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CAB evidence briefing March 2007 Gaps to fill CAB evidence on the first year of the NHS dentistry reforms Summary Fundamental changes to the delivery of NHS dentistry were introduced in April 2006, aimed at addressing the significant problems which patients have faced over the last 15 years in finding an NHS dentist. Primary Care Trusts (PCTs) in England and Local Health Boards (LHBs) in Wales now have a statutory duty to provide dental services to meet 'all reasonable requirements', and have been given ring-fenced budgets to help them deliver this. National statistics for the first six months indicate that the reforms have been effective in halting the decline in NHS dentistry. However there is little evidence of any real growth in dental services. Thousands of patients are still unable to get on a dentist's list for routine NHS treatment and access to dentistry is still a postcode lottery. Others face lengthy waiting lists or long and expensive journeys. Patients on low incomes living in rural areas and reliant on public transport are particularly disadvantaged, and patient choice is often non-existent. People are also unclear about the best way to find out about those services which do exist. One reason for this slow progress is that in 2006/07 the budgets allocated to PCTs/LHBs to implement the reforms were based on the historic spend in their areas. So, where dentistry provision was already under pressure PCT's/LHBs did not receive any additional funding to help them address the shortfall. Therefore PCTs/LHBs' ability to meet their new statutory responsibilities was put at risk. This report makes recommendations on what more needs to be done to ensure NHS dentistry delivers a genuinely patient-focused service – an objective clearly reflected in the Department of Health's key Public Service Agreement target to improve the patient experience. In particular, we argue that additional funding must be targeted at areas where gaps in service are worst to ensure that patients have equal and reasonable access to NHS dentistry, regardless of where they live. Inside ❑ Key points Page 2 ❑ Consequences for patients Page 12 ❑ Introduction Page 2 ❑ The role of PCTs/LHBs Page 15 ❑ Background Page 3 ❑ Conclusions and ❑ Looking for an NHS dentist Page 5 recommendations Page 19 ❑ Failing to find an NHS dentist Page 8 Gaps to fill Key points Introduction s There is still much to be done before all The last decade has seen major reforms across PCTs/LHBs meet their statutory duties to the NHS. The objectives of the reforms, which meet 'all reasonable requirements' for NHS have been accompanied by significant dentistry. As one PCT commented to a increases in funding, have included designing would-be patient: "having an NHS dentist services around the needs of patients rather should be viewed as an aspiration rather than providers, delivering patient choice, than a reality". cutting waiting times and moving away from a sickness service towards one where s Department of Health statistics indicate preventative care is given a central role. that the reforms have not so far increased overall access to dentistry – 56 per cent of Nowhere has the need for such reforms been the population in England received NHS more clearly demonstrated than in relation to treatment in the 24 month period prior to NHS dentistry. Since the early 90's it has September 2006, the same percentage as become increasingly apparent that the shape in the 24 month period to March 2006. of NHS dentistry services has been driven by s Thousands of patients remain unable to the choices of practitioners rather than access NHS dentistry for routine care. patients, that patient choice has been Often the only 'choice' is between private replaced by a struggle to find any service at treatment, even when this is clearly all, and that routine preventative care has unaffordable, or going without. been abandoned in favour of the need to concentrate scarce resources on emergency s The postcode lottery is illustrated by an treatment and pain relief. analysis of the NHS Direct website carried out in November 2006. The website The cost of this failure has been borne by showed that in almost a quarter of PCTs patients themselves who have either been 40 per cent of dentists were accepting forced to pay for private treatment at new charge-paying adults. However, in significantly greater cost or, for those on low another quarter of PCTs, none of the incomes, go without until acute pain qualifies dentists were accepting this patient group. them for emergency services. The hunt for s Some PCTs are seeking to manage demand that elusive NHS dentist has led many to their by setting up waiting lists, but these are local Citizens Advice Bureau (CAB). Bureaux often not well publicised and so may repeatedly report the anger, frustration and underestimate the scale of the problem. sense of betrayal which clients experience at Yet PCTs are using the size of their waiting being excluded from NHS dentistry. lists as a measure of unmet demand. Given the extent of the problem, measures to s Many patients are unable to manage or tackle it have been a long time coming. In afford the lengthy journeys often needed 1999 the Prime Minister announced that to reach the nearest NHS dentist. Patients within two years anyone would be able to see on low incomes living in rural areas and an NHS dentist just by contacting NHS Direct. reliant on public transport are particularly In fact it took another seven years to finally disadvantaged. put in place much needed reforms intended to s To meet reasonable requirements, access to address the problem. Even then, as this report NHS dentistry must be available at the local demonstrates, much remains to be done level, as there is no help through the before NHS dentistry delivers for patients the benefits system with travel costs to a bold objectives which the Government has set 2 dentist. for the wider NHS reform programme. Background Between 1990 and 2004, NHS spending on General Dental Services increased by only The root of the problem of access to NHS 9 per cent per capita, compared with a 75 per dentistry dates back 17 years to the 1990 cent increase in overall NHS spending. Since reforms which introduced changes to the way then the situation has improved, with gross dentists were remunerated, linking this to investment increasing by about a third, much numbers of patients registered. Dentists then of it targeted where access was poorest, and registered far more patients than had been the equivalent of 1000 additional whole time anticipated, resulting in NHS dentistry costs dentists were recruited by October 2005. exceeding forecasts and dentists exceeding However the fundamental problem was the recommended pay levels. The Government always the nature of the relationship between responded by cutting fees in 1992, which had dentists and the NHS, which in effect meant an immediate and significant effect on that the dental profession were in a position dentists' remuneration. to determine where and to what extent NHS dentistry would be delivered. The long term consequences are still felt today. Dentists responded by scaling back 2006 reforms their NHS work and expanding private treatment, particularly in more affluent areas This issue was finally addressed in the Health where market conditions were more and Social Care Act 2003 which introduced favourable. The effect of this was dramatic, what Ministers have described as the largest with five years of year on year underspend on reforms to NHS dentistry since its inception.3 NHS dentistry between 1993 and 1998 Citizens Advice has very much welcomed totalling some £330 million. Adult patient these reforms which, for the first time, give registrations fell from 23 million in 1994 to every Primary Care Trust (PCT) in England and 17 million in 2003/04 in England, most of Local Health Board (LHB) in Wales, a duty to which was between 1994 and 1998.1 In Wales 'to the extent that it considers it necessary to patient registrations fell steadily from 54 per meet all reasonable requirements, exercise its cent of the population in 1997 to 47.7 per powers so as to provide primary dental cent in 2006.2 services within its area, or secure their provision within its area'.4 The impact on patients has been profound. No longer could people choose between Given the urgency of the problem from the several local dentists on the assumption that patient's perspective, implementation of these virtually every practice would offer NHS reforms was a long time coming. The start dentistry. Instead, many patients already date of April 2005 was first put back to registered were suddenly told that their October 2005 and then postponed again as dentist would no longer be providing NHS protracted negotiations continued between treatment, and anyone moving to a new area the Department of Health and the dental or seeking NHS treatment for the first time profession. was likely to find lists closed. Bureaux regularly reported that for many people, the only The reforms finally came into effect on 1 April 'choice' available was between going private 2006. Under the reforms, patients pay one of or going without. three standard patient charges as set out in Table 1. 3 1 National Audit Office, Reforming NHS dentistry: ensuring effective management of risks, November 2004 2 Hansard, Welsh Assembly WA, 22 Feb 2007 3 Department of Health press notice, 30 March 2006, New era begins for NHS dentistry 4 Health and Social Care Act, 2003, s 170 Gaps to fill Table 1: Bands and charges (2006/07 rates) Treatment includes England Wales Band 1 Examinations, x-rays, scale and polish £15.50 £12 Band 2 Treatment covered by Band 1, plus additional treatment such as fillings, root canal treatment or £42.40 £39 extractions Band 3 All Band 1 and 2 treatment, plus more complex £189 £177 procedures such as crowns, dentures and bridges Dentists are contracted to deliver an agreed did target 10 per cent of the additional number of Units of Dental Activity (UDAs) 2006/07 funding on those LHBs with greatest over the year. The value of these UDAs relates access difficulties). It was therefore always to the three patient charge Bands, so a Band questionable how PCTs/ LHBs in areas with 1 course of treatment generates one UDA, a historically poor access would be able to fulfil Band 2 treatment three UDAs and a Band 3 their new duties to meet 'all reasonable treatment 12 UDAs. requirements' for access to NHS dentistry without additional pump priming resources. In order to deliver this new duty budgets, Yet ironically it was precisely to address the ring-fenced for three years, have been problems of poor access that the reforms devolved to every PCT/LHB. This has meant were introduced in the first place and it was in that where a dentist decided to reduce their these areas that patient expectations of the NHS work, the PCT/LHB has been able to act reforms were likely to be greatest. strategically to reinvest the funds in areas where the need is greatest. As a result, the Early statistics released from the Department first year of the reforms have seen many new of Health relating to England only, indicate practices opening across the country. The that the more modest aim of the April 2006 extent of the local press coverage given to reforms to stem the flow away from NHS these events demonstrates just how much dentistry has been achieved. Following some these new services are valued by the local early 'churn' where dentists delivering some community. A further indication of progress is 4 per cent of NHS services did not sign the that the Department of Health have told new contract, PCTs have been able to Citizens Advice that they have seen a 65 per recommission those services so that in the cent reduction in the level of correspondence two years ending September 2006, around on access to NHS dentistry problems between 28.1 million patients in England – 56 per cent July and December 2006. of the population – were able to access NHS dentistry, the same percentage as in the two However the size of the 2006/07 budgets years prior to March 2006.5 However there is allocated to PCTs/LHBs was linked to the no evidence of any noticeable progress historic spend in their area, rather than taking towards meeting the needs of the two million into account the existing postcode lottery in people in England which the Department of access to dentistry across the country Health has estimated would like to access NHS (although the Welsh Assembly Government dentistry but are unable to do so.6 (There has 4 5 NHS dental statistics for England, Quarter 2, September 2006, The Information Centre 6 Hansard, House of Lords, 27 April 2006, col 44 . been no comparative estimate published for The report is structured around the main Wales.) issues for patients arising out of the implementation of the reforms. These are: Moreover, the situation has not been uniform s the adequacy of information about what is across the country: in the two Strategic Health available Authorities with the lowest percentage of patients treated (South East Coast and South s the adequacy of NHS dentistry provision at Central) the percentage actually fell between the local level these two periods. This is further evidence s what patients do when they fail to find an that the reforms are not yet sufficiently NHS dentist and targeted on areas in greatest need. s how PCTs/LHBs are assessing unmet The picture in Wales is broadly similar, with demand and monitoring dentists' 55 per cent of the population having received compliance with the new contract. treatment in the two years ending September 2006. This figure varies significantly at LHB On the basis of this evidence, the report level – from over 70 per cent in Swansea to makes recommendations for what more needs just 30 per cent in Pembrokeshire. Overall to be done to build on existing progress and there was a 1 per cent drop in the number of to ensure that NHS dentistry delivers a patients treated as compared with March genuinely patient-focused service which 2006, suggesting again that at best the achieves the Government's wider ambitions reforms are delivering 'steady state'.7 for NHS reform. The CAB network, with over 3,000 local outlets across England and Wales including Looking for an NHS dentist – over 1,000 in healthcare settings, is well information gaps placed to identify any problems which patients A brief study of the dental pages of the NHS experience with the dentistry reforms. Direct website for England demonstrates the Between April and September 2006 Citizens postcode lottery which exists for NHS Advice Bureaux dealt with around 3,500 dentistry. Set up in order to help people find a enquiries relating to NHS dentistry, of which local NHS dentist, the website lists for every 35 per cent related to access problems. PCT details of dentists contracted to provide NHS services. For each one, the colours red This report is based on the reports and local and green are used to indicate whether those surveys which bureaux submitted as a result dentists are currently taking on new patients. of these enquiries, along with the results of an on-line survey on problems with access In November 2006, Citizens Advice analysed to dentistry which Citizens Advice included the website for all 152 PCTs to compare levels on its public information website of access to NHS dentistry across the country (www.adviceguide.org.uk) between May and for charge-paying adults. (We were unable to October 2006, to which 4,705 people do a comparable analysis for Wales because responded. In addition, information was the NHS Direct website is structured differently sought from PCTs where access problems are there.) worst, in order to assess their capacity to deliver on their new duties, and an analysis This patient group was selected as being the was undertaken of the access information category for which access was poorest. We published on the NHS Direct website. accept that the website may not provide the full picture, as in some hard pressed areas the 5 7 NHS dental statistics, Wales July-September 2006, issued by Statistical Directorate, National Assembly for Wales, November 2006. Gaps to fill situation changes from day to day, and in Particularly in these areas of poor access, others the information is simply incorrect. having an effective searching strategy is key. In However this is the most publicly accessible the past, many people would have relied on way of assessing access to dentistry and recommendations from friends or relatives, or indeed is the approach which the Department used the telephone directory on the of Health recommends patients use. assumption that most dentists would provide NHS treatment. But in many areas this is no Our analysis revealed huge differences longer likely to be effective. The Department between PCTs (see Appendix). In 22 per cent of Health recommends that people searching of PCTs at least four in ten contracted dentists for an NHS dentist should either contact their were accepting new adult charge-paying PCT or use NHS Direct, either by phone or by patients. However the website showed that in using the website. However these are 26 per cent of PCTs there were no dentists relatively new search strategies, and the CAB currently accepting this group of patient. This on-line survey of people who had had raises the question as to whether these PCTs problems finding a dentist suggests they are were in fact meeting their new statutory duty not yet well used: as Table 2 shows, only to provide reasonable access to NHS dentistry. 19 per cent had contacted their PCT or their As one survey respondent in West Yorkshire Patient Advice and Liaison Service (PALS). commented: Moreover, even amongst these self evidently 'internet friendly' respondents, only 52 per "When I complained to my local trust cent had used the NHS Direct website. they told me that having an NHS dentist should be viewed as an aspiration rather The most frequent response (56 per cent) was than a reality." using the Yellow Pages phone book, a method unlikely to be successful, and nearly half were Table 2: How did you go about trying to find an NHS dentist? Used the Yellow Pages 56 Used the NHS website 52 (www.nhs.uk) Through a friend or relative 43 Telephoned NHS Direct 39 Telephoned PCT or PALS 19 0 10 20 30 40 50 60 Percentage of responses (Based on 3,763 responses. Percentages do not add up to 100% as respondents were able to select 6 more than one option.) continuing to rely on friends and relatives. This was unaware of the fact that the PCT suggests that much more must be done to was holding a central waiting list. promote the role of PCTs and NHS Direct in finding a dentist. A CAB in Hampshire helped a traveller in pain to access emergency dental But this is not the full story. In the areas with treatment. In the process they also tried greatest access problems the NHS Direct to help him register on the waiting list. website is often of least use and can even be However he could not complete the misleading. We contacted the 40 PCTs which process because he did not have a our analysis of the website had suggested had telephone which was a condition no access for new charge paying adults. We required for registering on the list. found that in some areas, if patients got as far as using the dental enquiry line, it was The experience of the following young man possible to be matched up to a dentist as also demonstrates the confusion which can vacancies became available. Other PCTs were result when patients are not aware of the operating a central waiting list. In other words local access route: a locally managed system was replacing the national 'self service' approach for which the A CAB in Cheshire reported a young NHS Direct website was designed. As one PCT man in part time work, who had 'fallen explained: off' his dentist's list because he had not attended for over a year. He rang the "I would like to point out that our practice because he was suffering acute website doesn't indicate that any dentist toothache but was informed that they is taking on new patients because we no longer saw ex-patients, even in an operate a central waiting list system that emergency. Another dentist refused to tries to ensure fair and equitable access see him on the NHS but offered private to routine NHS dental care." treatment at £75 for a half hour appointment, which the client declined. Operating a waiting list clearly has the After making numerous calls to other potential to be a fairer system, and one which dentists, the client eventually rang the also avoids the negative publicity which has PCT, which resulted in an appointment been associated with reports of people being made for the following day. To his queuing round the block when a new NHS surprise he was treated on the NHS by dentist opens in a local town. However it does the dentist who the previous day would not support policy objectives to promote only see him privately. patient choice. Where local waiting lists are in operation, the Creating and managing a waiting list also NHS Direct website is not helpful. Although it raises a new set of challenges for PCTs. In includes details of PCT helplines for people particular, it is crucial that the waiting list itself having difficulties in finding a dentist, there is is well promoted so that everyone, especially no information provided as to whether or not those in 'hard to reach' groups, knows of its a waiting list is in operation and if so how to existence and how to join. join it. In practice, the route onto the waiting list is usually via the PCT helpline, but that One CAB in the West Midlands reported crucial piece of information is not given, and a client who had been without a dentist many website users, confronted with a screen for five years. During that period he had of dentists with closed lists, will simply assume had one check up at the Dental Access that there is no local access and will not use Centre. However despite this contact, he the helpline. 7 Gaps to fill Other promotion strategies are essential to "Our local PCT has made assurances reach people not using NHS Direct. Responses through the local press that they are from the PCTs we contacted in areas of poor working on the problem and that they access who were operating waiting lists, have created a waiting list so that as revealed that some were taking a more soon as places become available they pro-active approach than others. Strategies will contact clients. But this does not ranged from a one-off advertisement in the seem to work in practice…our client's local press, to the production and distribution problem was not an emergency but she of posters to local GPs, pharmacies, libraries certainly wanted to know a timescale in and bureaux. Only one of the 40 PCTs had which she could expect to be sorted done a mass mailing to households telling out." them how to access local NHS dental services. Other respondents commented on the Managing waiting lists also requires systems to difficulty in getting through on the telephone keep patients informed of their progress and or finding anyone able to provide up to date estimate their likely waits. Several survey information on likely waits. respondents commented that they were on a waiting list but had no idea how long they might have to wait. As one CAB in Dorset Failing to find an NHS dentist commented regarding a pensioner whose The CAB online survey respondents were dentures needed attention: asked why they had been unable to find an NHS dentist. Table 3 outlines their replies. Table 3: Why couldn't you find a suitable NHS dentist? No local dentists accepting new NHS patients 77 Long waiting lists for local NHS dentists 37 Nearest dentist is too far away, or too 25 expensive, to travel to Unable to talk to anyone who could help 17 Could not find any information which 17 would help Treatment needed was not offered 8 0 10 20 30 40 50 60 70 80 Percentage of responses (Based on 3189 responses. Percentages do not add up to 100% as respondents were able to select more than one option) 8 A local service? Even those willing to travel that extra distance may still not be able to find an NHS dentist. It is clear from this Table that the most One respondent from Lancashire commented significant problem is the lack of a local that dentists were not accepting patients from service in many parts of England and Wales. outside areas. Another respondent from When asked why they could not find a Devon stated, suitable dentist, over three quarters of respondents cited "there are no local dentists "Some dentists over 40 miles away accepting new NHS patients". In addition, a would not take me on because I did not quarter of respondents said that the nearest live locally even though they were NHS dentist was too far away or too accepting NHS patients." expensive to travel to. Access to a car is a major factor in enabling This is by no means exclusively a problem people to choose more distant locations. facing people living in rural areas. However in "I have to travel an hour by car to get England the number of dentists per thousand [to the dentist]. Without a car I wouldn't of the population is lower in rural than in have a hope in hell of seeing a dentist." urban areas: 4.5 dentists per 10,000 of the (survey respondent, Hampshire) population compared to 5.4 per 10,0008, and a 2004 survey of rural services in Wales Yet car availability is strongly related to showed that only 16 per cent of communities income, with those in the lowest income had access to a dentist.9 In 2006, the groups having the least access. In 2005, Commission for Rural Communities produced 53 per cent of households in the lowest for the first time a Rural Services Standard income quintile had no car compared with (RSS) for England. This "calls for local 10 per cent in the highest income quintile.11 standards of service and for these to cover the For those who do not have access to a car, the quality of services as well as access for rural difficulty of finding an NHS dentist is people".10 It does not however contain any compounded by the problem of finding one specific standards for accessing local NHS they can access by suitable public transport. dentistry. Similarly the Welsh Assembly Government is currently working towards a For one survey respondent in Cheshire, practical benchmark for a rural services the nearest dentist was just 14 miles standard but it is unclear whether NHS away. A car journey would take about dentistry will be included. 25 minutes but the journey by public transport would take far longer. There Comments from the survey respondents reveal were no rail services and only a few bus the distances that some people are travelling: services each day. One option involved "Travelled to old dentist 70 miles away leaving at 7.40 am and another involved (ie where they used to live)." three changes and took four hours (survey respondent, East Riding of including a wait of an hour. Yorkshire) A CAB in Nottinghamshire reported a "Went to an NHS dentist in Birmingham woman who needed to see a dentist 50 miles away." when she lost a filling. NHS Direct had (survey respondent, Gloucestershire) suggested a dentist in Mansfield, involving two bus journeys taking two hours in total. Buses ran infrequently so 9 8 Hansard, HoC, col 2286W, 13 September 2006. 9 Wales Rural Observatory (2004). Based on Town and Community Councils in rural areas 10 Fifth annual monitoring report on the Rural Services Standard, Commission for Rural Communities, December 2006 11 National travel survey, 2005. Department for Transport Gaps to fill the client would have had to wait some For others, public transport may be unsuitable time before coming back. The train because they have health or mobility problems would have taken over an hour and or have small children. involved a change as well as walks of "My son is 11 months and has seven about 30 minutes at each end. teeth. I have been advised to take him to a dentist, and I still cannot find one close Often the consequences of making such to us as I can only use public transport lengthy journeys are disproportionate; bureaux and with a buggy I can't get very far." reported clients having to take a whole day (survey respondent, Greater Manchester) off work, or removing their children from school for all or part of the day: A CAB in Suffolk reported a client with mental health problems including severe A CAB in South Wales saw a mother on anxiety. Her total income was £62.45 per a low income who had three children. week. The nearest dentist accepting She was unable to find a dentist near to charge exempt NHS patients was nearly where she lived and had to travel 20 miles away and there was only 13 miles each way. In the previous limited public transport. The trains only month the client had had to travel to ran every two hours, took 40 minutes, three separate appointments, a total of cost £5-£6.00 and included a change. 78 miles. She had also missed two The bus journey would have also appointments for her youngest child included a change and took 40 minutes because she didn't have a car and would each way, costing about the same as the have missed picking up her other two train. A local volunteer car organisation children from school. Her child lost a quoted a £25 return fare for the journey. tooth as a result. The client was very worried about going all that way and was not happy to travel The same bureau saw another woman by herself. The adviser stated that client with three young children, who was would find it very difficult to get to the dependant on benefits. She had to travel dentist, both emotionally and financially. 24 miles to reach the nearest dentist. She did not have a child minder so each Public transport can be very expensive, even time one child needed to visit the for short journeys. For many clients on a low dentist, she had to take all of them, and income this may prove prohibitive. A CAB because she did not drive she had to adviser in Lancashire stated that as the take public transport and pay fares for majority of their clients were on a low income, all the family. She had to travel twice in they would probably choose to go without one month because she did not have treatment. appointments on the same day. "I am a mother of three on income "I live in Wadebridge. The nearest (NHS) support, we were very happy with our dentists are Camelford or Truro, both of dentist but then with the new NHS which are too far away to reach, changes the practice became private, so involving a whole day away and taking we had to find a dentist that was NHS to my six-year-old daughter out of school still get free treatment. The nearest one for the whole day just to get her to a we could find was in the next town and dentist." (survey respondent, Cornwall) 10 the last time we went it cost me £18 in access dentistry, at least on a temporary basis, bus fares! That was just another slap in to ensure that people on low incomes are not the face for the 'poor'." disadvantaged. (survey respondent, Kent) It is also vital that PCTs/LHBs consider travel A Surrey CAB saw a client who could issues when deciding where to locate new not find a dentist for herself or her services, but some bureaux have reported that children. There were no dentists within transport factors often do not appear to rank six and a half miles. The bus cost £5.70 highly in PCT/LHB priorities. for herself and £3.70 for each of her children, and took over 45 minutes each For some people in rural areas, the choice of way. The train cost £5.00 for herself and either a tortuous and costly journey by public £3.10 for each of her children and they transport, or expensive private treatment is, in would then need to take a further bus reality, no choice at all. To meet reasonable to reach the dentist. requirements, access to dentistry must be available at the local level. There is currently no specific help available with the costs of travel to a dentist. The "There was no dentist closer than a means-tested hospital travel costs scheme 50 minute car/train ride. I now have to (HTCS) does not include help with travel to pay £80 for [a private] check-up and primary care services such as dentists, hygienist every 6 months. I only earn an presumably on the assumption that people average wage and this is a huge cost." will not need to make lengthy journeys to (survey respondent, Hampshire) reach these services because they are available in the local community. Regrettably though, as An elderly widowed client visited a CAB this report has shown, this is not the case for in Hampshire because her dentures NHS dentistry. In 2005, Citizens Advice wrote needed attention but her dentist, who to the Health Minister Rosie Winterton to did not sign the new NHS contract, suggest that, at least as a temporary measure, would only treat her privately. He had the HTCS should be extended to cover quoted £500 for the work. Her only journeys to dentists. Her response was that income was a state retirement pension "Any monies spent on such schemes…would and pension credit. The nearest dentist reduce funds available locally to expand the was 11 miles away. The client did not service in the way that is needed. Our plans to have a car, and the journey by public significantly increase the number of dentists transport was particularly difficult. available… will reduce the need for excessive travel in a sustainable and long term-way." Waiting lists Thirty seven per cent of survey respondents We strongly agree with the sentiment behind referred to long waiting lists for access to a this response – it is very clear from CAB local dentist. As outlined above, PCTs have evidence that what people want is a local increasingly been setting up waiting lists in an service so that the cost and inconvenience of attempt to manage the mismatch between lengthy journeys is avoided. However it is demand and supply. It is however ironic that equally clear that, two years on, despite the this is taking place at a time when in other Government achieving its aim to recruit 1000 parts of the NHS there are clear targets to cut extra dentists in 2005, this objective has not waiting times – to 48 hours for access to a GP yet been met. There therefore remains a and 18 weeks from GP referral to hospital strong case for some help with travel costs to treatment. 11 Gaps to fill Replies from PCTs with central waiting lists Consequences for patients showed that patients on lists could expect to wait anywhere between three months and Survey respondents who were unable to find a two years before being allocated to a dentist. suitable dentist were asked what they did as a Even then, some patients could face further result. Table 4 outlines their replies. waits before getting an appointment. Similar waits were reported at the level of individual Emergency treatment surgeries in areas where there was no central Emergency dental services are generally waiting list: available, for example through Dental Access Centres, even in areas where access to routine A CAB in Hampshire reported a single treatment is poor. Nine per cent of survey woman who was pregnant and in respondents unable to find a dentist for receipt of income support. She could not routine treatment ended up using A&E or find an NHS dentist and was faced with other emergency dental services when a crisis having to pay an unaffordable sum of arose. However the scope of this help is often £1,420 for private treatment. The bureau restricted. Patients may find that their problem contacted a local NHS dentist who said does not meet the locally applied definition of they had a six month waiting list of 500 an emergency, even though they are in pain. patients. The bureau resorted to They may have to wait until their problem is contacting a charity for help with the acute before they can be seen – precisely the costs of private treatment. opposite to the preventative approach to healthcare which the Government is keen to foster. In addition, the treatment provided Table 4: What did you do as a result? Went to A&E, or other 9 emergency dental service Went for private treatment 19 Went without treatment 65 Went to GP 2 Other 6 0 10 20 30 40 50 60 70 80 Percentage of respondents Based on 3,094 responses 12 may not deal with the underlying problem. "In July my partner's toothache was so Where there is easy access to routine follow bad he called NHS Direct, only to be told up treatment this would not be a problem, that because his jaw was not swollen but where emergency treatment is all that is enough to restrict his speech, they available, it is far from satisfactory. couldn't offer emergency treatment… (Later) it got to the point where he was A CAB in Lancashire reported a client taking time off university so we phoned who had been suffering from toothache NHS Direct again. This time he got an for two months. She had been emergency appointment but the dentist repeatedly contacting NHS Direct who just gave him antibiotics and told him to were unable to help her find a local find an NHS dentist. The pain in his dentist or refer her to emergency teeth was so incredible that he has gone treatment as her pain did not count as to a private dentist…The total cost of an emergency. the treatment will be £831 for which we have just taken out a loan that we A CAB in Devon reported a client who cannot afford." had a front tooth knocked out. The (survey respondent, West Yorkshire) emergency dental hospital cleaned it up but he faced a long wait for NHS Going private treatment for a replacement tooth. Many patients have felt forced to accept Unemployed and job hunting, he was private treatment even when this is not what finding it embarrassing going for job they wanted or indeed could afford. This was interviews with a missing front tooth. the case for 18 per cent of survey respondents. Many bureaux have reported The same CAB reported another client similar cases. with severe toothache. He attended the emergency service which provided A CAB in Wales reported a client in her temporary treatment, however his 80s and on a limited income who had underlying problems remained and he had dentures for 35 years and needed was unable to eat properly. replacements. As she was unable to find an NHS dentist she sought private In some cases patients have felt forced into treatment. She was very distressed that private treatment as a consequence, even the bill came to £642. when this was unaffordable. A CAB in Hampshire reported a client A CAB in Gloucestershire reported a whose only income was his state client with long term sickness problems pension, who had received private who was treated for an abscess caused treatment at a cost of £397 after five by ill-fitting dentures as an emergency at attempts to find an NHS dentist. He the Dental Access Centre. She needed faced financial and personal stress as a replacement dentures to prevent the result and wanted to know if he could problem recurring but these could not be reimbursed. be provided as it did not count as emergency treatment. When her doctor Bishops Waltham CAB asked people told her she should get her dentures visiting the bureau to complete a replaced she borrowed money from her questionnaire on the issue after the family to meet the cost of private bureau had failed to convince the PCT of treatment. the need for more dental provision in the 13 Gaps to fill Meon Valley area. Of the 230 people making ends meet, cannot afford who responded, 32 per cent had a NHS holidays and has to be careful buying dentist, 58 per cent had a private dentist food. and the rest had no regular dentist. Only 10 per cent of those with a private A CAB in Cheshire reported a client in dentist said this was their preferred his 90s who was told that he could only option. Eighty seven per cent of all the continue to see his dentist on a private respondents said that they would choose basis if he paid a minimum of £132 per to move to a local NHS dental practice if year. He could not find an alternative one opened in their area. Interestingly, NHS dentist in the area. the survey also showed that on average, NHS patients were travelling twice as far Going without as private patients to reach their dentist. As a result of their failure to find a suitable NHS dentist, by far the most common Often people have reluctantly agreed to go outcome, reported by 64 per cent of survey private when their dentist decided to respondents, was that they simply went withdraw from NHS work. In these without regular check ups or treatment. Many circumstances there is no requirement for the were angry and bitter at being let down by local PCT/LHB to provide patients with the system, and for others the knock on information and support in finding an effects were significant. alternative NHS dentist. As a result, the fear of being left without any dentist can make "I am currently on maternity leave and patients an easy target. Yet often the regular should be in receipt of free dental payments required are not affordable and treatment…However this is a complete create a serious strain on limited budgets. waste of time as no NHS dentist will take me on. In addition to this, like too A CAB in Devon reported a client on many unfortunate people to mention, I income support who suffers from am unable to pay for private multiple sclerosis. She was unable to find treatment…Finally as a result of this I a local NHS dentist and therefore used a was forced to give up breast feeding my private practice as she has difficulty baby due to having to constantly fill travelling far. However she fell behind myself with strong pain killers to rid with her payment for treatment, and is myself of the agonising pain. This in now faced with a county court claim for itself has been extremely annoying and £428 plus costs. upsetting. At the end of the day my child has also had to suffer." A CAB in Northumberland reported a (survey respondent, Lancashire) client in her 70s in receipt of means tested benefits who signed up for A CAB in Buckinghamshire reported a Denplan with her local dentist because woman who had had surgery for cancer she was afraid that otherwise she would and was due to start chemotherapy. be unable to get treatment when However she was told she must have needed. She pays £10.50 per month some dental work done first. She and which covers two check ups a year; her husband are struggling on a low however she will have to pay extra if she income with a mortgage and with needs other treatment – e.g. £40 for a outgoings exceeding their income. She filling. She is constantly worried about was unable to find an NHS dentist and 14 could not afford private fees. Clearly from the patients' perspective there (defined as no access for new charge paying remains much to be done before the goal of adult patients). The questionnaire asked how reasonable access is achieved across England unmet demand was being measured, what and Wales. plans there were to meet this demand, and what help was currently available to people seeking NHS dentistry. Thirty nine PCTs The role of PCTs/LHBs – responded, and from their responses it was commissioning and compliance clear that many PCTs have used the opportunity created by the withdrawal of For PCTs/LHBs, implementing the NHS some dentists from the NHS, to reallocate dentistry reforms from April 2006 has resources to areas of greatest need. presented a significant challenge. Firstly, in England the timing was hardly auspicious as There was little evidence however that the net many were facing the upheaval of result had been a significant increase in overall reconfiguration only six months later, as the access to NHS dentistry. Indeed several PCTs 303 PCTs were reduced to 152. Inevitably this appeared to be interpreting their will have meant changes in staff and responsibilities simply in terms of structures, created budget uncertainties and recommissioning the provision lost from made the development of long term strategies dentists who declined to accept the new more difficult. The reforms to patient charges contract, and spending their allocated, ring created further uncertainties as budgets have fenced budget, rather than in developing had to be set on assumptions about the broader strategies to meet their new statutory relative proportion of charge paying and duty to provide reasonable access. Thus one exempt patients treated under the new PCT replied that it had some 30,000 patients contracts. on its waiting list to whom it did not expect to allocate dentists before the end of 2007. It In addition, PCTs/ LHBs in areas of poor access also commented that whilst it was aware it were faced with the duty to provide was "an area of high need," it currently had reasonable access to NHS dentistry from April no specific plans for further expansion. 2006 with a budget based on their historic Another replied to a question asking how it spend. was meeting its statutory responsibility by commenting simply that the recommissioning Within this context PCTs/ LHBs have had to "action that the PCT has taken will ensure take on the commissioning of general dental that the ring-fenced dental allocation is fully services as well as responsibility for monitoring spent on providing an equitable access for dentists' compliance with the new contract. local residents". Only two of the PCTs we The latter includes a number of changes contacted in areas of poor access clearly aimed at ensuring a more patient centred indicated that they had spent any funds on approach to delivery. top of their ring-fenced budget in order to improve access. Commissioning A number of bureaux have contacted their This is perhaps not surprising given the local PCTs/LHBs to find out what plans are financial pressures and competing demands being made to address access issues, and to under which PCTs are operating. However it feed in their local evidence of the problem. In does strongly suggest that without addition as outlined above, Citizens Advice additional ring fenced funds directed sent out a brief questionnaire to 40 of the specifically at those areas with poorest PCTs which appeared from the NHS Direct access, the potential of the NHS dentistry England website to have poorest access reforms to resolve access problems will 15 Gaps to fill not be achieved. It is also important to Compliance ensure that PCTs facing budget deficits do not As commissioning bodies, it is also PCTs'/LHBs' raid their ring- fenced dentistry budgets to responsibility to ensure that dentists comply resolve wider financial problems. with their contract in delivering their services. The new contract includes a number of Another cause for concern is that many of the provisions intended to address some long PCTs we contacted in the poor access areas standing concerns and ensure that NHS appeared to be relying heavily on calls to their dentistry delivers a more patient-centred helplines or PALS, and/or the numbers of service. people on their waiting lists, in order to assess unmet demand. Yet our survey shows that For example before 2006, a common source only 19 per cent of respondents, all of whom of complaint was that patients were given had had difficulty in finding a dentist, had private treatment when they thought they actually contacted their PCT or PALS, which is were being treated under the NHS. The fact usually the route onto any waiting list. If that dentists are able to provide a mix of NHS patients looking for a dentist do not know and private care in the same course of about these sources of help and therefore do treatment means that such confusion is not use them, then this data inevitably always a possibility unless very clear underestimates the scale of unmet demand. procedures are in place. Under the 2006 We believe this goes a long way to explain reforms, the patient charging system has been why, in some areas, there appears to be a dramatically simplified, so that patients now sharp contrast between the view of the PCT pay one of three standard charges for a and the evidence from patients as to whether course of treatment. In addition, dentists are it is indeed meeting 'all reasonable required under their contract to display in the requirements' for NHS dentistry, as the waiting area a poster detailing these three legislation demands. A better estimate of charge bands. Several bureaux have however demand is probably the Healthcare reported instances where this poster was not Commission's most recent survey of patients displayed. In some cases patients were unable in primary care which found that 69 per cent to successfully challenge incorrect charging as of those not registered with an NHS dentist a result: said they would like to be (up from 67 per cent in their 2004 survey.)12 A CAB in Sussex reported the case of a client in his 70s who came to the bureau Only one of the 39 PCTs in poor access areas because he thought he had been which responded to our questionnaire, overcharged. However when he had mentioned that they were considering queried it with the receptionist, he had undertaking a local patient survey in order to simply been told that that was what he more accurately assess local demand for NHS had to pay. He had had a check up and dentistry, although several were undertaking a small filling which then caused him oral health needs assessments. Additionally problems. The dentist said he could have very few appeared to be consulting with local a crown which would be at least £200 patient bodies such as Patient and Public or have the tooth out. He chose the Involvement Forums or local authority latter which he assumed would cost overview and scrutiny committees, or indeed £42.40, but ended up paying £42.40 with local advice agencies such as bureaux, in twice, plus £15 for an x-ray. order to fully assess unmet demand. 16 12 Healthcare Commission, State of Healthcare 2006 A CAB in the West Midlands reported a "Was told (they) would only accept my client who had to have extensive daughter as an NHS patient if I went as treatment including five extractions plus a private patient. As I am registered dentures, x-rays and fillings. The total disabled and on full benefits I cannot cost was agreed at £189 and the client afford this." started on some of the treatment. He (survey respondent, Leicestershire) has now been to see another of the dentists in the same practice who says "My dentist will give my son a free he wants another £189 to cap some of check up if I make a private appointment the damaged teeth and to complete the so I feel I have no option…" dentures. (survey respondent, Merseyside) A CAB in Merseyside reported an "I went to an NHS dentist and paid for a unemployed client on income support check up and she said you have so much who had to have emergency treatment. work to do we will not do it on the She paid £65 for the treatment but was NHS…" told that it was done under the NHS and (survey respondent, Surrey) that she could claim the money back by picking up a form from the Jobcentre. "There is one remaining NHS dentist When she tried to do this she was told locally but you must first have any that this was not the case. treatment done privately with them and be 'stable' before you can become an Another key change is that dentists are no NHS patient" longer allowed to set conditions for accepting (survey respondent, London) patients – for example they should not refuse to accept patients with poor oral health or A CAB in Oxfordshire reported a client make the acceptance of a child as a patient who has had long term mental health conditional on the parent registering for problems which have resulted in years of private treatment. These practices are neglect of her teeth. Her health is now inconsistent with the fundamental principles improving and she has made efforts to of the NHS. Again there is evidence that not overcome her self neglect. She all dentists are complying with this condition approached two NHS dentists for as the following examples demonstrate. treatment but both refused to accept her because of the amount of work "I am extremely upset that when my required. She therefore took out a loan dentist wrote to me in March advising for private treatment which she is now that he was 'going private', the letter facing difficulty in repaying. stated that unless we paid the Denplan fee of £20 per month for me and my Other conditions such as the requirement to husband, the practice would not treat deliver all treatment necessary to secure and my young sons aged three and four. maintain oral health were always part of the Because we are on a tight budget we NHS contract, although were not always are too poor to afford £20 per month." delivered in practice. Again there is evidence (survey respondent, West Sussex) that these conditions are still not always being met under the new contract. 17 Gaps to fill A CAB in Lincolnshire reported a client in A CAB in Surrey reported a client who his 70s and in receipt of pension credit made a complaint about her experience who had all his teeth removed by his of poor treatment from her dentist. The dentist under the NHS. However the dentist then told her she was not dentist has now informed him that they wanted as a patient. She is currently in will not provide him with dentures on pain but has been unable to find an the NHS. He is left unable to eat properly alternative NHS dentist. and as he is on a low income he is not in a position to pay for private treatment. The NHS Direct website does provide some information about patients' rights with regard A CAB in Warwickshire reported a client to NHS dental treatment but there is a need whose 55 year old daughter is disabled for this information to be available in other with hemiplegia and epilepsy. She fell forms. PCTs/LHBs also need to develop their and broke two front teeth. Her dentist public profile by making patients more aware was unable to save the teeth and of their monitoring role and encouraging prescribed a fixed bridge because a feedback both positive and negative, to help removable denture is a choking hazard develop a more patient centred monitoring for an epileptic. However he did not give process. her the choice of having the work done under the NHS, at no cost, but instead With regard to the formal complaints process, did the work privately, charging £2,400. the CAB service has long argued that PCTs should have more direct involvement. Many A CAB in Essex reported a client who patients are reluctant to make a complaint to needed an essential crown. The dentist their primary care provider and would prefer refused to do this work under the NHS to deal with an independent third party such at a patient charge of £189, and insisted as the PCT. Channelling all primary care on doing the work privately at twice the complaints via the PCT would also create a cost. better evidence base for the PCT to monitor patient satisfaction with services Another CAB in Essex reported a client commissioned. who was incorrectly told that root canal treatment was not available on the NHS and that the work could only be done privately. It is not easy for patients to check whether what they are told by their dentist is correct, or indeed to know how to challenge such practices when they do occur. As long as access problems continue, patients are in a vulnerable position. Few will want to risk taking up the issue with the practice itself, for fear of jeopardising the dentist/ patient relationship or even being removed from the list altogether. 18 Conclusions and available for targeting LHBs in Wales. The reforms have had time to bed down and can recommendations now provide a stable base for growing NHS Citizens Advice has welcomed the April 2006 dental services and ending the postcode dentistry reforms which we believe provide a lottery on access to this much-needed NHS good foundation on which to rebuild the service. Although there has been some service as PCTs/LHBs are now able to invest discontent among dentists about aspects of resources more strategically. However, this the new contract, none of the PCTs we report has demonstrated that in some areas identified as having poor access told us they there is still much to be done before had any problem in finding dentists ready to PCTs/LHBs are fulfilling their statutory duty to take on additional Units of Dental Activity meet all reasonable requirements for NHS (UDAs). Several did however comment that dentistry. It is clear from Government statistics the main obstacle to expanding provision was that, whilst the reforms have been effective in financial. Further evidence of this has been arresting the decline in access, there has been recent reports of dentists running out of UDAs no significant growth in NHS dentistry since before the year end, and PCTs being unable to April 2006. The evidence set out in this report provide them with additional resources to indicates that as a result, access to dentistry bridge the gap. remains a postcode lottery. In many areas patients face unacceptably long waiting lists We also recommend that in these areas of and/or long and expensive journeys to reach a poor access, PCTs/LHBs should set local dentist. Patients on low incomes and living in access targets as recommended by the rural areas are therefore particularly Commission for Rural Communities' Rural disadvantaged. Too often patient choice is non Services Standard. No decision should be existent and many people have felt forced to made to end the ring-fencing of the use private dentistry as a result, even when dentistry budget until these access targets they are struggling on low incomes. have been met in all PCTs/LHBs. The responses we received from PCTs in areas of This situation is not surprising since, whilst the poor access indicated that plans were largely reforms brought in new contracts and new being drawn up in terms of their allocated duties, they were not accompanied by budgets rather than on comprehensive additional funding to enable PCTs/LHBs to assessments of local demand. PCTs/LHBs are fulfil these duties to ensure reasonable access. currently facing significant financial pressure Moreover in England no allowance was made and if the ring fencing were ended before for the fact that PCTs were starting from very access problems had been resolved, there is a different levels of provision: in some areas real danger that investment in dentistry would access for new patients was not a significant lose out through competition with other problem, whilst in others it was virtually non- demands, especially where cuts in services are existent. needed to balance budgets. Levels of funding In these areas, PCTs/LHBs should consult with local stakeholders including patient We therefore recommend that the representatives to set local access targets, Government takes the opportunity which must reflect that there is no help with presented by the Comprehensive travel costs to a dentist available through the Spending Review to address this problem. benefits system. An inclusive service must It should end the postcode lottery by therefore ensure that no one is denied access targeting additional ring-fenced resources to an NHS dentist by the difficulty or cost of at those PCTs with historically poor access travel. 19 to NHS dentistry, and making similar funds Gaps to fill We also recommend that the Hospital of the PCT/LHB in helping people find a Travel Costs Scheme should be extended dentist, in assessing and meeting unmet to include help with travel costs to NHS demand, and in monitoring dentists' dentistry appointments until a sustainable compliance with contracts. local service is available for all patients. Without this change, patients on low incomes Improving information provision will continue to be disproportionately It is also clear that many patients are not well disadvantaged in accessing what provision is informed about the best way to find a dentist available. under the new arrangements. In particular, where PCTs/LHBs are operating waiting lists, Assessing demand more needs to be done to advertise this route. This report has indicated a number of areas We therefore recommend that the where the work of PCTs/LHBs needs to be Department of Health and Welsh expanded in order to properly underpin their Assembly Government draw up, in new duties to meet all reasonable consultation with patient organisations, requirements. guidance to PCTs/LHBs on best practice in publicising how people can join waiting Firstly, it is essential that PCTs/LHBs develop lists. more inclusive strategies for monitoring unmet demand. The numbers of people on waiting We also recommend that the Department lists will not fully reflect demand if many of Health should amend the standard text people are unaware of their existence. We on the PCT dental pages of the NHS recommend that PCTs/LHBs are required to website to make it clear that where the undertake full assessments of local website information shows limited access, demand by employing a range of the PCT may be holding a waiting list, and strategies including asking specific that patients wishing to join the waiting questions on access to dentistry in patient list should contact the helpline number surveys. provided. Raising the PCT/LHB profile There is also a need to provide a more joined up service for patients without a dentist who More broadly there is a need to promote the are left with ongoing needs after receiving patient-facing role of the PCT/LHB in relation emergency treatment, and for patients who to dentistry. Many patients will not have had lose access because their dentist ceases NHS direct interaction with their PCT/LHB and, in work. Where patients are left with England, particularly since reconfiguration, underlying problems following emergency there may be no PCT presence in the local treatment, we recommend that PCTs/LHBs community. The National Audit Office has should ensure patients are given raised similar concerns in its recent report and appropriate information and advice on has recommended that PCTs should finding an NHS dentist for routine demonstrate how they have built patients' treatment and if necessary given priority views into the design and delivery of on any waiting list that may be in services.13 We therefore recommend that operation. PCTs/LHBs work with local Patient and Public Involvement Forums, as well as local Where a contracted dentist ceases to provide advice agencies such as Citizens Advice NHS treatment, it is essential that a patient is Bureaux, to encourage patient feedback fully informed about options to continue on dentistry issues and publicise the role 20 receiving NHS treatment. We therefore 13 Improving quality and safety – progress in implementing clinical governance in primary care: lessons for the new Primary Care Trusts, National Audit Office, January 2007 recommend that, where this happens, the local health practitioner, for fear this will have PCT/LHB should have in place an impact on their ongoing care. It would also arrangements to contact all patients on help PCTs with their monitoring role by the dentist's list to provide advice and increasing their sources of information. information including any options for transferring to an alternative NHS Monitoring the PCT/LHB role provider. Finally, we recommend that Strategic Health Authorities, the Healthcare Complaints Commission, the Healthcare Inspectorate We also reiterate the recommendation we Wales, and the Welsh Assembly made in our 2005 report on health Government all include within their complaints14, that, as recommended by monitoring procedures measures to assess the Health Service Ombudsman in 200515, the extent to which PCTs/LHBs are patients in England should have the fulfilling their duties to provide dental option to lodge complaints about primary services to meet all reasonable care providers, such as dentists, directly requirements. We believe that the with their PCT. This option, which already recommendations in this report are some of exists in Wales, would help overcome patients' the indicators which should be used to reluctance to make a complaint about their measure this. 21 14 The pain of complaining, Citizens Advice, 2005 15 Making things better? Health Service Ombudsman, 2005 (HC413) Gaps to fill Appendix – Percentage of NHS dentists accepting charge paying adults by PCT (source – www.nhs.uk November 2006) 22 23 Written by Liz Phelps, Kim Maynard Published by Social Policy Myddelton House 115-123 Pentonville Road London N1 9LZ www.citizensadvice.org.uk Telephone 020 7833 2181 Fax 020 7833 4371 www.citizensadvice.org.uk Registered charity number: 279057
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text: Hi there, this is a beautiful portrait picture ! i take it it has to do with parkinsons disease as it is tagged with it ? Would n't it be nice if there is some explanation underneath the photo's as they are public ? I suffer from the illness but are also an artist , mainly portraits

subset: commoncrawl


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Type: Posts; User: GMackey32; Keyword(s):
If KU fans "didn't care" about the conference tournament this past weekend, then how come they set some land speed records clearing out of the P&L District Saturday night?
I formally petition to rename the "Play-In Game" to the "Fran McCaffery 5 year plan" round.
Dale Doback and Brennan Huff. Package deal.
Why, so we can outnumber them in a different sport in their backyard?
Why are KU fans obsessed with wearing KU basketball jerseys and why are they obsessed with wearing them over long sleeve button up dress shirts?
Thread title is redundant
I saw this thread title and at first I thought it said "Ribs". Hell yeah I want to talk about ribs.
This would be a great contribution to the "Minute Splits" thread that has now turned into a spiderman thread. I'm dead serious.
Dognuts said "we" when referring to ISU? El oh el.
I have a feeling we may see Monte take over some games in the tourney like we haven't seen before from him. Just seems like he's gonna have one of those "breakout tournaments" we see some younger...
There's a rumor that he plans on going pro. Hence why his mom has been following him around the last 2 weeks of the season, watching him play on the road and at home.
Huggy returned nobody outside of Staten and still had WVU right there until the last week of the season. I have no qualms about him getting it.
TaShawn Thomas- 11.1 pts, 6.2 rebs, 1.5 assists, 1.4 blocks
Jameel McKay- 11.3 pts, 7.2 rebs, 0.6 assists, 2.4 blocks
Brannen has a mangina.
We want WV if we want the 2 seed.
I'm currently training for the Lincoln Half in May. Ran it last year. I want to bump up to marathons eventually. My end goal is qualifying for Boston.
I reopened some wounds and went back through our schedule/results from the McDermott era. We lost to Drake 3 straight years, 2 of them in Hilton and the one we lost at the Knapp Center was a 35 point...
If any two of the combination of TCU/KSU/OU/WVU could do us a solid, that'd be great.
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"BABYLON" Recap: Episode 102 (Maze Hill)
During a training exercise, Robbie is reprimanded for failing to "shoot" an armed and dangerous female.
Liz meets ex-boyfriend Granger at a bar and ends up going home to his flat and getting high on cocaine.
Commissioner Miller asks Liz to obtain a retraction from a his favorite newspaper after spotting an article which calls one of his legendary acts of heroism into question –the article suggests that Miller only saved two, rather than three, men from a fire bombing early in his career. Liz agrees without getting details and proposes her new idea: the Metwork, a Metropolitan Police Service news division, which would air both positive and negative police-related stories instead of feeding the information to unpredictable press.


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1 of 43 Items
Atlas 49. Vol. 10, pt. 2, 1909.
Cities & towns -- New York (State) -- Maps
Fire insurance -- New York (State) -- Maps
Real property --New York (State) --Maps
Sanborn Map Company
Early Real Estate Atlases of New York
Stephen A. Schwarzman Building / The Lionel Pincus and Princess Firyal Map Division
All Any
Image ID: 1996055
Insurance maps of the City of New York. Borough of the Bronx. Volume 10. Published by Sanborn Map Co.,11 Broadway, New Y...
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This is a cute home that the seller was remodeling and it has hardwood floors in living room, dining room, hallway and bedrooms. Tiled floors in kitchen and bathroom. Rock fireplace, ceiling fans, dual pane windows, remodeled kitchen, indoor laundry, remodeled bathroom in good condition. 3 bedrooms, 1 bath, approx 1356sq. ft. with central air and heat. Click here to learn more about this listing.
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Need a plan
Ive actually posted on the oklahoma page but would love some opinions from landscape minded people too. I know i cant/wont do everything at once but id like to have a total plan before i start so i dont end up having to undo things ive done.
Also i am i computer person what sites would you recommend using to plan out my space?
In order to make THIS thread viable, you'd need to layout your issues and with pictures here. Switching back and forth to another thread is too cumbersome. It would be good if you list code for all the pictures in a single message. Explain what the pictures show. (For example, I'm not clear why there appears to be 2 houses--one yellow and one blue--on your piece of property. It's not clear where the divide is. I didn't see any straight-on picture of the front of your house which would be the basic one you should show...taken from far back enough that the whole front yard can be seen. It's good to show an additional view, but the straight-one one should be included. Also, if you add a link, use the "Optional Link URL" (available below every message creation window) so that the links are clickable.
Over in your other thread you mention removing a tree because of water and gas lines. But is there a conflict between the tree and lines that has manifested?
Are there functions that occur on your property that you must take into account in a landscape design? (Driveway, patio, etc.) Or are you limiting your quest here to planting design?


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Comment: Re:I hate not being culture (Score 3, Informative) 229
This is one thing I wish the US could import from France. Over there, all radio stations, newspapers, and other places have to have a percentage of their artists be local to that country.
Canada has that sort of system, too, to protect local "culture" from the US marketing behemoth.
When it works, it seems to work pretty well.
The main issue with that sort of system is that it's based on a minimum quantity of local content. Yes, you do get some good local talent which you might not hear about otherwise. Unfortunately, most of the time you just get Nickelback.
I think the majority of Canadians would prefer to just drop the CanCon requirements entirely.


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Steelers RB Parker denies report of torn labrum
Steelers starting running back Willie Parker denied the NFL.com report on Sunday and told ESPN\'s Bob Holtzman no one has told him he has a torn labrum. According to NFL.com, Parker was told this week he has a torn labrum in his shoulder that will require offseason surgery. Parker said the first he heard of the report was when he got a call from his agent Sunday morning. Parker said his body is "beat up" but does not expect to be out for the season and hopes to play next week.
[phpbay]Steelers Willie Parker, 3, "", ""[/phpbay]
← Previous Story Steelers HC Mike Tomlin Colts Post Game Press Conference


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Wedding Fayre at Tewekesbury Park Hotel, Golf and Country Club!
Jack Boskett Photography, based in Tewkesbury, provides high-quality photography for your personal and business needs....
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Ronnie L
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Rage Hair
I wish to leave a testimonial to share my first experience with potentially new & regular clients. I walked into the Salon a couple of days ago to be greeted to a warm welcome from the lovely Brian & the team.... Added October 2014
Susan M
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Halfords Traditional Butchers
Wonderful locally sourced meats. Can always tell you where meat is from.... Added February 2014
Jane R
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Clive Woolford Motor Engineers Ltd
They provide a 5-star service every time with friendly courteous staff. I wouldn't go anywhere else! Added February 2014
The stage is set for local rock and pop bands to wow audiences and raise money for good causes at the Mayor of Tewkesbury Borough's first charity concert....
With a continuing updating portfolio of properties available for rent in Tewkesbury, CGT Lettings should always be your first choice....
A summary of properties to let in Tewkesbury this week from Tewkesbury's best letting agents, CGT Lettings
If you don`t want people to be critical of you, don`t be critical of them. If you do have to give criticism, however, make sure it`s the type that is constructive. There is more than one right way to do things, so try not to be so set in your ways. Once you open yourself up to new possibilities, you`ll wonder why you were so strict about your processes and procedures in the first place. If you find something new that works for you, be sure to write down the details so that you can repeat your success in the future.
Use diplomacy to get what you desire. Of course, you can always take the direct approach, but you can certainly lure more flies with honey than you can with vinegar at the moment. Sometimes the truth hurts more than it should, so there`s nothing wrong with telling a little white lie every now and then, Taurus. Right now, a well-timed compliment can win you the affections of the person you are interested in getting to know better, and a slight exaggeration of the truth can bring a smile to someone`s face who otherwise wouldn`t have much to smile about.
There`s a lot of talk, but very little substance in what people are saying. It`s easy to get sucked into trivial conversations with your neighbors, friends and relatives, but you`re much more interested in pursuing topics that really matter to you. Your attention to detail is great at the moment, which makes it easy for you to remember all the little things that other people tend to forget so easily. So, if you want to get the most out of the interpersonal communication situations you find yourself in, cut the useless chatter to a minimum and focus on what`s truly important.
There may not be a lot going on right now, but this is the perfect time to make plans for the future. They can be big or little, but the important thing is to plan something now so that you`ll have something to look forward to later. If your friends don`t usually follow through with what they say they`re going to do, don`t feel like you have to include them. You can have just as much fun on your own as you can with other people, so don`t hesitate to map out a vacation or a similar exciting event for you to go on or participate in alone.
If things aren`t going according to plan, this might be a good time to step back and reassess your situation. Don`t be too down about setbacks right now, Leo. As long as your mistakes aren`t huge, you should be able to recover form them quite nicely. Of course, it would be ideal to catch your potential mistakes before they actually occur, but hindsight is always better than foresight. You know the drill -- if at first you don`t succeed, try, try again. And who knows, with a little luck, maybe the third time really will be a charm.
Virgo can`t stand to be around anything messy or dirty right now. If the place you live or work in needs some tidying up, it looks like you`re going to have to be the one to do it. Not that you mind, of course. Right now, you`re an expert at any type of projects that require organizational skills, including do-it-yourself projects. You have fun rearranging closets, cupboards or whole rooms full of furniture as well as cleaning bathrooms, washing dishes and doing yard work. As long as something looks better after you`ve finished working on it than before you started, you`re one happy Virgo!
Accept all apologies. Holding grudges will only make you and your loved ones miserable, Libra, so the `forgive and forget` policy is the best one for you to adopt right now. You`re a particularly good at listening right now, which means that you may be used as a sounding board when the people close to you are having problems. Try not to take anything they say too personally, especially if they`re upset while they`re talking to you. Everyone has a habit of saying things they don`t mean in the heat of the moment, but it`s your job to overlook those types of human error.
You`re in a position to do a friend, relative or coworker a favor, and you couldn`t be more glad to do it. Of course you don`t expect much in return, but if you go out of your way in order to help someone out, a simple `thank you` would be nice to hear. Small acts of kindness, like holding the door open for a stranger or helping an elderly woman across the street definitely count toward your good deeds for the day, but you probably have something much bigger in mind. Keep your eyes open for someone who is truly in need of the kindness that you have to offer.
If you`re running, you need to slow down to a walk, and if you`re walking, you need to slow down to a crawl. The pace you`ve set for yourself is much too fast, which could cause you to make a big mistake. Even Archers with tight deadlines to meet can afford to take a break for at least a couple of minutes. Look away from what you`re doing and focus your attention on something trivial for a change. Your perspective has become much too narrow from looking so closely at the same thing day after day, Sagittarius. Once you become willing to take your time, you`ll be able to see some of the wonderful things that have been right under your nose all this time.
Instead of saying that you don`t know, do some research to find out the answer. The facts you need to know can be found in books, on the Internet or by interviewing people you already know, but you have to be willing to make an effort. If you don`t know exactly where to start, ask someone for help. Trying to find out information about something you know nothing about can be overwhelming at first, but once you catch on, you may even have some fun. Be sure to double-check each fact as you learn it, though, Capricorn, so that you don`t misquote any of your sources.
Take care when dealing with anyone whom you don`t completely trust, Aquarius. Yes, it would be nice to be able to give other people the benefit of the doubt, but when the stakes are this high, you`re better off being safe rather than sorry. It`s especially important to be cautious when you`re taking care of business, and even more so if there are large sums of money involved. If you can find a way to put your personal and your financial well-being first in any situation, then you should be able to adequately protect yourself from people who want to do you harm.
You want to analyze all of the facts before you do anything, but time is of the essence. You might find yourself in a position where you have to make a split-second decision at some point during the day, Pisces, and it won`t do you any good to second-guess yourself. Even though you aren`t always comfortable acting in a spontaneous fashion, the fast-paced events of the day call for a quick reaction from you. When all of the choices are laid out before you, choose the first one that makes sense. If you`re lucky, you`ll have time to go over your decision in more depth at a later date.
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Mofos indoors VIDEOS (1565)
How did this guy take a rando tourist girl and talk her into showing her titties in the park? Smooth talk and a couple bucks. Aruna took him home to watch and film her showing off that juicy ass, banging her boyfriend, and taking a fat load!
Public Pick Ups
75 %
61777 views - Feb 22, 2015
What kind of babysitter invites a guy over to have sex while on the clock? This hot amateur Hannah had her mouth full of cock when Chanel walked in the door. Chanel took turns sucking the dick, and gave those young nymphos the fuck of a lifetime.
Busted Babysitters
83 %
55295 views - Feb 21, 2015
Nothing could have prepared this amateur teen Daisy for the night she had when the swinger couple came home early. They spied on Daisy in the shower and then that Milf invited her to join them for a nasty threesome while Julia's man filmed it all! ...
Busted Babysitters
95 %
75760 views - Feb 21, 2015
When Ashley and her husband came home and found her babysitter taking naked selfies with a friend, she was pissed! But when she found Kimber was having guy troubles and just needed a good fuck, she brought her straight to bed with her husband!
Busted Babysitters
96 %
118010 views - Feb 21, 2015
When they got home early Anikka caught the babysitter webcamming a private show for her fans. She took pity on the poor desperate girl, and showed her how to work her body to make real money, and then she and her husband tapped that amateur teen ass....
Busted Babysitters
95 %
120376 views - Feb 21, 2015
When India and her man came home from their date, they found the babysitter doing a private striptease for her boyfriend in their bedroom. Once they chased the guy out, India showed Aidra how to work her hot teen body and how to fuck like a pro!
Busted Babysitters
97 %
101891 views - Feb 21, 2015
When you get two slutty BFF's like Valentina Vega and Natalia Mendez together, it's only a matter of time before one of them gets their tits out. They got the party started with a little dick sucking, then took cocks deep in their amateur pussies!
Real Slut Party
86 %
41108 views - Feb 20, 2015
Drone Hunter was on the scene with a fresh biddy, nailing her POV porn style, and he needed another set of eyes while he pounded that sweet pussy. The Drone arrived in no time, filming Rachel's big boobs and ass while they fucked in the open air!
Drone Hunter
63 %
34335 views - Feb 19, 2015
When the GF of the anon who submitted this amateur clip suggested they try anal, he raced home to fuck that ass! This horny chick Samantha described everything she wanted him to do, then let dude slip in some fingers, and build up to his entire cock!...
Lets Try Anal
84 %
55964 views - Feb 18, 2015
However this genius managed to twist pranking his girlfriend into filming a their own sex tape. Once Kaylee caught the joke, she started teasing him with peeks at her perfect tits. Then she gave him a deepthroat blowjob on camera, and fucked him too!
I Know That Girl
92 %
76495 views - Feb 16, 2015
Sometimes Euro babes do all the work seducing our camera-guy buddy. Amarna was so desperate for cash, she was willing to do whatever he suggested, including showing her perfect breasts on the street, and going back to his apartment to fuck!
Public Pick Ups
86 %
75836 views - Feb 15, 2015
Any day at the beach would be a raunchy good time with a horny nympho like Ruby Knox. With the camera rolling, Ruby pounced and sucked down her man's rod like the dick-starved amateur babe she is! Then she bounced her big perfect booty on that shaft!
Mofos B Sides
82 %
33688 views - Feb 14, 2015
Doesn't matter whether Carrie set out to make a private sex tape and tease just her BF with peeks at her bubble butt, or a homemade porn to show off all over the net! This babe sucked cock like a champ, got fucked hard, and then took a big facial.
Latina Sex Tapes
92 %
56537 views - Feb 13, 2015
All her BF cares about is his video games, so Eva Lovia decided to fuck a real man instead! After teasing the camera with her perfect tits and that ripe ass, Eva locked the loser outside to have a nasty romp with a step-father who knows how to fuck!
Pervs On Patrol
95 %
92291 views - Feb 12, 2015
To have a little fun, Rachael and her man decided to prank the pizza delivery guy. Rachael got a free pizza letting him squeeze up on her juicy thick ass, and being bad got her so horny she decided to let her man pound her tight virgin asshole!
87 %
61057 views - Feb 11, 2015


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New Study Shows Dramatic Revenue Potential from a Wall Street Tax
A robust tax on Wall Street transactions would raise far more revenue – as much as 17 times as much – than more limited proposals, even accounting for the worst case scenarios of reduced trading as a result of a tax. That's the findings of an important new research brief from prominent University of Massachusetts Amherst economists Robert Pollin and James Heintz. —NNU Press Release, 01/09/12 More »