EXECUTIVE SUMMARY

  The primary driver of the NHS Dental Reforms was to devolve the service to make it responsive to local need and address problems of accessing NHS care. Also, as stressed in the Department of Health's report on the reforms, One year on, they were intended to "shift the service away from the old system, which operated on a piecework basis (often described as `drill and fill' treadmill) . . ."

  In doing this we have seen a significant reduction, around 46%, in Band 3 treatments, treatments that repair the consequences of the "drill and fill treadmill". Moreover, the cohort of the population that need these treatments, who benefited from NHS dentistry, are going to make the greatest demand on dental care during the next 20-30 years but are in danger of being abandoned by the service.

1.  THE PROBLEM

  1.1  We begin our evidence by looking at what has gone wrong following the most fundamental change to NHS primary care dentistry in England and Wales since its inception, with the introduction of personal dental services (PDS), before considering the implications, if not addressed, and a possible way forward.

  1.2  Our concerns are not only about the significant fall in the provision of Band 3 treatments (treatments requiring laboratory work like crowns, bridges and dentures) but also the quality of what is provided. Of the 480 or so fees under the old fee per item, general dental services (GDS), just over 40% involved laboratory work. Significantly, these accounted for around 8% of courses of treatment (CoTs), Band 1 (checkups, scaling and diagnostic procedures) 52% and Band 2 (fillings, root canal treatment and extractions) 40%.

  1.3  However, NHS Dental Statistics for 2006/07, published by the NHS Information Centre (IC), show Band 3 treatments during the first year of PDS 50% lower than under the GDS, at 4% of CoTs. These treatments have probably settled at around 56% of what they were or 4.5% of CoTs. This was the level in quarters three and four of 2006-07, following a recovery from 2.2% at the beginning of the first quarter, rising to 3.7% by the end of it and 4% in the second quarter.

  1.4  The reason for very low Band 3 CoTs during the early months of the PDS was that these courses of treatment generally take longer than others to complete. Also, and more significantly, there was a lot of activity, particularly in the provision of what were to become Band 3 treatments, during the final quarter of the GDS contract, as general dental practitioners (GDPs) attempted to provide these under fee per item of service, before the changeover to PDS.

  1.5  The latter resulted in patients benefiting from lower patient charges for single treatments before the significant increases accompanying the PDS. The Department has exclusively focussed on the reduction in the maximum patient charge from £378 under the GDS to £189.00 during the first year of the PDS—the patient charge for Band 3 treatments. But for single treatments, like a porcelain jacket crown, the patient charge increased by 168%; a full or jacket crown in non-precious metal by 139%; a full upper or lower denture by 151%; and a full upper and lower set of dentures by almost 50%. Increases in price of these magnitudes will have significant effects on the demand for dental care.

  1.6  This reduction in Band 3 treatments was identified in our surveys of dental laboratories, conducted at regular intervals following the introduction of the PDS and during the pilot schemes. In the first year, this showed an overall decline of 57% in units of Band 3 appliances supplied to GDPs in England and Wales, compared to increases of 15% in Scotland and 17% in Northern Ireland, both of which retained the GDS. For individual items, the decline ranged from 41% for non-precious metal crowns to 84% for chrome framed dentures. This was not matched by an increase in private work, which increased by just 18%.

  1.7  Band 2 items also experienced a fall in demand, from around 40% of CoTs under the GDS to 30% under the PDS, again reflecting increases in patient charges for individual treatments. The patient charge for a Band 2 CoT was introduced at £42.40, which compared, for example, to a price of £7.75 for a simple, amalgam filling under the GDS, an increase of over 580%, and even when combined with an examination, included under Band 2, increased by 180%.

  1.8  One of the consequences of a reduction in demand for Band 3 and, to some extent, Band 2 CoTs has been a significant shortfall in patient charge revenue, with knock-on effects for primary care trusts (PCTs). In NHS Dental Reforms: One Year On, the Department stated that patient charges were expected to raise around £600 million, although warning that "a number of PCTs, though not all, have been projecting lower than expected income from patient charges during the first year . . . the Department has increased funding allocations for 2007-08 to allow for slightly lower levels of patient charge income as a proportion of gross expenditure."

  1.9  As it turned out, patient charge revenue was £475, a massive £125 million short of the £600 million assumed in the indicative gross allocations issued to PCTs. The Department had plenty of warning that this might happen from the PDS pilot schemes—we estimate that patient charge revenue from these were some £80 million short of the £190 expected, out of a total spend of £764 million in England and Wales.

  1.10  As well as demand-side effects, there were also supply-side effects influencing the provision of band 3 treatments. If a patient needed multiple crowns, for example, and could afford the maximum charge, GDPs were quite willing to provide these under the GDS as their fee was not constrained—simply the number of crowns times the fee. Although the PDS contract value, target of units of dental activity (UDAs) and therefore value of UDAs were determined by a GDP's previous activity under the GDS, GDPs have been reluctant to provide multiple treatments as they incur higher direct costs for the same fee (12 x £UDA). This will be compounded after April 2009 when the dental budget is no longer ring fenced and UDAs begin to float.

  1.11  Partial dentures have bucked the trend, with the Dental Treatment Band Analysis for England, published by IC, showing that within Band 3, CoTs containing partial dentures rose from 27.4% to 34.7%. Our surveys show that during the first year of the PDS, there was a 76% increase in the most basic partial denture—the single tooth denture.

2.  DEMAND FOR DENTAL CARE

  2.1  The Department's mantra accompanying the introduction of the PDS and repeated to PCT commissioners at every opportunity since, has been prevention, prevention, prevention. The move away from intervention to prevention is appropriate for children—according to the World Health Organisation, UK 12 year-olds have the lowest levels of tooth decay in Europe. It is also appropriate for adults brought up post 1960's, who benefited from the introduction of fluoride toothpaste and a more preventative approach to dental caries. However, it is totally inappropriate for those born in the 1930's, 1940's and 1950's.

  2.2  This cohort of the population was at high risk of developing caries and increasingly enjoyed access to dentistry through the NHS. Techniques universally favoured cavity preparation based on the principle of "extension for prevention". These patients had decayed teeth that entered into the "restorative cycle"—repeated placement and replacement of restorations, with progressive loss of tooth structure and weakening of the tooth. In short, those most likely to need Band 3 treatments under the PDS.

  2.3  It is these patients, with their huge volume of restorations and expectations to maintain a natural dentition, who will have the biggest impact on the demand for dental care over the next 20-30 years but are in danger of being abandoned by the PDS. The question has to be asked can one fee, however it has been arrived at which, through time, will inevitably degrade, ensure that this cohort of the population receives the treatment it needs when it covers such a wide range of appliances and therefore costs?

3.  THE SOLUTION

  3.1  We do not, however, see a return to more fees for band 3 treatments as the way forward. Dentistry is unlike medicine in that there are often a variety of ways of restoring/repairing/replacing the dentition that differ in quality and cost. The problem of having a different fee for a procedure to reflect the laboratory component is no different to a specific allowance built into the fee as under the GDS—it inevitably becomes the maximum and the GDP has no incentive to involve the patient in decisions about what is used.

  3.2  The patient is unaware of this cost minimisation pressure, nor of its significance in limiting options, even though there may be considerable choice available—choice about the aesthetic and durability of something that will be present in their mouth for some considerable time. This complete lack of transparency and consumer sovereignty is at variance with market efficiency and is particularly difficult to accept in a health care system where patient charges have been a feature since 1951, introduced, ironically, for dentures.

  3.3  However, if, as we propose, the patient pays for the laboratory component and the NHS subsidises treatment, we will see the emergence of an enfranchised patient, making real and informed choices about the dental care they receive.

December 2007