1.  EXECUTIVE SUMMARY

  1.1  Denplan welcomes the House of Commons Health Select Committee inquiry into dental services and the chance to contribute to it.

  1.2  The Committee's terms of reference focus on the impact of the dental reforms made in April 2006. In this written submission to the Committee, Denplan aim to consider these terms of reference in the wider context of the future of the entire dental care sector. We aim to address how the under-lying aim of dental care provision should be framed in order to achieve a high quality of preventive, comprehensive and inclusive dental care in the long term, and the implications of this on a sustainable model of dentistry which can be created going forward.

  1.3  We believe that private dentistry is an important part of dental provision in the UK. It can serve to complement, rather than compete with, NHS dentistry by providing additional options for patients and by helping to reduce the costs of running a modern dental surgery. The capitation approach of Denplan also incentivises both patients and dentists to achieve and maintain dental health, and discourages "episodic" dentistry. Any further reform to the dental system must take the complementary role of the private sector into account.

  1.4  We have set out how we feel that the current system puts the wrong emphasis on short term care provision whereas a long term vision based around preventive care and oral health could improve efficiency, and reduce the need for surgery. Firstly, the system must allow the outcome of dental care to be measured in such a way as to ensure that oral health is demonstrably maintained and improved. Secondly, the system does not align the best interests of the dentist and the patient. It may incentivise patients to "save up" their problems, whilst dentists see themselves as financially discouraged from caring for those with the greatest dental needs. It encourages "episodic" dentistry. Thirdly, the current system does not encourage the dentist or the patient to focus on preventive care which would give the patient a much better chance of avoiding major disease and treatment and would save considerable resources, making dental provision more sustainable in the long term.

  1.5  Finally, we believe that the current system is not sustainable in the long term and we feel that the failure of successive reforms have demonstrated this. Therefore we have set out both short term and long term proposals for a more sustainable model of dental provision in the UK.

  1.6  We feel that we have significant experience to contribute to the on-going debate around dental provision in the UK and would be pleased to give oral evidence during the inquiry should you wish us to do so.

2.  COMPANY PROFILE

  2.1  Denplan was founded by two dentists, Dr Stephen Noar and Dr Marilyn Orcharton in 1986 around the principle of a capitation payment system, rather than dental insurance. The dentists aimed to create an alternative approach where the best interests of patients and dentists were synonymous: prevention-based capitation. In this approach, patients would know in advance the reasonable sum they would pay for their dental care needs, whilst dentists would have a sound and regular income allowing them to invest in their teams, their practice and their development. Over 20 years on, our main product is the capitation based plan, Denplan Care; although we also provide other financing products as well as support services including professional development and training, quality assurance and risk management, complaints handling, marketing and business advice.

  2.2  In 2007, Denplan works with over 6,500 dentists and has 1.9 million patients registered, of whom 90% are contracted individually to their own dentist, the remainder being served under employer-arranged plans. Over the past 20 years, most Denplan member dentists have retained a balance of private (fee-paying) and NHS patients. Our internal research shows that the "average" spread of patients in a Denplan practice is as follows: 39% capitation, 40% private fee-paying and 21% NHS.

3.  POLICY SPHERE EXPERIENCE

  3.1  As a pioneer of dental provision and the largest private sector provider in their field, Denplan endeavour to remain engaged with policy makers and we feel that we have much to add to the on-going debate about the future of dentistry. Denplan's objective is the support of ethical, high quality, preventive-based private dental care through appropriate funding mechanisms, where the dentist remains in control of his/her practising circumstances. We believe that, whilst the issue of NHS dental reform does not affect Denplan specifically, a healthy NHS dental system is important for dentistry in the UK and encourages patients to take responsibility for managing their own oral health.

  3.2  We gave oral evidence to the Health Select Committee in 1993, in the aftermath of a previous NHS contract reform, and written evidence to the inquiry in 2001 when we were positively commended and acknowledged in the subsequent report[45]. In 2002, we participated in the "Options for Change" work published by the Department of Health and which was widely cited as the principal forerunner of the current reforms[46]. We have also commissioned research over the years into the provision of dentistry, notably from Demos (1996 and 2000), York Health Economics Consortium (2003), and Office for Public Management (2005).

4.  HOW PUBLIC AND PRIVATE DENTISTRY COEXIST IN THE UK

  4.1  The Health Minister, Ann Keen MP, recently estimated that around nine million people seek private dental care[47]. However, industry commentators believe that the private dental market is worth up to £3 billion overall in the UK[48] and Information Centre (NHS) figures note that more than half of the income of the practice-owning dentists, for whom they have information, is derived from private treatment (51% in 2004-05; 58% in 2005-06).[49] Overall, we estimate that the NHS contributes between 50% and 60% by volume and 40%—50% by value of the total dental market.

  4.2  The majority of dentists—as evidenced by the NHS information statistics cited above—work in a "mixed NHS and private" model. The option that a dentist has to devote a proportion of their time to providing private dentistry is often a vital factor in enabling them to continue to provide NHS treatment to those patients who need it. The statistics suggest that this position is now becoming polarised, with more dentists working almost wholly in one sector or the other.

  4.3  Our internal experience is that the cost of running a contemporary dental surgery, which complies with the plethora of modern regulation and legislation, averages out at around £160 per hour. This is similar to the figure recently confirmed by the British Dental Association (derived from Scottish government estimates).[50]

  4.4  Private dentistry is sometimes characterised as being "in competition" with the NHS, however many dentists see mixed practice as a logical solution to these business needs in the provision of good quality care for all their patient population.

  4.5  We strongly believe that a comprehensive (all necessary treatment) and inclusive (for all the population) system of primary dental care delivery cannot be provided by the public sector alone. The spread of available public finance simply cannot stretch to cover identified dental demand. Unidentified dental need is yet another issue.

  4.6  The polarisation of practice which the current reforms are engendering will not best serve the interests of the public, the Government or the profession. We therefore believe that it is very important that a more holistic approach is taken when considering further and future reform and that the likely impact of any change on the entire dental profession and industry, and the ability of a dentist to provide mixed NHS and private care must be considered.

5.  HOW CAN DENTAL PROVISION BE IMPROVED IN THE UK?

  5.1  We feel that there are some fundamental elements the 2006 dental reforms did not address, which would bring about significant improvements in the way in which care is given and managed, and which would significantly strengthen the long-term viability of the dental system. Firstly, the system must allow the outcome of dental care to be measured in such a way as to ensure that oral health is demonstrably maintained and improved. Secondly, the system does not align the best interests of the dentist and the patient. It may incentivise patients to "save up" their problems, whilst dentists see themselves as financially discouraged from caring for those with the greatest dental needs. It encourages "episodic" dentistry. Finally, the current system does not encourage the dentist or the patient to focus on preventive care which would give the patient a much better chance of avoiding major disease and treatment and would save considerable resources, making dental provision more sustainable in the long term.

i.  Lack of health measurement within system distorts the focus of care

  5.2  We believe that a major flaw in the current UDA system is that it intrinsically encourages the dentist to focus on the short term outcome of the course of treatment, whereas the long term health of the patient is in fact the only real indicator of how successful the care provided has been. Although details of specific treatment provided under NHS care will once again be identified by dentists on claim forms from April 2008, there is no measurement of the effectiveness of dental care delivered. There therefore needs to be a better measurement as to how dental health can be achieved and the dental system needs to be able to accommodate this. Health gain seems to us to be the most obvious choice when measuring the effectiveness of dental care.

  5.3  Other than the decennial Adult Dental Health survey, no good measure exists of the oral health of the population at large, nor in individual areas or contracts, although widespread inequities in the prevalence of common dental diseases are acknowledged.[51] Measurement of the oral health of 12 year olds, whilst a good international measure, is a narrow one.

  5.4  Within Denplan's capitation approach, both patients and dentists are incentivised to achieve and maintain dental health. Under Denplan's Excel programme, oral health is measured and monitored by both dentist and patient. This measurement system has been externally reviewed and is based on the academic model originally intended for the (then) Dental Practice Board.[52] The Public Accounts Select Committee and the National Audit Office both drew on essentially the same index for their reports.[53] A similar measurement system would enable the long term oral health of patients to be tracked and would therefore encourage care geared towards the improvement of long term health.

ii.  The patient's relationship with their dentist

  5.5  It is widely believed amongst industry commentators that the current attention to access and the effects of the UDA target system, along with recent guidance from NICE that patients who do not need treatment should only be seen by a dentist once every two years, may be encouraging episodic dentistry, and discouraging relationship dentistry.

  5.6  Statistics (such as those quoted by the NHS and in Parliamentary answers) on "access" consistently fail to distinguish between these types of dental demand, as distinguished from dental "need". It is of course desirable to have need translate into demand, but consistently, some 20%-30% of the population do not believe that they have cause to visit regularly, whilst others visit only infrequently[54]. This of course affects the type of care that they receive and they miss out on the regular check ups which can catch any problems before the need for treatment arises.

  5.7  Many patients do seek ongoing, preventive care and increasingly this proportion of the population—who value dental health and not merely the absence of current dental disease—is growing. This is despite their identification as the "worried well". These patients require and seek an ongoing relationship with their dentist—usually their dentist of choice and whom they have grown to trust.

  5.8  Patient who choose episodic dentistry should have their needs met: both NHS and private systems can address these needs and, importantly, provide an opportunity to convince patients of the advantage of on-going regular and preventive care, should they wish to avail themselves of this. Those who do wish to do so should be encouraged to take individual responsibility for this, with state-aided funding for those who require it.

iii.  The value of preventative dentistry

  5.9  Unlike medicine, dentistry is principally about the management of two, almost entirely preventable, conditions: dental caries and periodontal disease. An opportunity therefore exists for a preventive approach to these conditions. Public health measures (including fluoridation and education) are important components, but on-going management and reinforcement at the individual patient level is also key.

  5.10  For dental caries, the "tooth death spiral" suggests strongly that the avoidance of the first "surgical invasion" of a tooth (by the dentist's drill) is the most significant objective of preventive care. Minimal invasive techniques are the most likely to prolong tooth life.[55] Periodontal disease requires, for the most part, intensive personal monitoring and meticulous care (by both patient and the dental team), although it probably presents a serious risk to only a proportion of the population. Identification of the at-risk is an important task, since links with diabetes, heart disease and the damaging effects of smoking have been shown.

  5.11  Good evidence-based dentistry is expensive to provide, both in terms of facilities, equipment, materials, and whole-team professional development and training. Dentists have, in the past, invested significant amounts to secure this environment. Future funding cannot solely depend on state provision unless, again, major changes are made in budget allocations.

6.  THE FUTURE OF DENTAL CARE

  6.1  In the long term, we believe that a complementary approach to the provision of primary dental care, where both the public and private sectors work together, is essential for meaningful progress, the efficient use of public funds and the exercise of patient autonomy.

  6.2  We believe that in order for the public provision of dentistry to be sustainable in the long term future, public health and the provision of urgent and "episodic" care would sit best with the public sector. Ongoing routine maintenance and preventive care would be best served by a responsible and ethical private sector, with assistance for those who are genuinely unable to afford it. Elective and cosmetic dentistry should rightly remain in the domain of the individual's choice and funding.

December 2007

46   Department of Health (August 2002) Options for Change Back

47   Rt Hon Ann Keen MP, Parliamentary Under Secretary of State for Health (12 September 2007) speech to Primary Care Trusts Back

48   Market & Business Development Dentistry Market Research Report (June 2007); Laing and Buisson Dental Market Report (2003) Back

49   NHS Information Centre: Dentists Earnings survey, (September 2007) Back

50   British Dental Association (November 2007) Better Health, Better Care, response from the British Dental Association Back

51   See for example: London Health Observatory Oral Health Overview http://www.lho.org.uk/viewResource.aspx?id=9570 Back

52   Burke FJ and Wilson NH (1995): Measuring Oral Health: an historical view and details of a contemporary oral health index (OHX). Int Dental J 45(6): 35-70 Back

53   House of Commons Committee on Public Accounts (July 2005) Dept of Health-Reforming NHS Dentistry HC167: Recommendation 12. Back

54   Bradnock G, White DA, Nuttall NM et al (2001). Dental Attitudes and Behaviours in 1998 and implications for the future Br Dent J.190 (60-68) Back

55   Elderton RJ (2003). Preventive (evidence-based) approach to quality general dental care. Med Princ Prac Suppl 1: 12-21 Back