1.  EXECUTIVE SUMMARY

—  The reforms to the dental contract have created opportunities that should have positive benefits for the service, patients and dentists alike, through improved access to NHS dentistry, reduction of health inequalities and promotion of a more evidence based, preventative approach to dental care.

—  The success of these reforms relies on meeting the oral health needs of the local population alongside partnerships with dental service providers including dentists and other dental professionals.

—  The Workforce Review Team (WRT) believes that it is too early to comment on many aspects of the impact of these reforms.

—  Primary Care Trusts (PCTs), who may be focused on other priorities, need to be able to access appropriate independent expert advice to support and drive these improvements as they move away from contracting and focus on commissioning.

—  WRT recommends that greater use should be made of a "basket of indicators" that monitor dental services and capture oral health, access patient experience, alongside weighted measures of activity.

—  More thought needs to be given to ways of dealing with those dentists who reach their targets early.

2.  BACKGROUND

  2.1  The Workforce Review Team (WRT) is a national body working on behalf of the NHS in England, primarily to support workforce decision making within the 10 strategic health authorities. WRT's core role is to review in detail the supply of and demand for the healthcare workforce across all specialties and professions, and to advise on the most practical and effective use of resources. It employs expert professional advisors from the healthcare professions, including dentistry. This intelligence and WRT's relationships with key dental stakeholders enable it to have a strategic overview of the dental workforce and its challenges.

  2.2  It currently works through a service level agreement with the Department of Health (DH) and provides valuable workforce information to key stakeholders including DH, strategic health authorities (SHAs), employers and commissioners. Profiles of healthcare workforce groups are published on the www.healthcareworkforce.nhs.uk portal.

3.  THE IMPACT OF THE REFORMS ON THE ROLE OF PCTS IN COMMISSIONING DENTAL SERVICE

  3.1  Initially, in their new roles, PCTs have focused on continuation of existing services ("contracting"), but increasingly are commissioning new and additional dental services informed by local oral health needs assessments.

  3.2  PCT dental budgets are based on a test period that took account of patients' charges. In the event of a shortfall in forecast patient charge revenue, there is a risk that PCTs' commissioning budgets are effectively reduced as they underwrite these shortfalls.

  3.3  These new obligations place increasing pressure on PCTs to have appropriate dental public health advice and a competent, knowledgeable commissioning team.

  3.4  Paradoxically, concurrent changes to PCT and SHA configurations have led to a loss of dental expertise at many levels, which risks undermining the dental services commissioning process.

  3.5  WRT believes that PCTs will need to retain a focus on improving the working lives of dentists and their teams in order to secure services and maintain access for patients.

4.  THE IMPACT OF THE REFORMS ON NUMBERS OF NHS DENTISTS AND THE NUMBERS OF PATIENTS REGISTERED WITH THEM

  4.1  WRT has commissioned a report[44] which comments on the lack of descriptive literature on successful workforce planning in relation to healthcare (WRT 2007). Consideration should be given to a range of measures that demonstrate a dental service that is clinically effective and promotes best practice.

  4.2  There is a challenge in analysing information on numbers of dentists and patients because data collected before and after 1 April 2006 cannot be directly compared.

  4.3  When comparing the numbers of NHS dentists on 31 March 2006 (21,111) and 31 March 2007 (21,041), it would appear that there has been little change in numbers. There are a number of other significant factors that should be considered when making assumptions about the impact of reforms on dentist workforce supply.

  4.4  The number of dentists on the General Dental Council (GDC) register with addresses in England on 31 March 2006 was 24,935 and on 31 March 2007 was 26,105. A factor in this increase is international recruits from both within and outside the European Union. These extra dentists provide predominantly NHS dental care.

  4.5  Analysis of available data from the Information Centre (IC) suggests that the number of patient visits to dentists measured over a two year period has remained relatively stable since the introduction of the new contract.

  4.6  The number of dentists is not an indication of activity, which may be monitored through a range of indicators including weighted measure of courses of treatment using units of dental activity (UDAs) and units of orthodontic activity (UOAs).

  4.7  WRT suggests that any assessment of primary care dentistry should take account of primary dental care provided by dental care professionals.

5.  THE IMPACT OF THE REFORMS ON THE NUMBERS OF PRIVATE SECTOR DENTISTS AND THE NUMBERS OF PATIENTS REGISTERED WITH THEM

  5.1  Data on private sector dentistry is poor.

  5.2  Based on early feedback from some PCTs, the number of dentists providing purely private dental care is likely to have increased since the introduction of the new dental contract. However, this will have had very low impact on local access because those extra dentists are mostly ones who had small NHS commitment, and because PCTs were able to replace these lost services.

  5.3  As with mixed and NHS dental practices, private dental practices do not normally have registration lists.

  5.4  In the light of reported experience, WRT believes that patients are most likely to migrate to private care because of a wish to stay with the dentist of their choice or because they are unable to access NHS dental care, rather than because they have a specific wish to have private dental care.

6.  THE IMPACT OF THE REFORMS ON WORK OF ALLIED PROFESSIONS

  6.1  Data on dental care professionals (DCPs) remains very poor, but is expected to improve with the arrival of mandatory registration in July 2008.

  6.2  PCTs may commission dental services from registered DCPs acting as providers.

  6.3  Effective deployment of DCP skills creates the potential to free up dentists' time.

7.  THE IMPACT OF THE REFORMS ON PATIENTS' ACCESS TO NHS DENTAL CARE

  7.1  WRT believes it is important to ensure that we measure:

—  opportunities for access;

—  subsequent real activity increases; and

—  improvements in oral health including addressing oral health inequalities.

  7.2  WRT believes it is too early to say whether there has been increased access to NHS dental care.

  7.3  The reforms have created significant opportunities to improve access (including equality) to NHS dental care because PCTs can retain funding and reinvest in dental services whenever a contract is relinquished.

8.  THE IMPACT OF THE REFORMS ON THE QUALITY OF CARE PROVIDED TO PATIENTS

  8.1  WRT believes that it is too early to assess the impact of these reforms on the quality of care provided to patients. A robust primary care dentistry clinical governance framework is already in place.

9.  THE EXTENT TO WHICH DENTISTS ARE ENCOURAGED TO PROVIDE PREVENTATIVE CARE AND ADVICE

  9.1  Changes to recommended recall intervals should free up time and enable dentists to spend more time on prevention and health promotion. It is the view of WRT that there is a risk that this may not happen without appropriate monitoring, incentives and realistic and achievable targets.

10.  THE IMPACT OF THE REFORMS ON DENTISTS' WORKLOADS AND INCOMES

  10.1  Because of the changes in measuring activity and reporting, it is not possible to meaningfully assess the impact on workloads.

  10.2  Data from the IC suggests that the number of interventions by dentists has decreased. This is in line with aims of the reforms, which aspired to fewer interventions, freeing up more time for a preventative approach.

  10.3  Dentists who have not achieved their agreed targets may be subject to recovery of payments which will affect their salaries. WRT suggests that PCTs and dentists need to work together to monitor and manage activity effectively.

11.  THE IMPACT OF THE REFORMS ON THE RECRUITMENT AND RETENTION OF NHS DENTAL PRACTITIONERS

  11.1  Dental performers list regulations mean that older dentists and overseas graduates who have not undertaken dental vocational training (VT) nor can demonstrate equivalent experience, must undertake a period of training before joining the list. As practices become more familiar with these new regulations, more opportunities should become available for these dentists. Most deaneries provide "Introduction to the NHS" courses to support new (non-VT) entrants to the NHS, which includes EU qualified dentists.

  11.2  WRT considers it too early to assess the full impact of these reforms on the recruitment and retention of NHS dental practitioners.

  11.3  Because dental services are now commissioned to meet local needs, recruitment and retention initiatives for NHS dental practitioners will be driven by local demand.

  11.4  Nonetheless this must be considered in the context of the national picture. The combination of significant expansion of dental undergraduate places, increased numbers of dental therapists and continued migration of overseas qualified dentists into the UK, poses a risk of over-supply of the primary care dental workforce.

NHS Workforce Review Team

December 2007