1.  Summary

  1.1  The London Regional Group of LDCs agrees with the London Assembly's findings that "only half of Londoners regularly visit an NHS dentist, meaning that oral disease and decay are common".

  1.2  The LRG also agrees with the London Assembly that "much more work is needed to ensure Londoners are well-informed and able to access dental care that meets their needs".

  1.3  The LRG agrees with the London Assembly that "Low uptake of dental care is an important public health issue for London, as people who do not attend a dentist regularly are more likely to have untreated dental problems and disease, which can impact on other aspects of their health."

  1.4  The LRG agrees with the London Assembly that "The reforms have introduced measures that could actually reduce access to NHS dentistry" and "Some dentists . . ..because no new money was available . . . . . . had to close their doors to NHS patients . . ..."

  1.5  The LRG agrees with the London Assembly that "in future, the Department of Health should base PCTs' funding allocations on local needs assessments, rather than historical provision".

  1.6  The LRG maintains that to improve quality dental services for Londoners, it is essential to address the limiting factors listed in this paper. Dentists feel that when they raise these issues "nobody is listening".

2.  Who we are

  The London Regional Group of Local Dental Committees includes representation from Local Dental Committees throughout the whole of London, ie the NHS London Strategic Health Authority area. Each Local Dental Committee represents the dentists in their respective Borough.

3.  Low morale of dentists

  Local Dental Committee representatives throughout London hear constantly and consistently that dentists are demotivated and disheartened by the new dental contract.

  They feel that the new contract was imposed with no meaningful consultation. The "Units of Dental Activity" scheme was not piloted.

4.  Uncomfortable pressure to perform Units of Dental Activity

  We hear every day comments from dentists such as "I used to enjoy my job, but now when I arrive at work I feel under pressure to carry out the requisite number of Units of Dental Activity and I feel this distracts me from concentrating on looking after my patients and doing what is best for them."

5.  Threat of money being "clawed back"

  Dentists call us in distress because their PCT insists on part of their earnings from the past year being repaid to the PCT, if they have not carried out the requisite number of fillings and other treatments. It was never explained to dentists prior to the introduction of the new contract that the relationship between their earnings and their dental interventions would be so strictly linked.

  We are aware of many examples of dentists falling short of their UDA (units of dental activity) targets through no fault of their own (eg changing patterns of patient attendance) yet the PCTs have no sympathy for such circumstances. This creates a demotivating and depressing culture for dentists.

6.  Dentists who are able to walk away from the NHS are doing so

  We have many examples of this. There are young recently qualified dentists who have decided to change career because of the new contracts; some dentists nearing retirement have chosen to retire early because of it, and some have decided to reduce their time in NHS dentistry because they have become disillusioned.

7.  Dentists are feeling overwhelmed by the extent and duplication of "monitoring" of their professional lives

  PCTs are sending ever increasing numbers of compulsory questionnaires, systems of monitoring quality and quantity of dental work, statistical record-keeping, and audits etc. Whilst most of these are not unreasonable in themselves, the cumulative effect becomes too heavy a burden on dentists, and often requires them to spend their evenings and weekends completing paper work, which is a further demotivating factor.

8.  Additional regulatory responsibilities are not resourced

  Dentists are supportive of high standards of infection control, radiation protection, control of substances hazardous to health, etc. However when more onerous requirements are imposed, the increased cost represents an effective decrease in dentists' earnings, unless properly resourced. For example, the latest infection control requirements necessitate the purchase of additional equipment, and longer times spent by staff that is not recognised by Units of Dental Activity.

  These additional costs represent a pressure on dentist's personal income.

9.  Primary Care Trusts wish dentists to treat more patients for the same money

  We are aware of situations where dentists have withdrawn from working within the NHS, and where PCTs have recommissioned the resultant shortfall in activity at a much lower cost.

  Whilst we recognise PCTs have an obligation to achieve value for money, this is often emphasised above the need for high quality patient care.

10.  The new contract's intention to "improve the working lives of dentists" has not figured highly in PCTs' thinking

  We are not aware of many, or any dentists who feel that the new contracts have improved their working lives, despite this being one of its stated intentions.

11.  Preventative dental work not recognised by the new contract

  The incentive within the new dental contract is to achieve the correct number of Units of Dental Activity, which do not emphasise preventative work, nor oral health education, nor general health improvement. Whilst dentists embrace a preventative approach, this is not recognised in their contracts. The London Regional Group of LDCs agrees with the London Assembly in concluding that "The Department of Health should look at including preventive care in the way PCTs manage and monitor dental contracts and consider whether dentists should be financially rewarded for providing preventive advice."

12.  Restrictions on dental activity

  The Regional Group of LDCs is concerned to read in the London Assembly's report that 205,000 adults in the capital may never visit a dentist.

  Whilst only 51% of Londoners went to an NHS dentist in the two years to March 2007, dentists are consistently being told by their PCTs that there is no scope for growth, and practices with imaginative ideas to increase access are being actively discouraged from implementing them, as PCTs wish to contain dental activity within the limits of the year before last.

  Dentists who carry out dental activity in excess of their allocated target are not being funded for this.

  Some PCTs (notably Bexley) used funding intended for Access Quality and Choice in dentistry for other purposes, without public consultation. The Secretary of State for Health and the Department of Health were asked to intervene but refused.

  The London Regional Group of LDCs agrees with the London Assembly in its conclusion that "The Department of Health should base PCT's dental funding allocations on what local people need, rather than basing it on what has been provided in that area in the past".

13.  Dentists are being pressurised by PCTs not to prioritise the most needy patients

  Children and adults who are exempt from NHS charges are among the most in need of dental help.

  Yet PCTs require dentists to ensure that a certain proportion of the patients they treat are sufficiently well off to pay for their own NHS treatment, in order to maintain the PCT's financial balance. We know of dentists who have been told that unless they see a higher proportion of paying NHS patients, they will have their contract capacity curtailed. This attitude tends to increase rather than reduce socio-economic inequalities.

14.  UDA targets are being imposed too rigidly

  Dentists find it almost impossible to ensure that they achieve exactly the required number of fillings and other interventions over a 12-month period. We maintain that providing dentists achieve within 10% of this target, they should be allowed to address the under or over achievement during the following year. But this is not happening.

15.  Dentists are being financially disadvantaged by patients who fail to attend appointments

  Prior to the introduction of the new contracts, dentists were allowed to make a small charge to patients who failed to keep appointments. This was an excellent incentive to remind patients of their appointments, and avoided them having to be "struck off" for non-attendance. Since the new contract dentists have been prevented from carrying out such incentive programmes, and as a result many appointments are unused, which in turn affects the achievement of UDAs, and can lead to financial penalties to dentists. We maintain that it is often the patients from the most deprived backgrounds who find it hardest to remember appointments, and dentists should not be disallowed from running an incentive scheme to discourage "Did not Attends".

16.  Dentists are out of work because of the financial limitations on NHS dentistry in London

  For example, when dentists finish their vocational training, there are no NHS dental jobs for them.

Dr Henrik Overgaard-Nielsen

December 2007