EXECUTIVE SUMMARY

  1.  The new dental contract introduced in April 2006 was the most fundamental change to the system of delivery of NHS Dentistry since the inception of the NHS. It followed a long term review and far sighted reports such as "Options for Change" which had promised a radical move away from the perceived treadmill of NHS dentistry and a "drill and bill" model towards an approach which was patient centred with an emphasis on prevention. Personal Dental Service pilots were supposed to trial the proposed changes but in the event much of the funds allocated for these trials were hijacked to the provision of Dental Access Centres to try (with no possible chance of success) to fulfil the Prime Minister's pledge of NHS Dentistry availability for all.

  2.  The new contract when it was finalised failed to implement many of the proposals contained in "Options for change" and has implemented a new simplified "drill and bill" structure.

  3.  Following such a major change it would have been expected that some parts of the new contract would work well and others would need further development and adjustment. The unwillingness of the Department of Health to consider any significant and meaningful changes to the system imposed in April 2006, assuming that they got it all right first time round is to be deplored.

  4.  In practice whilst lip service is given to greater emphasis on prevention this has not been recognised within the payment system and an opportunity has been lost.

  5.  The charging system for patients has been simplified but in the process when combined with the UDA system the effect is that patients are in general paying more for similar treatment than they were doing prior to institution of the new contract.

  6.  The simple three band UDA system has introduced perverse drivers into the system with radical reductions in the levels of complex treatment provided under band 3, little or no molar endodontics and an increased incidence of extractions and provision of partial dentures.

  7.  Local commissioning whilst admirable in principle has in many cases led to insecurity for practitioners, uncertain career pathways for the newly qualified dentist and has failed to address differences in the cost base of practice across the country.

  8.  The removal of ring fencing for dental funding to PCTs in 2009 combined with a perceived downward pressure on UDA values is perceived as presenting a real threat to those dentists continuing to work within the health service and to the availability in the future of a quality NHS Dental Service for patients.

  9.  Lack of provision of NHS orthodontics remains a major concern and the new contract has made an already appalling situation of undersupply far worse. The problem here is, however, a chronic one and can only be solved in the long term by the provision of more training places for orthodontists.

INTRODUCTION

  1.  The British Dental Health Foundation is the UK's leading charity dedicated to the promotion of good oral health by the population. It was formed in 1971. The charity receives no government funding. It runs a national dental helpline answering over 40,000 patient enquiries a year, distributes over a million patient education leaflets a year and runs two major annual awareness campaigns, National Smile Month, established 31 years ago and Mouth Cancer Awareness Week. The author of this evidence, the Chief Executive Dr Nigel Carter was a practising dentist for over 20 years and is a member of the New Dental Contract Implementation Group by invitation of the then Minister of State Rosie Winterton MP (now Key Stakeholder Group).

2.  The Role of PCTs in Commissioning Dental Services

  2.1  In principle devolution of commissioning of dental services to a local level is to be welcomed, but in practice the effectiveness of this measure has been very mixed across the country. Some PCTs have embraced their new role and appear to be using the funds available effectively to provide high quality services within their area whilst others do not appear to have adapted so well to their now role and are showing little in the way of innovation and good practice.

  2.2  A real opportunity was missed in development of the new contract to redistribute funds or allocate new funds to ensure equality of provision across the country. If a PCT had low levels of provision of NHS Dental Services prior to the Institution of the new contract the funding they received did not allow them to address this imbalance.

  2.3  Where contract values come up for re-allocation the ability of the PCT to determine where they wish to provision new services is to be welcomed since this can address areas of previous lack of provision within the community and to shape the service to meet need. This is being implemented with various degrees of effectiveness.

  2.4  Some PCTs are concerned about their levels of patient charge revenue (PCR) and as a result have not been reallocating units of dental activity to provide improved access but instead have kept the funding to mitigate any PCR shortfall. This is to be deplored since it prevents extension of provision to those wishing to find an NHS dentist.

  2.5  It is a matter of concern that where units of dental activity (UDAs) are returned to the PCT there seems in many cases to be a wish to retender for this provision on a lowest cost base. Whilst this may appear to potentially allow for additional provision, in practice if pursued this course will lead to provision of a poorer level of service by the contractors and a tendency to exclude those patients not currently accessing the service who may have the greatest need for treatment and be uneconomical for the practitioner at low UDA levels.

  2.6  The reorganisation of PCTs which took place in the first few months of the contract was counterproductive to efficient delivery since staffing changes in many cases meant that developing knowledge and skills in the dental arena were lost.

  2.7  The number of Consultants in Dental Public Health has been severely reduced since the introduction of PCTs. Many consultants are split over several PCTs on a part time basis and with a lack of consistency of direction are hampered in delivering effective advice.

  2.8  Some Strategic Dental Health Authorities do not even have an identified dental priority or lead which is an appalling state of affairs.

  2.9  The ability of PCTs to adequately monitor dental practices is of some concern especially when it comes to items such as infection control procedures.

  2.10  PCTs have responsibility for provision of out of hours service. In some cases this is difficult to access and inadequate. More robust systems need to be in place.

3.  Numbers of NHS Dentists and the number of patients registered with them

  3.1  Following the initial fall out of dentists who did not accept the new contracts offered to them the numbers of dentists appear to having remained substantially stable. It is discouraging, however, to now see an increasing number of dentists either leaving or planning to leave NHS Dentistry. This trend appears to be greatest amongst the most experienced practitioners who see the potential for selling their practices within the NHS (traditionally part of their retirement planning) to be diminished by PCT control over whether a contract would be offered to their successor and at what level.

  3.2  2009 when the dental budget for PCTs loses its ring fencing is seen by many as a great threat. At this stage the PCTs will be able to renegotiate contract values with the practitioner and many feel that this will lead to a general reduction in value per UDA and thus their income for similar levels of activity.

  3.3  Traditionally practices grew based on the perceived demand for that practice's services and new dentists were then taken on as appropriate. This ability for dynamic expansion has been removed from practitioners under the new system as their income is effectively capped. The only alternative left to a practitioner in many cases to expand their practice is by increased private provision.

  3.4  Many vocational dental practitioners were taken on as associates by their training dental practice at the end of their period of training. This allowed for further development of the skills of newly qualified dentists within a supportive environment. In the vast majority of cases this further employment cannot now take place as there are not additional funds available for the expansion of practices in this way.

  3.5  Patients are of course no longer registered with a dentist but attend for only one course of treatment at which time their relationship with the practice may be terminated. This move away from the concept of continuing care implied by registration under the old contract is to be deplored since it does not encourage regular attendance and a preventive approach.

  3.6  The initial period of the new contract saw some practitioners leaving the NHS and refusing to take up the new contract. This amount to about 4% of provision. Whilst not large this could be seen to equate to over one million patients disenfranchised at this point.

  3.7  Whilst recommissioning of the lost UDAs may have been successfully achieved was in many cases slow to take place and even slower to come on stream. As a result the total number of UDAs delivered at the end of year one did not meet targets and patient's access must have worsened as a result.

4.  Numbers of Private Sector Dentists and the number of patients registered with them

  4.1  As seen in 3.6 a number of NHS dentists totally left the NHS system at the beginning of the contract.

  4.2  Since the early months of the contract the perception is that the number of dentists leaving the system has reduced, although there are still conversions to private practice taking place.

  4.3  Current estimates are that six to eight million attend for dental people privately, some 21% of the total number of regular attenders.

  4.4  Two main threats appear to exist to ongoing commitment of dentists to the NHS going forward. The first of these is the perception that their level of income will be potentially reduced in 2009 when PCTs are free to negotiate revised UDA amounts. The second of these is the perceived threat to goodwill value by these changes in 2009. Both of these factors may be considered likely to influence some dentists to leave the NHS.

  4.5  The current patient charge system may be seen in a number of cases to encourage private dentistry since the fee payable by the patient privately may be less than that on the NHS.

5.  The work of allied professions

  5.1   It is too early to determine the impact of the wider registration of dental professionals on the skill mix and delivery of NHS Dentistry.

  5.2   Some early indications with effective "capping" of NHS income was that dentists were choosing to make less use of dental care professionals with associated salary cost to deliver their targets. This would potentially have an adverse effect of both the DCPs, in this case largely hygienists and therapists, and the level of preventive care provided to patients.

  5.3  The reduction of quantity of Band 3, complex treatments involving laboratory work, has led to many dental laboratories going out of business or having to drastically downsize.

  5.4  The lack of commitment to dental technician training over the last 20 years, combined with an increasing tendency to have technical work carried out abroad in the new EU accession countries or the Far East on a lower cost base could lead to almost annihilation of the dental laboratory industry in the UK.

  5.5  Extended duties for the newly registered dental nurses could help to improve productivity of the scarce dental workforce but this is unlikely to be embraced by the profession unless additional funding is also provided.

6.  Patient's Access to NHS Dental Care

  6.1   Over one million patients were disenfranchised by the failure of dentist to take up NHS new contract offers. Whilst this work has been recommissioned it is not always in the same areas and in many cases has been slow to come on-stream.

  6.2  Figures at April 2007 the first anniversary of the contract showed 50 000 patients less being seen. More worryingly the latest Department of Health figures show 250 000 less patients being seen in the two years to September 2007 than in the period prior to the contract. It is worrying to consider that if this increase is extrapolated by the end of two full years of the contract as many as half a million patients may have lost access to care.

  6.3  Much work has been carried out by the Department of Health and PCTs in areas with little or no provision to commission new contracts and restore NHS Dentistry to areas where it had become scarce or non-existent.

  6.4  Threats of dentists leaving the NHS in the run up to 2009 are detailed in paragraphs 4.4, 9.3 and 9.4. Whilst the principle is now well established of recommissioning lost activity there is a considerable time lag until this recommissioned volume comes on-line and in the meantime patient access is disadvantaged.

  6.5  The announcement of an additional 11% funding for NHS Dentistry in 2008-09 is to be welcomed and it is hoped that a substantial proportion of this additional income will go towards addressing improved access.

  6.6  There is evidence that the most disadvantaged in society, those irregular attenders with high oral health needs are having greater difficulty in accessing dental treatment since they have large amounts of work to be carried out for the same fee and are not perceived by the dentist to be economical. A greater understanding of the economic drivers is needed by both the profession and PCTs to ensure no patients are disadvantaged in this way. It is particularly important therefore that PCTs are aware that new contracts awarded in areas where there has not been previous previous may need to reflect higher UDA values than those where the majority of patients are regular attenders. This recognition clearly only exists in a handful of cases at present.

  6.7  Patient charges are now simpler for the patient to understand but in many cases patients are paying more for similar items of treatment than prior to the new contract and this is a disincentive to change.

  6.8  Operation of the current charging system for emergency treatment and continuation of treatment is open to abuse (in a number of cases encouraged by the PCTs to maximise charge revenue) and should be reviewed.

7.  The quality of care provided to patients

  7.1  NHS Dentists in general continue to provide a high level of care for their patients but drivers have been introduced by the UDA system in the new contract which have tended to reduce this quality of care.

  7.2  Molar endodontic treatment, taking at least an hour of chairside time, but attracting only the same number of UDAs as a simple filling taking 10 minutes has almost become a thing of the past. Our helpline has multiple calls on a daily basis from patients who are being denied this conservative treatment.

  7.3  Levels of extractions are increasing, almost doubled from the Department's own figures and as a result we may expect to see an overall decline in the nation's oral health over a period of time. The dental trade have witnessed significant increases in the sale of dental forceps supporting this perception.

  7.4  Cost neutral models to address this slant in prescribing have been proposed but are rejected out of hand by the Department.

  7.5  The number of crowns and volume of advanced restorative treatment being provided within band three has decreased greatly. Whilst it may be true that the previous system tended to encourage overt treatment it seems increasingly clear that the current system is encouraging under treatment. In these days of evidence based health it is simply not adequate to suggest that the previous system encouraged over provision and the current system has things right. The Department has a duty to commission research to determine the appropriate volumes of treatment to be provided.

  7.6  Some cases exist where excessive UDA targets have led to delivery of a poor quality of service and little attention to diagnosis and such items as smoking cessation.

8.  The extent to which dentists are encouraged to provide preventative care and advice

  8.1  Options for change contained promises for a new focus on prevention to produce long term improvements in dental health.

  8.2  The last minute introduction of volume measures for treatment in the form of Units of Dental Activity (UDAs) in an attempt to retain control over dentist's treatment output meant that this opportunity for prevention was lost since prevention per se did not attract a payment for UDAs.

  8.3  Overall allocation of UDAs was at a level to commit the dentist to lower levels of activity than in the previous year. It was the stated intention that this shortfall of activity be allocated toward preventive treatment. With the major adaptations required by dentists to work within the new system, an untried volume measure in UDAs and a requirement to meet UDA targets by the year end, few if any practitioners have focused on prevention.

  8.4  The development of an Evidence Based "Toolkit for Prevention" in Primary Dental Care with the production of which the author of this evidence was involved is to be welcomed. Extensive distribution of the toolkit to PCT Commissioners and general dental practitioners should give a basis for high quality delivery of a preventive approach.

  8.5  In the absence of specific funding for this preventive approach which is resource intensive for the practitioner it is difficult to see that the impact of this document will be to deliver increased levels of prevention.

  8.6  As the co-ordinator of Mouth Cancer Awareness Week the Foundation has a particular interest in the role of practitioners in carrying out regular screening of patients for mouth cancer, particularly at risk groups. Mouth cancer is one of the fastest increasing of all cancers and unlike most other cancers survival rates have not increased over the past thirty years. This is largely as a result of late detection. It had been hoped that a new preventive approach would encourage greater and more detailed screening but pressure to achieve UDA targets has meant that this has not been seen.

9.  Dentist's workloads and incomes

  9.1  It is not within the remit of the Foundation to comment on this item specifically.

  9.2  The new system was designed to be workload neutral, indeed to free up time for prevention. In the event some practitioners have been challenged to achieve their targets, others have achieved them early and not been able to provide treatment at the end of the contract year. This inequitable situation disadvantages patients and flexibility needs to be introduced into the system to ensure maximum access by patients.

  9.3  Dentists are clearly worried by reallocation of unused contract funds at lower levels than they are currently being paid and what the impact of this will be when fee levels are renegotiated in 2009.

  9.4  Control of assignment of contract when a practice is sold now being vested in the PCT leads to uncertainty for the practitioner leading up to sale, often at retirement and this could impact adversely both on the practitioners overall financial management and provision for retirement and their long term commitment to the NHS.

  9.5  There is an acute lack of NHS orthodontists both in primary and secondary care and the effect of the new contract appears to have been to exacerbate what was already an acute problem as many general dental practitioners who carried out limited orthodontic treatment no longer do so. It is essential if waiting lists are to be shortened that further training places for orthodontists are provided as a matter of urgency. Mechanisms should also be sought to re-engage general dental practitioners happy to carry out orthodontics with appropriate payment mechanisms.

10.  Recruitment and retention of NHS Dental Practitioners

  10.1  Whilst many practitioners remain disillusioned about the new system and their future within NHS Dentistry it is difficult to envisage that it will be an attractive career option and for the reasons already discussed more dentists are likely to look to leave the NHS in future years.

11  Recommendations for Action

  11.1  Greater dissemination of good practice to PCTs and further training in the delivery of quality commissioning leading to quality delivery of care.

  11.2  Imposed focus on Strategic Health Authorities with regard to their role in provision of good quality dental care for their population.

  11.3  Review of distribution function and workload for Consultants in Dental Public Health.

  11.4  Review of current UDA system to encourage a more preventive approach and to ensure that the system encourages delivery of quality dental care.

  11.5  Research into the appropriate level of band 3 complex treatments.

  11.6  Provision of a specific incentive for prevention.

  11.7  Institution of a requirement to screen for mouth cancer.

  11.8  Review of the current application of the patient charge system for treatment continuations and emergency treatment to reduce patient disadvantage inherent in the current operation of the charging system.

  11.9  Review of the patient charge system to make this more equitable, this could align with a review of UDAs.

  11.10  Provide practitioner security and reassurance to stop a drift away to private practice.

  11.11  Further training places for orthodontists should be provided as a matter of urgency.

  11.12  Mechanisms to re-engage general dental practitioners able to provide some orthodontic services should be introduced.

  11.13  More robust systems for out of hours service need to be introduced in some areas.

Dr Nigel L Carter BDS LDS(RCS)

Chief Executive

December 2007