EXECUTIVE SUMMARY

  1.1  Members of the southern group of the Oxfordshire PCT Patient & Public Involvement Forum undertook two independent surveys in October 2007 in order to assess the situation for patients, public and dentists in Oxfordshire.

  1.2  The evidence provided for the Select Committee in this report supplements that contained in the National Dentistry Watch Survey Report from the Commission for Patient and Public Involvement in Health but reflects locally expressed views only.

  1.3  The report highlights the serious concerns articulated by Dentists and the public in Oxfordshire on the adverse effects of the reforms on the dental health of many people. Dentists are particularly angry about the Units of Dental Activity (UDA) banding system that acts as a disincentive to patient needs-based treatment in some cases, and frequently fails to cover real costs.

  Members of the public are primarily concerned about restricted patient access to NHS dental services and the inability of some people to find an NHS dentist at all. People are angry about the high cost of both NHS and private dentistry, particularly people in lower income groups.

  On behalf of patients and public, members of Oxfordshire PCT Patient & Public involvement Forum are particularly concerned about the discriminatory effect the reforms have had on access to dental treatment for persons with low incomes and those with high dental needs.

  1.4  The report also notes the high number of dental practices providing NHS care, albeit frequently combined with private practice, and the high levels of satisfaction expressed by NHS patients about the treatment they receive.

2.  IMPACT OF THE REFORMS: EVIDENCE FROM SURVEY OF OXFORDSHIRE DENTISTS

  The Forum found that 94% of responding dental practices offer both NHS and Private treatment.

  However, 59% of responding dentists believe that the quality of NHS dental care has been compromised by the reforms, and 73% believe that it is inferior to dental care provided in private practices.

2.1  Impact of the reforms on NHS dental service provision in Oxfordshire

  73% of responding dentists indicated they have serious concerns related to the Contract, and none feel satisfied with it.

  Issues raised include difficulty in maintaining standards of treatment, the loss of clinical freedom to address individual needs, the unhelpful nature of restrictions placed on the numbers of patients that can be accepted and the shortfall in remuneration received for the use of high quality materials as indicated by patient need, all of which are seen as disadvantageous for patients. Patient need is seen as secondary to meeting targets imposed by the system.

  For some dentists, full NHS provision has become financially unviable, with financial survival forcing a change either to part time or full private provision. Only a very few dentists take an altruistic approach, indicating that they view discriminatory treatment provision as unacceptable, and therefore choose to provide equal quality of care for both NHS and private patients through supplementing the shortfall through their private practice income.

  A number of dentists see private practice as the only way to enable them to update equipment and materials used.

2.2  Impact on NHS service provision of the Units of Dental Activity (UDA) banding system

  Dentists made many adverse observations about the UDA system. Pressure is placed on dentists to reach their UDA target; this is likely in many cases to result in the quality of treatment being offered to be reduced.

  The UDA system is seen to encourage a "treadmill" target-driven service. The treatment bands penalise dentists prepared to take on patients with high dental needs. Dentists are effectively penalised for taking on patients with a history of poor oral health on the NHS as these patients cause dentists to miss their UDA targets.Some practices are restricting treatment based on UDA values such as crowns and bridges.

  Complex treatment on the NHS attracts the same UDA value as some quick simple treatments. One example given of this financial disincentive is the situation where remuneration for providing twenty fillings to an individual within a single course of treatment is the same as if providing one filling only. Thus, in some practices, treatment is now being staged, ie necessary treatment delayed, to make it financially viable for the dentist.

  A further point raised concerns the lack of continuity in the contract arrangements after 2009 which compromises the ability of dental practices to plan future services.

2.3  Impact of the reforms on the ability to provide quality care to patients

  Dentists expressed a number of concerns relating to the quality of care they are able to provide under the current Contract.

  Some dentists are finding it more difficult to provide adequate NHS dental care. It appears that high quality treatment is not valued as the Reforms make it more difficult for dentists to give adequate care through imposed financial disincentives.

  Dentists cannot afford to provide high quality materials and laboratory work where needed for NHS patients, unless they subsidise their NHS work with private work.

  Some dentists no longer accept new child patients due to impossibility of maintaining standards of prevention, conservation and laboratory work. These issues potentially pose more adverse outcomes for patients.

  The ability to upgrade equipment and materials is also compromised by the reforms. Equipment and material upgrades are commonly entirely dependent on the ability to subsidise from private practice incomes.

  Concerns are also being expressed about the potential adverse impact of the reforms on some people's general health through reduction in ability to access dental treatment and preventative initiatives.

2.4  Negative incentives for dentists arising from the Reforms

  The reforms are seen to provide an incentive for dentists to provide the cheapest, shortest treatment rather than the most appropriate, with a potentially negative impact on patient care. For example, the current system encourages tooth extraction rather than restoration/root canal treatment and provision of spoon dentures rather than bridges.

  The system also makes dentists unwilling to register patients with poor oral history as limits on UDAs available to the dentist, and the UDA banding structure does not encourage the care of patients at high caries risk and/or with multiple treatment needs. In some cases, fillings are being postponed for 6 months in order to gain remuneration that better covers the costs.

  Dentists believe that the system may discourage some patients from seeking a regular check-up.

  The impact of the reforms on children's dental health is a major concern. Inevitably, children who require a lot of treatment are less likely to be accepted by dentists, who will effectively be out of pocket if they treat them properly. This is especially true of children with high decay rates and children requiring root canal therapy as the 3 UDAs allowed for either 1 restoration or 15 means these patients pose a disproportionate drain on limited resources.

2.5  Impact of the reforms on Patients' access to NHS dental care

  All responding practices tried to offer appointments at times which were convenient to patients (including early, late, or Saturday morning). 83% provide a practice leaflet to keep patients informed.

  Dentists are aware of patients complaining that there are very few NHS dentists who accept new patients. Dentists are also concerned that patients with high treatment needs may have difficult finding a dentist willing to do multiple items of treatment.

  Concerns were expressed that some practices have been given much larger contracts than they can treat well but many continue registering patients and not providing regular care. But some practices are severely restricted in the number of patients they are able to treat under the contract; in some cases their contract is too small to deal with the demand for NHS services.

  It was also suggested that waiting lists are growing due to increase in demand/need but there is no commensurate growth in NHS provision.

2.6  Impact of the reforms on provision of preventative care and advice

  Some dentists said they no longer accept new child patients due to impossibility of maintaining standards of prevention. The reforms give little time or incentive for preventive work or dental health education for children. One dentist who would ideally like to spend more time with children to educate them in regard to their oral health said that they do not have any extra time to set aside to achieve this.

  Whilst hygienist services are recognised by the profession to be an important preventative measure, under the reforms these are being denied to people on low incomes who cannot afford to access them now.

2.7  Impact of the reforms on specialist service provision

  The reforms disallow growth potential in delivery of NHS specialist services.

  Orthodontics is an area of real concern in terms of reduced access and long waiting times. The reforms are seen to effectively operate a rationing system.

2.8  Impact of the reforms on Dentists' workloads

  While over two thirds of dentists surveyed say they have a reasonable workload, others consider their workload to be excessive in terms of "endless waiting lists and huge pressures", "a paperwork mountains that fills every lunch break and some evenings", "pressure to achieve UDA targets" and "having no tea break, no lunch break, starting at 8 in the morning and not getting home until after 6. Paperwork requires working on at weekends".

  One dentist points out that they "are a dental surgeon and this is what they do best".

2.9  Impact of the reforms on private dental service provision in Oxfordshire

  The majority (94%) of responding dentists provide combined NHS and private services and many have been forced to take up private work to maintain the viability of their practices.

2.10  Finally

  It is clear that only a minority of dental practitioners are able to make the current system work to their advantage but it is questionable whether all patients receive an adequate deal in these circumstances. Securing an acceptable level of income (over and above practice overheads) requires an unacceptably swift throughput of patients. This inevitably compromises the dentist's ability to accept those who have complicated dental needs. Current policy is likely to favour shorter rather than longer treatments and is potentially open to abuse. Those on very low incomes who do not qualify for exemption are doubly disadvantaged by the introduction of the new contract. Even when they secure access to an NHS dentist, the costs of some treatments are prohibitive for those not exempt and at the least anomalous for others. Private care is not an option for many, and some people are either going without dental care altogether, or declining elements of treatment needed because of cost. The dental health of children may now be satisfactory, but will not remain so unless a better service at a more attainable cost can be introduced.

3.  EVIDENCE FROM MEMBERS OF THE PUBLIC

3.1  Patient access to NHS dental care

  31% of the 384 people surveyed by the Forum were current NHS patients, 54% were private patients and 14% not registered with any dentist. 3% of NHS patients have to travel over 100 miles to see a NHS dentist.

  Amongst the private patients, almost half have been unable to register with an NHS dentist although they wish to do so, and many of these people find the cost of private dentistry excessive in relation to their means.

  Some private dentists continue to treat the children of private patients on the NHS, and with the lack of NHS places available, this locks parents into the private system in order that their children can receive dental care.

  Finding an NHS dentist in Oxfordshire is a major issue for many people. The procedure for finding an NHS dentist is complex and fraught with misinformation. Many people follow this tortuous path only to fail.

  People with high treatment needs are uniquely disadvantaged; even if they can afford to use an NHS dentist they are not welcome as their treatment uses too many units of dental activity which both disadvantages other patients and leaves dentists out of pocket. This also applies to same-day access to emergency treatment where units of dental activity are confined to a daily quota that cannot be exceeded.

  Some patients entitled to free treatment during pregnancy are having to pay for dental treatment due to lack of NHS places.

  7% of respondents have had to resort to self-treatment at some point.

3.2  Quality of care provided to patients in Oxfordshire

  Although a few members of the public did identify some quality issues relating to NHS dental treatment they had received, 90% of patients receiving NHS dental care in Oxfordshire say they are happy with the treatment they receive. The shortage of NHS places remains a key issue in Oxfordshire.

4.  CONCLUSION

    This Forum believes that the Reforms were introduced with insufficient consultation with patients" groups, insufficient regard to the principles of good dental practice, insufficient consideration of ethical principles and public health interests. Insufficient consideration is also evident of the impact of the Reforms on children, people on low incomes and other disadvantaged groups. The inadequacies and anomalies of the UDA system have resulted in sub-standard dental health provision for many people in Oxfordshire. A more effective contracting system is required that addresses some of the adverse impacts of the current Contract on patients and public in terms of preventive measures and quality and availability of treatment including rationalisation of payments to dentists. The aim should be to promote high levels of both dental and general health in the whole population.

  There is a huge swell of public anger reacting to this lack of availability of NHS dental services, and indeed a concern that the current NHS contract discriminates against the dental needs of those who are on low incomes and those with high dental needs. Many dental practitioners are also angry and disillusioned with the reforms.

  The procedure to find an NHS dentist who will agree to take patients is seen to be so complex and so dependent of the state of a potential patient's mouth and teeth, that the system discriminates against older and less advantaged people who may not have the means, the energy or the determination to find out how to proceed.

  Within such a utilitarian system where individual patient need is secondary to the needs of all patients on a dentist's caseload, inevitably the reforms in their current configuration place many individuals at higher risk of both oral and general health problems. Also, with the associated reduction in dental health promotion activity and reduced access to preventative treatments, Forum members are concerned for the future dental health of those least able to access dental services if further reform of the current system is not enacted.

5.  RECOMMENDATIONS FOR ACTION

  Members of the Oxfordshire PCT Patient & Public Involvement Forum recommend that the Committee agrees the following areas for action:

To revise and update the present dental contractual arrangements to allow:

—  A more patient-focused, rather than cost focussed philosophy within existing funding constraints.

—  A system where extra funding can be accessed in cases of high dental need.

—  Better and easier access to NHS dentistry for all who wish to use it.

—  More flexibility within contracts to enable dentists to use their clinical judgement in cases where individual needs may vary.

—  Better and swifter access to orthodontic treatment for children.

—  A higher level of dental health promotion activity, both individually and in the wider public arena.

—  A root and branch review of the current UDA system that takes realistic account of practice overheads and allows more flexibility in choice of treatments and materials.

—  A more flexible charging system for patients that more closely reflects the value of dental treatments received.

  Copies of the Oxfordshire PCT Patient & Public Involvement Forum's full reports on their Dentist and Public Surveys are available on request from the Forum.

Marion Judd (member)

Oxfordshire PCT Patient & Public Involvement Forum

December 2007