3.6 posts to be equitably distributed if the suggested model of 29 consultants for England were implemented. 3.3 We understand that this process will follow the consultation period and take account of need and submissions received. 3.4 It is recognised that an equitable distribution of Dental Public Health Consultants across England is desirable as this will enable all areas of England to have access to specialist Dental Public Health advice and support. In terms of achieving this, the BDA view is that, contrary to the suggestion in the PHE consultation documents of staff slotted in and staff at risk, the change to equitable distribution should be evolution rather than revolution, i.e. redistribution should be staged, leaving all existing WTE consultants in their current posts. As the pre-consultation model was developed on the basis of a national budget for Dental Public Health, these posts could be supported during the transition to a new arrangement. 3.5 Further moves towards the planned equitable distribution could then take place as consultants retire or leave posts voluntarily. 3.6 The benefits of a staged redistribution would be: Retention of Dental Public Health expertise within PHE By having a staged approach to redistribution of the Dental Public health workforce the existing skills and expertise will be maintained, as will business continuity. As a consultant post becomes available, the funding could be transferred to a part of the country where the Dental Public Health resource is inadequate. The alternative is that consultants who were unsuccessful in any formal competition process would be required to relocate to other areas of the country. Many consultants are very experienced and have worked in one area for a number of years. They may have dependants and caring responsibilities and will have social ties making relocation difficult. It is likely that these consultants would look for alternative employment opportunities outside Dental Public Health and therefore their skills and expertise within the PHE Dental Public Health workforce would be lost. Sustainability of ongoing projects Consultants in Dental Public Health provide leadership across the whole dental community. For example, they establish and lead clinical networks and are often the lead for local projects such as service redesign and oral health improvement interventions. A staged approach to redistribution of the workforce would allow these projects to continue in the short term whilst enabling PHE to consult with stakeholders such as NHS England and local authorities as part of a workforce review, and giving the stakeholders time to plan for change. Conversely, a rapid reduction in the current consultant workforce would undermine the sustainability of these projects. This would create a reputational risk for PHE. 3

4 Sustainability of training Training of the future Dental Public Health workforce is carried out by Consultants in Dental Public Health. Dental Public Health Specialty Registrars (StRs) undertake a four year training programme. The clinical supervision of StRs is provided by Consultants and Consultants also fulfil the Educational Supervisor and Training Programme Director roles for the programmes. Unlike public health StRs, Dental Public Health Registrars usually remain in one area for the entirety of their training. A minimum of two consultants is required to supervise each registrar, therefore, the current distribution of trainees is matched to the current distribution of consultants. Rapid redistribution of the consultant workforce could have a detrimental impact on the sustainability of training programmes in some areas and consequently the sustainability of a future Dental Public Health workforce within PHE. 3.7 Rapid redistribution of Consultants in Dental Public Health would have an adverse impact due to the loss of important local relationships and knowledge built up over time. 3.8 Implementation of the changes as set out in the consultation document would not have an equal impact in all parts of the country. For example, there would be a disproportionately large detrimental effect in the north of England, where the proposed reduction in consultant numbers is greatest and population oral health is amongst the poorest in the country. 4. Consultant in Dental Public Health job description 4.1 Prior to April 2013, Consultants in Dental Public Health were employed on NHS medical and dental consultant contracts with local job descriptions. Job descriptions were developed by the employing organisation (PCT) and were agreed by Faculty advisors. 4.2 As part of the consultation, PHE is proposing a single national job description for Consultants in Dental Public Health. Any national job description change should be taken to the PHE Local Negotiating Committee (LNC), where Trades Union will have the opportunity to negotiate with PHE on the content. The BDA requests that PHE follow this procedure. 4.3 Pending negotiation via the LNC, we would like to note that the BDA has specific concerns about the proposed national job description for Consultants in Dental Public Health. Some of the most significant issues are as follows: The job description should recognise both the local and national remit of Consultants in Dental Public Health. The Health and Wellbeing Directorate Dental Public Health structure was based on the premise that Centre-based consultants would devote time to supporting national work. We note that input from operational consultants has been crucial to the delivery of high quality national programmes such as the development of Commissioning Better Oral Health and the PHE dental epidemiology programme. National-level work also includes activities such as undergraduate- /postgraduate-level teaching and examining, and this should be reflected in the job description. 4

5 Specific job plans and objectives for each Consultant in Dental Public Health will need to be agreed on the basis of the job description, in conjunction with the individual s line manager and the national Dental Public Health lead or a representative (regional or functional). Further concerns about the proposed job description are outlined in Appendix 1 below. 5. Impact on training the future Dental Public Health workforce 5.1 PHE, as the sole employer of the non-academic Dental Public Health workforce, has a responsibility to ensure that any new structure supports development and training of the workforce. For PHE to provide effective specialist Dental Public Health advice and support to its stakeholders into the future, the organisation must ensure that there is succession planning. The continuation of effective training programmes within PHE is an essential part of this. The potential negative impact on training if PHE were to not introduce a staged approach to redistribution of the Dental Public Health workforce is outlined in section In addition to ensuring the continuation of the future workforce, Specialty Registrars provide a valuable resource to PHE. The salary for registrars is funded by Health Education England but by working alongside PHE consultants, the registrars contribute significantly to the delivery of the Dental Public Health work programme within PHE. Any PHE structure that negatively impacts on training will, therefore, also impact on the overall delivery of work. 5.3 At present there are 12 non-academic Dental Public Health Specialty Registrars undergoing training in England. Three registrars have recently completed their training and, with no jobs on the horizon in the near future, are considering their career options. To maintain Dental Public Health expertise within PHE, the organisation must ensure that vacant consultant posts are advertised and recruited, and that PHE is seen as an attractive employer. 6. Summary/recommendations 6.1 The BDA recommends the following: To ensure effective service delivery, an evidence-based workforce review should be undertaken to determine appropriate workforce numbers and distribution to meet the needs of stakeholders and the delivery of the oral health agenda and to tackle persistent inequalities in oral health. To achieve sustainability of the workforce and service delivery, staging of any redistribution of Consultants in Dental Public Health, via appropriate location of the unfilled WTE followed by natural workforce turnover is necessary. The profession should be consulted on the distribution of any unallocated resources. To enable valuable national programmes to continue, ensuring a provision for Consultants in Dental Public Health to contribute to national-level work is essential. To safeguard the future of Dental Public Health expertise, supporting training and ensuring, where possible, that opportunities are available for Specialty Registrars in Dental Public Health to practise their specialty within PHE upon qualification is vital. 5

6 The LNC should be consulted on a new national job description. We would welcome the opportunity to work with PHE to address these issues, and we urge that other key stakeholders also be involved in discussions of the future shape of Dental Public Health in England including NHS England and the Local Government Association. This will help to ensure that any new structure is based on an evidencebased workforce review, which takes into account the needs of stakeholders in addition to economics. British Dental Association 64 Wimpole Street London W1G 8YS May

7 Appendix 1: Specific comments on the proposed CDPH job description As indicated above (Section 4), the BDA notes that any proposed changes to the Consultant in Dental Public Health job description should be negotiated with the LNC. We would like to highlight a number of specific concerns about the new draft job description, to be addressed in this discussion: General: As noted above, we are concerned that the previously agreed contribution to nationallevel work is not reflected in the proposed job description (Section 4.3). Job purpose/summary: Specialist should be included when referring to the role of giving advice. The consultant role should be to provide advice on oral health improvement. References to dental health should be amended to Dental Public Health. Key relationships: PHE relationships should include other Consultants in Dental Public Health within the same Centre, and the national Dental Public Health lead. Relationships outside PHE should include other dental clinical networks and not be limited to the LPN. Additional: We would urge PHE to consider whether a job plan is the appropriate way of encouraging staff to the new way of working, or whether this should be done via objectives setting. Clarification of what it means to be an account holder would be useful, as this is not defined. Key job specific responsibilities: We suggest the following amendments to the key job specific responsibilities: 1. Providing professional leadership for the local development and implementation of oral health strategies. 4. Remove this point. Consultants may only give advice; they cannot ensure that this advice is taken. 10. Include reference to other clinical networks. 11. This requires further clarification; it is not clear what this would mean in practice. 17 iii) Managing knowledge and promoting the use of research evidence in clinical dental practice. 18. Remove reference to Health and Wellbeing Boards, as this applies across a range of stakeholders. 24. Remove this point. GDPAs are not employed by PHE, and many areas are severely short of GDPA capacity; therefore, opportunities for development are limited. A national job description should not be subject to review with an individual; it is the job plan that should be negotiated with the post holder. The job description, once agreed, will remain unless re-negotiated. 7

8 This section should include reference to the provision of advice and support to local authorities, to enable them to deliver their statutory responsibilities in relation to Dental Public Health. Mobility: We are concerned by the statement that the post-holder will be expected to work at any establishment at any time. This limits the right of individuals to challenge PHE if they are requested to work in locations that are not within a reasonable distance of their base. We would not support an arrangement whereby PHE could effectively relocate an employee without a formal re-negotiation of their base. Person specification: The final point under essential attainments should be amended to, Possession of a certificate of accreditation or eligibility for a CCST in Dental Public Health, or within 6 months of eligibility. Appendix 2: Implications of a reduction in Dental Public Health services: GDP views As the trade union representing dentists in all areas of practice, the BDA would like to highlight some concerns raised predominantly by BDA members working in general dental practice about the possible implications of any reduction in Dental Public Health services: 1. With the advent of LPNs and CCGs, Consultants in Dental Public Health have a key role in supporting the commissioning of new services and retention of existing ones. 2. The provision of support to LPNs by Consultants in Dental Public Health is already challenging in terms of capacity in some areas, and would be severely compromised by any reduction of Dental Public Health services. 3. NHS England depends heavily upon Consultants in Dental Public Health to develop the methodology for, and undertake, needs assessments, and to support the implementation of commissioning decisions made on the basis of these assessments. 4. Dental Public Health advice is currently required by all key stakeholders in the general dental contract reform process (particularly in the consideration of possible deprivation weighting of capitation payments), as well as in the development of national service specifications for enhanced, specialist and hospital dental services. 5. Consultants in Dental Public Health have a central role, working with Health and Wellbeing Boards, in orchestrating measures to improve children s oral health, which is increasingly becoming a focus of public and professional concern and continues to be a drain on NHS budgets. Activities include providing leadership for action on sugar reduction. 6. Any reduction in Consultant in Dental Public Health capacity poses a threat to innovative projects with built-in evaluation, such as the delivery of smoking cessation services through dental practices and utilisation of dental services for promotion of the wider public health agenda. 7. Dental Public Health expertise is essential in areas where water fluoridation is being considered. 8

9 8. Consultants in Dental Public Health have an important role in promoting antibiotic stewardship among dental professionals. 9

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