EXECUTIVE SUMMARY

—  Access to NHS dentistry has been an issue of longstanding concern to the CAB Service. Citizens Advice has therefore welcomed the fact that, under the April 2006 reforms, Primary Care Trusts (PCTs) now have a statutory duty to provide dental services to meet "all reasonable requirements".

—  However we regret that, although the key aim of the reforms was to improve access, no attempt was made to reduce the postcode lottery by targeting additional funding on those PCTs where access had traditionally been poor. We believe this is a key explanation for the failure of the reforms to deliver any growth in NHS dentistry since April 2006.

—  CAB evidence from around the country continues to demonstrate serious access problems at the local level. Many people have gone without regular treatment, instead relying on emergency services when they are in pain. Others have felt they have no option but to seek private treatment even when this is not what they want or can afford.

—  NHS charges can also be a barrier to access. There is a need for better promotion of the help available through the NHS low income scheme.

—  In a recent CAB online survey, around a third of respondents who had received NHS treatment since the reforms, said they were not satisfied with their treatment. Some reasons given reflected a service under pressure. Others said that they had been incorrectly told by their dentist that necessary treatment such as scale and polish and root canal treatment were not available under the NHS.

—  We are concerned that some PCTs with significant access problems may be adopting a narrow interpretation of their new duties, focusing on spending at the level of their ring-fenced budgets based on historic spend in the area, rather than on undertaking a comprehensive assessment of local need and commissioning to meet all reasonable requirements.

INTRODUCTION

  1.  Citizens Advice welcomes the opportunity to submit evidence to this inquiry. In 2006-07 bureaux in England and Wales dealt with 6,260 enquiries regarding dentistry, the main concern being the availability of NHS dentistry (34%).

  2.  Ever since the early 90's, bureaux have been reporting this problem and the concern of local people when they are unable to find a dentist. There can be no doubt that people see access to NHS dentistry as a priority—whenever a local dentist withdraws from the NHS or a new practice opens, the story usually finds it way to the front page of the local paper.

  3.  Citizens Advice has therefore welcomed the dentistry reforms introduced in April 2006, which had improvement in patient access as a key objective. We have particularly welcomed the fact that PCTs now have a statutory duty to provide dental services to meet "all reasonable requirements". This, together with clear statements from Ministers that the Government is "committed to providing NHS dental services for all those who wish to use them"[56] has rightly raised public expectations.

  4.  It is therefore very disappointing that Government statistics from the first 12 months of the reform showed no increase in the number of patients receiving NHS dental treatment but rather a slight fall. Moreover this fall appears to have accelerated in the first quarter of 2007-08. We believe that the key explanation for the failure of the reforms to improve access is that the ring fenced funding allocated to PCTs to deliver their new duty was not based on any assessment of local need, but rather on the historic spend on NHS dentistry in each area. This therefore perpetuated existing inequalities in access and has made it extremely difficult for those PCTs in the historically most under funded parts of the country to fulfill their new duty.

  5.  This submission is informed by case evidence submitted by bureaux since April 2006 and by two on line surveys. The first of these, to which 4,705 people responded, was carried out between May and October 2006 and focussed on people who had been unable to find an NHS dentist (access survey). The results were included in our 2007 report Gaps to fill[57]. The second survey carried out between August and November 2007, to which 341 people responded, provides some information on the experience of people who have had NHS treatment since the reforms came into effect (patient experience survey).

  6.  In our response we have focussed on those aspects of the inquiry on which we have evidence.

PATIENT ACCESS TO NHS DENTAL CARE

  7.  A key objective of the April 2006 reforms was to improve access to NHS dentistry. It is therefore very disappointing that the statistics for the first year of the reform showed a reduction of 50,000 in the number of patients receiving treatment in the previous 24 months. This means there was no progress in meeting the needs of the two million patients who the Government estimates are unable to find a dentist. Moreover the most recent figures covering the first quarter of 2007-08 show a fall of over 200,000 in the number of patients receiving treatment, compared with the previous quarter. This suggests that even the more modest aim of ensuring through recommissioning that access does not deteriorate, is not being met.

  8.  Nor has there been much progress in reducing the postcode lottery at the local level. For example in South East Central Strategic Health Authority (SHA) where access was already relatively poor, the percentage of patients seen fell from 51.4% to 49.8% over the 15 month period—a reduction of almost 56,000 patients. And within the SHA, falls were even greater amongst those PCTs with poorest access—in Surrey PCT numbers of patients seen fell from 47.1% to 44.2% and in West Kent PCT from 48.7% to 43.9% over the period.

  9.  Another way to assess the postcode lottery is to look at the number of dentists taking on new patients. In our CAB evidence report Gaps to fill, we analysed the data on the nhs.uk website, and this revealed huge differences between PCTs. Whilst in 22% of PCTs at least four in 10 dentists were accepting new charge paying adult patients, in another 26% of PCTs, no dentists were shown accepting this group of patients.

  10.  It has not been possible to update this analysis because the information is now presented differently on the website. Nor is information about the number of dentists with open lists publicly available either nationally or at PCT level. However bureau evidence from around the country continues to demonstrate serious access problems at the local level. People on low incomes living in rural areas appear to be particularly affected, often facing long and expensive journeys to reach the nearest available dentist. It is important to note that, unlike travel to hospital, there is no help available from the NHS low income scheme with travel costs to primary care services such as dentists, presumably on the assumption that these services will be available in the local community.

A CAB in Northumberland reported a young mother on a low income, who needed emergency dental treatment. She had to travel 10 miles to the nearest available treatment centre, which was not easy with three children. She would have to take half a day's leave and therefore lose wages.

A CAB in Hampshire reported an 87 year old woman who was enquiring about the possibility of finding a local dentist. She currently has to travel from her rural town to Southampton—a journey which she cannot manage on her own and therefore has to rely on her daughter. There used to be two NHS practices in the town but both have now gone private and the bureau has been calling on the PCT, to no avail, to replace the lost NHS service.

A CAB in Kent reported a 77 year old client who had a broken tooth. She had been into bureau previously for debt problems and cannot afford a private dentist. To get to the nearest NHS dentist involved an 8 mile bus journey, followed by a train and then a walk.

  11.  From our access survey it was clear that patients faced limited options. The majority of respondents (64%) said they simply went without regular check ups or treatment. 9% said that, instead of adopting a preventative approach to their case, they relied on emergency dental services for treatment, including A&E, when a crisis arose. This was not always satisfactory as the treatment provided would often not deal with the underlying problem.

A CAB in Surrey reported a woman in low paid work who had problems with wisdom teeth. There are no NHS dentists available but she couldn't afford to see a private dentist. She therefore waited until the problem was sufficiently severe that she could go to the emergency dentist at the local hospital. She ended up with an infected wisdom tooth and was given treatment and very strong painkillers which made her feel so unwell that she was off work for five days. She still has an ongoing problem needing further dental work.

"I cannot register with a NHS dentist, so I had to go to an emergency one when I had an abscess. He told me my teeth were in a poor state, but seeing as he was only an emergency dentist, all he was allowed to do was treat the abscess. The dentist staff was fabulous; it's just that their hands were tied." (survey respondent)

  12.  18% said they had felt forced to accept private treatment even when this was not what they wanted or indeed could afford.

A CAB in Suffolk reported a client who had severe toothache at the weekend. There was no NHS dental care available in the area and he was referred to Great Yarmouth for treatment. He could not get up there and therefore went to a private dentist in a nearby town and had an extraction—costing £110.00. He wanted to know if there is any way he can get any help with this cost.

A CAB in Hampshire reported a 79 year old client who had been unable to find an NHS dentist when her previous one ceased taking NHS patients. She finds travelling difficult and so feels she has no choice but to use a private dentist.

NHS CHARGES

  13.  27% of dentistry enquiries to bureaux in 2006-07 related to NHS charges and it is clear from CAB evidence that these can also be a barrier to access. The structure of the charges was radically changed from April 2006 and Citizens Advice was represented on the Department of Health's Patient Charges Working Party which proposed the current structure. The advantages of the changes are that the structure is much simpler so that it is less easy for patients to be confused as to whether they are paying for NHS or private care. It is also welcome that the maximum charge has been reduced from nearly £400 to £194, and that the flat rate structure goes some way to breaking the link between poorer oral health and higher charges. It is crucial that charges do not fall disproportionately on those with greatest health needs, thus deterring them from accessing the NHS services they need.

  14.  However the fundamental problem remains that NHS dental charges are significant. The review of charges was undertaken on a nil cost basis, with the requirement that the same proportion of revenue should be recouped through patient charges as under the previous scheme. This was despite the fact that there had long been criticism of the affordability of NHS dental charges, as discussed in our 2001 report Unhealthy Charges[58]. This found that the main reason why patients who had an NHS dentist had not had a check up the previous year was because they could not afford the cost.

  15.  Between August and November 2007, we included a questionnaire on the Citizens Advice website for people who had had NHS dental treatment since the April 2006 reforms. 77% of the 329 people who responded had paid for their NHS treatment (the rest were exempt). Of these, 42% said they found it difficult to meet the cost of this charge. This percentage reduced to 27% amongst those paying the Band 1 charge (currently £15. 90), but increased to 54% amongst both those paying Band 2 (£43.60) and Band 3 (£194) charges.

  16.  Help with charges is available for people on low incomes through the NHS Low Income Scheme. However the dental contract does not require dentists to provide any information about this scheme or to hold the relevant leaflets and claim form. As a result, bureaux often report that clients fail to claim for the help to which they are entitled. Recent MORI research undertaken for the Department of Health as part of their review of Help with Hospital Travel Costs, found that, of a sample of respondents all in social grade D and E (and therefore likely to be entitled to help) only 11% had heard of the NHS Low Income Scheme.

A CAB in Norfolk reported a client who was on long term incapacity benefit with a weekly income of £81.35. He therefore assumed that he was entitled to free NHS treatment. He did not have his reading glasses with him and wrongly signed forms to get free treatment by ticking the box that he was receiving income support (IS). As a result he was charged a £79.50 penalty fee with an additional charge of £39.75 if the money was not paid within 28 days.

The bureau found that the client should have been entitled to a small IS top up, which would have given him automatic entitlement to free dental care.

THE QUALITY OF CARE PROVIDED TO PATIENTS

  17.  Only 6% of CAB enquiries in 2006-07 were related to issues around the quality of care, suggesting that this is not such an issue of concern for patients as access and charges. We therefore specifically included a question in our 2007 patient experience survey about how satisfied they were with the treatment provided. 32% said they were very satisfied and a further 36% said they were fairly satisfied. However 32% said they were not satisfied with the treatment they received. Patients who had had Band 2 treatment were more likely to say they were dissatisfied (41%) than those who had received Band 1 (26%) or Band 3 (11%) treatment.

  18.  Many of the reasons given reflect a service under pressure, with patients saying they felt rushed, found themselves repeatedly seeing a different dentist or had to wait months for appointments.

"I was told that I would have three fillings in the appointment I made but when I turned up on time my dentist was running late. When I finally went in he said he only had time to do one filling."

" . . . The only practice that would take me on employs all locums."

  19.  Some respondents and CAB clients have also complained that they received incorrect information and were not given all the treatment needed on the NHS, as they are entitled.

A CAB in Devon reported a client in her 70s and exempt from charges on grounds of low income. She had a tooth removed by an NHS dentist who then recommended that her teeth needed cleaning. However he wouldn't do this on the NHS and referred her for private treatment at a cost of £26.

"A few days ago my husband was in a lot of pain. He went to our dentist who we have been with for many years (NHS). He was told he had an abscess and needed root canal treatment (band 2). He was told by our dentist that he couldn't afford to do the treatment on the NHS."

  20.  It is not easy for patients to check whether what they are told by their dentist is correct, or indeed to know how to challenge such practices when they do occur. And as long as access problems continue, patients are in a vulnerable position. Few will want to risk taking up the issue with the practice itself, for fear of jeopardising the dentist/ patient relationship or even being removed from the list altogether.

A CAB in Surrey reported a client who made a complaint about her experience of poor treatment from her dentist. The dentist then told her she was not wanted as a patient. She is currently in pain but has been unable to find an alternative NHS dentist.

THE ROLE OF PCTS IN COMMISSIONING DENTAL SERVICES

  21.  Undoubtedly from the PCT perspective, April 2006 was not an auspicious time to take on new duties in relation to the delivery of NHS dentistry as many were still coping with the consequences of reconfiguration which took place in Autumn 2005. In addition many faced the need to manage significant budgetary problems over 2006-07. Then the initial challenge was to cope with recommissioning the dental activity from those dentists who decided not to sign the new contract.

  22.  During the winter of 2006-07 Citizens Advice contacted 40 PCTs which appeared from the nhs.uk website to have the poorest access. The responses from these PCTs highlighted two issues of concern.

  23.  Firstly PCTs appeared to be adopting a narrow view of their new duties. Rather than commissioning services to meet the reasonable requirements of their area, they were only recommissioning lost activity where a dentist withdrew services and so spending only up to their ring fenced budget, regardless of its adequacy. Thus one commented that "action that the PCT has taken will ensure that the ring fenced dental allocation is fully spent on providing an equitable access for local residents".

  24.  This is also reflected in the more recent experience of local bureaux, several of whom have undertaken their own surveys of local demand in order to demonstrate to the PCT the need for additional dentistry in the local area. Interestingly, despite the fact that many dentists have been critical of the new contract, PCTs have not said that they have a problem in finding dentists prepared to take on NHS work. Rather the barrier to improving access appears to be inadequate PCT budgets.

  25.  The second issue was that some PCTs appeared to be basing their estimates of need for services on the number of enquiries to their dental helpline or the numbers on their waiting list. But this assumes everyone in need of a dentist is aware of these resources and has used them in their search for a dentist. Responses to our access survey suggested very differently, with only 19% replying that they had contacted their PCT or their PALS as part of their search, although this is usually the way to access the waiting list and helpline. Only one PCT said they were considering undertaking a local patient survey in order to accurately assess local demand for NHS dentistry.

  26.  We also believe that PCTs need to do more to increase public awareness of their new responsibilities with regard to NHS dentistry and make sure people know the best way to find a dentist. Recent changes to the NHS Choices website have increased the visibility of the local PCT dental helpline number. However even amongst respondents to our on-line access survey, who by definition were web users, only 52% used the website in their search for a dentist, so it is clearly important that other publicity strategies are used. Some PCTs have displayed posters in key areas such as GP surgeries and libraries, informing people about how they can get help with finding a dentist, but this practice is not universal. This becomes particularly important in circumstances where a dentist is withdrawing from providing NHS services, and so large numbers of patients in a local area will be looking for an alternative provider.

  27.  It is also important that mechanisms are put in place so that patient satisfaction with their treatment is fed into the PCT contract monitoring process.

CONCLUSIONS

  28.  It is extremely disappointing that, 15 months after the dentistry reforms were introduced; Government statistics are still showing a decline in overall access to NHS dentistry. We believe that a key reason for this failure is that those PCTs which had poorest access before April 2006 were not given any additional funding to help them fulfil their new duties to meet all reasonable requirements. As a result, at PCT level, inequalities in access have only been entrenched by the reforms.

  29.  Given the serious financial budget constraints which many PCTs faced in 2006-07 it is perhaps not surprising that many appear to have focussed only on spending their ring fenced budget. We believe that the priority now must be to address access inequalities through targeted additional funding before the three year ring fenced period ends in 2009. Otherwise it is very unlikely that the reforms will achieve their objective of providing NHS dental services for all those who wish use them.

December 2007

57   Gaps to fill: CAB evidence on the first year of the dentistry reforms, Citizens Advice, 2007 Back

58   Unhealthy charges: CAB evidence on the impact of health charges, Citizens Advice, 2001 Back