EXECUTIVE SUMMARY

  1.  This submission, produced by CHALLENGE argues that while many of the principles underlying the reform of NHS dental services were to be welcomed, the manner of their introduction has been seriously flawed. In particular, key areas of the reforms have been introduced without the necessary preparatory work and forward planning.

  In consequence, the new arrangements have failed to provide many of the important benefits that the DoH wished to achieve: there are growing inequities in access to care; the quality assurance mechanisms are woeful, and there are few, if any data to answer the specific questions that the Health Committee wishes to investigate. Furthermore, as numerous external agencies have highlighted, considerable risks remain.

  The PCTs are, in the majority, ill equipped to handle local commissioning of NHS dentistry largely due to the lack of data on which to base any commissioning decisions, growing inequalities in care arrangements, a lack of quality assurance arrangements, and a growing likelihood of unemployment for expensively trained dental personnel.

  We conclude our submission by offering our ideas on a positive way forward to try to resolve the many difficult issues facing the parties involved. In order to help those with limited time to spare our conclusions are outlined in the next part of this paper.

PROPOSALS

  2.  CHALLENGE would argue that reforms to the previous NHS dental service were required and, providing sensible proposals with an open dialogue are introduced, a new arrangement could work with the support and good will of all sides.

  3.  The attitude of all parties needs to be moderated. The increasingly personal fighting that has been raging for the last 20 months must cease and a semblance of peace must be restored if progress is to be made. The Health Committee might wish to promote a new working relationship between the Department of Health and the dental profession. That relationship is, according to many commentators, irretrievably damaged. For the good of the population's oral health that situation cannot be accepted, efforts must be made to rebuild it.

  4.  The present arrangements have led to a polarisation of the parties. The factions should meet in public and discuss their problems afresh but based on a clear understanding of what is to be achieved. If the dental profession can be convinced that real improvement is the goal this move could herald real progress.

  5.  The NHS must once again be seen as a "a good employer" or "a trustworthy contracting partner" if the downward spiral of NHS dentistry is to be reversed. This may require some acknowledgement of past errors and a new policy direction.

  6.  PCTs need staff who will be capable of commissioning dental services in an appropriate manner. The current programme of training and education is weak and the low priority given to dentistry by PCTs means that few staff have remained in position for sufficient time in order to develop a working relationship with the dental providers.

  7.  The payment system needs to be completely overhauled. The work undertaken in Personal Dental Services (PDS) pilot sites from 1998-2005 needs to be revisited and the perceived failures ironed out. The PDS contracting model came from an earlier report "Options for Change" that was widely supported by the profession. Going back to that model and that report would be seen as a very positive step.

  8.  The new contracts were introduced with many legal features that favoured the PCT to the detriment of dentists working under NHS regulations, those issues need to be addressed sensibly and modifications agreed.

  9.  The issue of patients' charges need to be re-examined. Cost remains the biggest single barrier to accessing care. Alternative mechanisms for raising revenue to fund dental care should be explored.

  10.  New funding arrangements that make best use of allied professionals easier in general practice, especially where dentists are difficult to recruit, should be created.

An introduction to CHALLENGE

  11.  CHALLENGE is a dental political pressure group (formed in October 2006) seeking to persuade the Department of Health to alter the way that NHS dentistry works. Our members do not believe that NHS dentistry is working for patients and it is certainly not supporting the many thousands of dentists who would still like to work for the NHS.

  The three founder members of CHALLENGE are:

Eddie Crouch, Secretary of Birmingham Local Dental Committee, Chairman of the Annual Conference of Local Dental Committees 2008 and an orthodontic practitioner in Birmingham.

John Renshaw, former Chairman of the British Dental Association (2000-06) and general dental practitioner in Scarborough.

Ian Gordon, Chairman of Tees Local Dental Committee and a general dental practitioner in Teesside.

  We have sought help in the writing of this response paper from Paul Batchelor, Consultant in Dental Public Health and University Lecturer.

Background to this enquiry

  12.  The current contracting arrangement for the provision of NHS dentistry has been in place for 20 months but it is still causing severe problems. In many places patients are unable to gain access to NHS care and dentists are still leaving the NHS for the private sector. The situation has been investigated many times recently by several important bodies.

  13.  The Prime Minister (Tony Blair) in 1999 stated in a Party Conference speech that he would make sure anyone who wanted to could see an NHS dentist. The Health Committee itself, under then Chairman, David Hinchliffe, looked into access to NHS dentistry in 2001, the Audit Commission looked at NHS dentistry in 2002, the Office of Fair Trading looked at private dentistry in 2003 and the National Audit Office looked at NHS dentistry in 2004. Following the external assessments, new contracts were introduced supposedly to support dentists providing NHS dentistry. However, the problems have not been solved; there have been patient focused reports on NHS dentistry from the Citizen's Advice Bureau, the Consumers' Association and the Patients' Association.

COMMENTS ON THE HEALTH COMMITTEE'S INQUIRY

  14.  CHALLENGE welcomes the opportunity to submit evidence to the Health Committee and to comment on the principles underlying the reforms of dental services that were introduced in April 2006 and in particular the extent to which the changes have been consistent with the principles.

  15.  The benefits for patients outlined by the Chief Dental Officer at the time were:

—  to improve access to NHS dentistry;

—  to improve oral health; and

—  to reform and improve NHS dental services.

  16.  To achieve this, the Department of Health proposed to introduce new working arrangements and ensure a fair deal for dentists and their teams. The benefits for the dental team included:

—  more time to be spent with patients;

—  more time to allow improved quality;

—  less bureaucracy; less work pressure;

—  the ability to plan and invest in their businesses;

—  integration with the NHS National Programme for IT; and

—  a chance to modernise premises with the help of the NHS.

  17.  Using these objectives, our submission will address the nine key points in turn that the Committee wishes to explore. In addition, CHALLENGE will also comment on the future issues that will need to be addressed if the overall objective of a fair and equitable NHS dental care system is to operate within England.

COMMENTS ON THE NINE KEY ISSUES OUTLINED IN THE HEALTH COMMITTEE'S TERMS OF REFERENCE FOR THIS INQUIRY

The role of Primary Care Trusts in commissioning dental services

  18.  Low staff numbers, inexperience and high rates of turnover amongst PCT personnel have to date produced widely variable success in managing NHS dental services. There is clear evidence to show that relinquished contracts are not being rapidly re-commissioned and important commissioning decisions have been influenced by internal PCT budget considerations. There is a lack of transparency within PCTs to allow an assessment of dental expenditure, or indeed on commissioning arrangements. Bureaucratic processes vary widely, even in similar localities, with a postcode lottery affecting policy and service delivery. There is suspicion of favouritism and a lack of openness in commissioning procedures, "preferred providers" receiving favourable treatment, with the winning factor often declared to be "value for money" but the criteria used being obscure and, in particular, the patients' voice is absent.

Numbers of NHS dentists and the number of patients registered

  19.  While the number of NHS contracted dentists has risen, as has been highlighted in other reports, this does not necessarily equate to overall increased capacity. There is a lack of accurate and sophisticated data on the whole time equivalent (wte) workforce. In reality, the NHS has no idea how many dentists actually work in the service.

  Patients no longer "register" with an NHS dentist. The new contracts abolished registration. Many patients find this a real mystery. They still value and regard "registration" as a most important feature of NHS dentistry.

  The new measure of patient activity is the number of patients who have been seen in the last 24 months. Given that the new arrangements have only been in place for 20 months that data are invalid. What data do exist highlight a considerable growth in the non-NHS sector suggesting increased inequalities.

Numbers of private sector dentists and the number of patient registered with them

  20.  Estimates vary and no data are held centrally but survey work undertaken by CHALLENGE suggests that there may be as many as 2,000 wholly private practitioners in England and they, along with the many thousands of practitioners who provide a mixture of NHS and private treatment, may be providing privately funded care for as many as 7.5 million patients.

The work of allied professions

  21.  Allied professionals may be able to make a contribution under the new arrangements but currently the numbers of such trained professionals are relatively small. We would wish to split the allied professions into two categories: clinical operators and non-clinical operators. For the clinical operators, namely dental hygienists (4,000) and therapists (400 qualified in 2006), due to their small numbers and the current structure of dental premises, the opportunities for benefits through their increased adoption are limited. Furthermore, the only major review of the cost-effectiveness of their employment showed few if any financial benefits. The other allied professionals, especially dental nurses, are crucial to the efficient and effective running of dental practices. However we would wish to draw to the attention of the Committee that, due to the General Dental Council's new registration requirements for dental nurses, there is a growing risk that many practices will be unable to comply fully with the necessary requirements and may even have to cease delivering care in July 2008. Currently less than 8,000 of the notional total of 40,000 dental nurses are registered and therefore compliant.

Patients' access to NHS dental care

  22.  We wish to break this issue into two separate questions. First, can a patient find an NHS dentist willing to take them on when he or she wants one and, second, if an NHS dentist can be found, will that dentist be willing or able to provide the kind of treatment the patient needs?

  The answer to the first question is that NHS access remains patchy. If you live in Bradford or Teesside you will probably find access fairly easy. If you live in Epsom or Winchester you will not be so fortunate. This is yet another NHS postcode lottery. In some areas, like Birmingham, where access was never a problem under the old system, there have been signs of an access problem for the first time.

  The second, new and additional access problem—the availability of appropriate forms of treatment through NHS arrangements—is a direct result of the introduction of the new contracts in April 2006. There is growing evidence of a substantial alteration in prescribing patterns within the NHS. The pattern of the changes would suggest that patients are getting inferior care with less and less advanced work being carried out.

The quality of care provided to patients within the NHS

  23.  The present arrangements have completely removed the most cost-effective quality assurance mechanism that existed anywhere in the world. NHS dental contracts are now monitored solely by counting Units of Dental Activity (UDAs) with no capacity for the quality of the treatment to be assessed or rewarded. The Department of Health wanted simpler courses of treatment, but there is no evidence to suggest that simpler treatment is the kind of service patients need or want. No part of the new contract allows additional rewards for dentists who provide quality care with quality treatment planning appropriate to patient needs.

The extent to which dentist are encouraged to provide preventive care and advice

  24.  The new dental contract includes preventive care within band 1 of the UDA linked payment system. This band encompasses examination, basic scaling and any appropriate diagnostic tests such as radiographs, so there is no additional reward for preventive care. The contract was introduced with an alleged 5% reduction in treatment targets (UDAs) to allow dentists more time with patients and to provide more preventive care. In reality, inflated output targets and inaccurate conversion of previous treatment patterns into UDAs have not reduced dentists' workloads at all and prevention is not being supported. Many practitioners are finding that their output targets are not being reached, some 47% having fallen short in the 1st year.

Dentists' workload and incomes

  25.  The evidence on dentists' workload has been badly damaged by the new contracts. We no longer know how much work is being done by NHS dentists although the numbers of patients accessing care remains roughly the same. Anecdotally, dentists claim they are doing more NHS work than ever to meet their imposed UDA targets but it is impossible to find a way to verify these claims. Evidence recently brought to light from DoH data shows that 47% of NHS dentists failed to reach even their 96% minimum output target for the year 2006-07. This would indicate—as has often been alleged—that UDA targets were deliberately calculated higher than was sensible prior to the new contracts coming into force.

  Dentists' incomes are equally difficult to establish. Data published recently shows good income figures but the sample is narrow and badly skewed, reflecting the earnings of single-handed practice owners whose incomes may be derived from a variety of sources. This is a very strange sample to use and it has been criticised previously. Extrapolation from this data across the whole profession is very dangerous in statistical terms.

  The closing down of the old system and the introduction of a new system has created a bubble of practice turnover but this will not be repeated as contract values and UDA values come under pressure and expenses rise.

The recruitment and retention of NHS dental practitioners

  26.  Recruitment of dentists to the NHS is now limited by national and local fixed budgets. PCTs find themselves with too little cash and too many demands on it. New recruits to the service have to go cap in hand and bid for a share of a limited pot. Once dentists do enter the NHS they find the work unrewarding in professional terms with the emphasis on the simplest form of treatment that will cost the least to put the patient's immediate problems right. This is bad news for someone coming into the profession to exercise their newly acquired skills to the best advantage for the population. Opportunities for long term professional development are severely limited within the NHS.

CONCLUSIONS

  27.  The new arrangements for NHS dentistry have failed to improve the service to patients. The reasons for that are simple for all to see. Contract managers working within PCTs do not have the time, the ability or the capacity to make the most of the opportunities that the new contracts offer.

  Dentists have been forced into new contractual arrangements they would never have agreed to if they had been given any real choice, they have been forced to reduce the quality of the service they offer, to work harder than ever and to accept poorer working conditions. Many of them find the lure of the private sector to be very powerful. They can find there the freedom of professional expression and the ability to provide a wide range of modern treatments simply denied to them and their patients within the NHS.

  This combination of weak NHS management, disillusioned and disheartened professional staff and inflexible working arrangements is a massive disincentive for all the parties involved. As always in situations like this, it is the patients who are caught in the cross fire and they find themselves on the receiving end of a poorer service that is patchy at best and comes to them at greater cost than before.

  The only party that seems to see nothing but good in the current situation is the Department of Health and their judgment is highly questionable.

John Renshaw BChD MFGDP FDSRCS

December 2007

REFERENCES

NHS Dentistry: Options for Change, Department of Health, August 2002, London

NHS Dentistry: Delivering Change, Report by the Chief Dental Officer (England) July 2004. DoH: London