Select Committee on Health Minutes of Evidence

Memorandum by the British Dental Association (D 7)


  1.  The BDA is working constructively with the Government to try to fulfil the Prime Minister's pledge that, by this September, anyone who wishes to will be able to find a dentist to provide NHS care.

  2.  Modernising NHS Dentistry concentrates on short-term solutions to the problem of access, offering a single episode of treatment to relieve current symptoms.

  3.  In the long term, access to regular care must be maintained across the service and access improved for disadvantaged groups in areas where there is poor oral health.

  4.  The British Dental Association has found that there are access problems for non-registered patients, but those registered with a NHS dentist have little difficulty in gaining access to NHS dental care. Many people in disadvantaged groups fail to access dental care.

  5.  The BDA estimates that around 1,000 full time additional dentists are needed if the Government is to achieve its objective of giving access to NHS dental care to two million more people.

  6.  The intensity of dentists' workload prevents many dentists from taking on new patients. The BDA will begin its own fundamental review of remuneration and working conditions of dentists in general practice.

  7.  The Government has proposed a range of measures to improve access. These are useful but their long-term benefit needs to be monitored.

  8.  The BDA has a five-point plan to improve NHS dental care, including an end to the postcode lottery of NHS dental provision, where access in some areas is much worse than in others, incentives to ensure dentists continue to work within, or return to, the NHS and investment in services and equipment of £100 million in real terms each year for the next five years.


  1.  The Health Committee is to examine: "whether the Government's strategy, Modernising NHS Dentistry: Implementing the NHS Plan, will improve access to NHS dentistry in the long term".

  At the 1999 Labour Party Conference, the Prime Minister asserted that by September 2001, anyone who wanted NHS dentistry would be able to get it by making a phone call to NHS Direct. The British Dental Association (BDA) saw this statement as significant. It was the first time, to our knowledge, that dentistry had been mentioned in such a speech by a serving Prime Minister. Patients may well have thought that this indicated that they would again be able to choose a dentist for comprehensive dental care on a regular basis. It was also an opportunity for the dental profession to regain its full part in NHS primary health care.

  The BDA believes that the Government may be able to fulfil the Prime Minister's pledge in the short term, but a comprehensive system of regular dental care for all is still a long way off. The Government's current strategy for dentistry, Modernising NHS Dentistry, has concentrated on short-term solutions to the problem of access, offering a single episode of treatment to alleviate a current dental problem. Evidence shows that it is those who do not attend regularly who have the greatest difficulty in finding an NHS dentist. We understand, therefore, why the Government is initially targeting its efforts on this aspect of the problem, but this will not solve the long-term problem of primary care access to dentistry, nor the many outstanding oral health problems and health inequalities. Hence efforts must continue beyond September 2001 to address the long-term problems of access to NHS dentistry.


  2.  Access to NHS dentistry has been difficult for many patients in recent years. David Kidney MP described this in the debate, which he initiated in Westminster Hall on 20 December 2000, as "a matter that is frequently raised by Honourable Members at Question Time and in correspondence with Ministers". The Government's strategy, Modernising NHS Dentistry admits that "about a third of health Authorities report serious problems in finding dentists for at least some of their residents".

  We have also carried out a number of surveys. In 1996 the BDA commissioned a Harris Poll, which found that more than one in three people (35 per cent) claimed it was difficult to find an NHS dentist in their area. In this survey those living in the south east of England claimed much greater difficulty, with over half of respondents saying it was a problem. Members of the public finding the most difficulty were those aged 18 to 34 years with nearly half expressing concern.

  Early last year, the BDA carried out a survey of Health Authorities. We found that they received a total of some 20,000 phone calls each month, regarding problems finding a dentist. When NHS Direct starts taking dental enquiries, there may well be a substantial increase in the numbers of such calls. Two-thirds of Health Authorities reported a shortage of NHS dentists locally and one third reported an increase in the number of calls they received about the problem since the previous year. Travelling distances were also said to be adding to access difficulties, with over half of Health Authorities saying that the distance patients had to travel to obtain NHS care was a problem. Of these around two-thirds said public transport was insufficient.

  In June 2000, the Doctor Patient Partnership, with the BDA, published results of an independent survey. Over two-thirds of respondents said they would be more likely to go to see a dentist if they could definitely get NHS treatment.

  In the Westminster Hall debate, Julia Drown MP raised the subject of patients being re-registered if they returned to their dentist within 15 months. Registration levels with dentists have been relatively static over the last three years with 18.4 million adults and 7.45 million children being registered with a dentist in England and Wales in June 2000. These figures represent an increase of 1.3 per cent for adults and 0.6 per cent for children over the previous year. On average each month in England another 568,450 new patients are registered, although a similar number leave dentists' lists, usually because they have not returned and their registration has lapsed. The recent Adult Dental Health Survey in 1998 found that 71 per cent of adults had visited their dentist over the last year, although there is no indication as to whether they were seen under the NHS or as private patients.

  There is also substantial research evidence that many specific groups of people fail to access or even seek oral care. These include people with learning disabilities, certain ethnic groups and housebound older people. Many people are also regular patients of the Community Dental Services even if they are not registered in the same way as in the GDS.

  From these findings the BDA concludes:

    —  there are access problems for non-registered patients, especially in areas where dentists are not taking on new NHS patients;

    —  people registered with an NHS dentist have little difficulty in gaining access to NHS dental care;

    —  not all of these dentists have increased their private work; some are unable to take on new patients owing to pressure of work; and

    —  many people in disadvantaged groups fail to access dental care.


  Three main issues arise from these access problems:

    —  Workforce—are there enough dental professionals to meet patient need?

    —  Workload—many of our members tell us that they are already working to full capacity and cannot take on any additional patients.

    —  Registration—Modernising NHS Dentistry questions the value of registration as the sole measure of availability. The BDA supports registration as a measure of access to routine care.

3.1  Workforce

  The BDA estimates that around 1,000 full time additional dentists are needed if the Government is to achieve its objective of giving access to NHS dental care to two million more people (Modernising NHS Dentistry (para at 2.17))—on the basis that a whole time dentist will look after about 2,000 patients.

  Based on a survey of our members, we have some doubts about whether the target of two million extra patients can be achieved. The main reason for thinking this way is that there is currently a shortage of dentists. The output of UK dental schools in 1999 was 810 dentists a year, around half of whom are men. That year 891 dentists joined the Dentists Register from overseas—including the European Union (375). However, increasingly, young dentists are choosing to practice on a part-time basis, often to balance a career with family care or other responsibilities.

  The shortage of dentists cannot be addressed in the short or medium term by training more students. University courses last five years, with an additional year for vocational training. However, there are a number of ways in which the overall work force in the NHS could be increased:

    —  encourage dentists to see more patients under the NHS and fewer privately;

    —  encourage those dentists who have chosen to work part-time to increase their hours in practice;

    —  create better working conditions for women to encourage them to return to work after a career break;

    —  for the Government to make greater capital investment to provide more facilities and modernise practices;

    —  make better use of the skills of professionals complementary to dentistry, especially hygienists and therapists;

    —  train more professionals complementary to dentistry; and

    —  Modernising NHS Dentistry appears to suggest that, by restricting the range of treatments available under the NHS, more patients could be seen.

  The Chief Dental Officer (England) has set up a Dental Modernisation Steering Group to implement the strategy and take it forward into new areas. The Government has also commissioned a study into the career aspirations and working patterns of women dentists. The BDA warmly welcomes both these initiatives. Prior to giving evidence to the latter inquiry we surveyed a sample of our women members, who told us that the conditions of service and the remuneration system within the General Dental Services discouraged them from returning to work.

  The Government has been slow to encourage professionals complementary to dentistry to play a greater part in NHS dentistry. The BDA believes that the recent decision by the Privy Council not to allow dental therapists to work in general dental practice was a wasted opportunity, as there are hundreds of such professionals who are unable to return to dentistry because of a lack of employment opportunity. The BDA has been pressing for more training places for all members of the dental team.

  There are proposals within Modernising NHS Dentistry under the general heading of "safe and clinically effective treatments" (paras 4.25 to 4.39), which suggest that some prioritisation may occur in relation to which treatments are allowed to be provided under the NHS. The BDA is not opposed in principle to making such changes, but feels that these should be done within the context of evidence-based research, with an open debate into priority setting in NHS dental services.

  If the Government is to succeed in its aim to improve access, it must encourage dentists to increase their commitment to NHS work. Modernising NHS Dentistry has made proposals to achieve this, which will be commented upon later. The Review Body for Doctors and Dentists Remuneration, in its most recent report at the end of last year, looked at morale within the profession and the need to encourage dentists back into the NHS. The recently introduced commitment payments, which they recommended to help address the problem, should persuade many dentists to continue working in the NHS. But they are unlikely to encourage many of those who have left the NHS, to work in the private sector, to return.

3.2  Workload

  One of the reasons why BDA members consider that it will be difficult to solve the access problem, within the short term, is the intensity of dentists' workload. In recent years there have been reports of high levels of stress within the profession and many dentists tell us that they cannot take on more patients. Although between June 1999 and June 2000, the average list size per dentist rose by 2.2 per cent, this will have little effect on the overall access problem.

  A recent independent survey carried out for the Review Body for Doctors' and Dentists' Remuneration looked at the reasons why dentists were turning away from NHS dentistry:

    —  about 70 per cent said they felt rushed when treating NHS patients;

    —  around 60 per cent said that their workload did not allow them to provide the professional standard of care with which they were comfortable; and

    —  while at present 60 per cent of dentists spend at least 90 per cent or more of their time working in the General Dental Services, only about 16 per cent expected to be so committed in five years' time.

  As long ago as 1964, A BDA committee looking at dentists' methods of remuneration concluded: "There is no future for the profession or indeed for general dental practice as an art or a science, in a system of remuneration as presently operates." More recently, in 1993, a Government inquiry by Sir Kenneth Bloomfield and a report by the House of Commons Health Select Committee suggested that there should be radical changes in the way in which dentists are paid, but no action was taken on either report.

  The BDA was disappointed that the Strategy made no provision for change in this area. Later this year, the BDA will begin its own fundamental review of remuneration and working conditions of dentists in general practice. We will invite the Department of Health to work with us on this project.

3.3  Registration

  Modernising NHS Dentistry questions the value of registration as a measure of availability (para 2.19) and that the registration system introduced in 1990 was a significant factor in the reduction of access to NHS dentistry (paras 3.3-3.4). The value of regular check-ups and scaling and polishing of teeth are also questioned (paras 4.37-4.38). While challenging existing ideas is always valid, it is also important to understand the health advantages of continuing care and a preventive oral health approach that registration and regular check-ups bring.

  The BDA supports Dr Peter Brand MP, who, in his contribution to the debate in Westminster Hall, dealt with the contrast between emergency treatments provided in Dental Access Centres with a more holistic approach with an emphasis on prevention found in general practices. Dr Brand concluded: "If emergency treatment is delivered through a separate agency, there is no support between preventive, maintenance and emergency work. That is why I find the direction we are taking problematic". Clearly, Modernising NHS Dentistry will have failed to deliver, in the words of the Secretary of State, "fast, accessible care" if greater access for the unregistered patient is provided at the expense all those who attend on a regular basis.


  There are three main areas in which the Government has made proposals to improve access to NHS dentistry:

    —  information;

    —  new facilities; and

    —  incentives.

4.1  Information

  NHS Direct will be expanded this April to include NHS dentistry, advising patients where to find an NHS dentist and how to get services outside normal working hours. The BDA supports this and is working with the Department of Health to ensure that it is implemented successfully. However, there is little evidence at present that there is sufficient spare capacity to deal with this demand. It will be important to monitor the impact of NHS Direct on the access problem.

4.2  New facilities

  The first Dental Access Centres were set up in Cornwall and Shropshire two years ago. In all there were eight projects up and running when Modernising NHS Dentistry was published with plans to have 50 by 2002, which will treat up to half a million patients a year. The BDA supports, in principle, Dental Access Centres, which will increase the number of patients that can be seen. However we have reservations about their operation. We are concerned about the pay differentials for those dentists working Access Centres and those in NHS Trusts, of which the Dental Access Centres are part. We are also anxious that they should be evaluated, particularly as they appear to be very expensive to run. Any part of the evaluation should be an inquiry into their cost-effectiveness.

  The Dental Care Development Fund will allocate up to £4 million to assist dentists in the General Dental Services to expand their facilities and see more patients. The BDA has been consulted over the process for authorising these funds. We note that the Government will monitor the outcome of this expenditure and decide if more funding is needed in 2001-02. We will be pressing the Government for further allocations if this proves to be necessary.

  Modernising NHS Dentistry also envisages new partnerships being developed between dental practices and local Health Authorities. We understand that dentists may be paid to keep some time free to see unregistered patients. The proposal is both novel and imaginative. Working with the Government, the BDA hopes that this can be developed to provide improved access for patients with proper remuneration for dentists.

  Properly funded salaried dental services, such as Personal Dental Services, Community Dental Services and a Salaried Dental Service represent a huge opportunity to develop and improve services for people with difficulty accessing NHS GDS dentistry.

  The Community Dental Service already provides services for patients with recognised access problems. This role should be protected and expanded alongside efforts to improve access in the General Dental Services.

4.3  Incentives

  Encouraging General Dental Practitioners to work more within the NHS is a prime objective of Modernising NHS Dentistry. Commitment payments, which are paid to dentists over the age of 35 who show a high level of commitment to the NHS, only started to be paid three months ago. It is difficult, therefore, to assess how significant their contribution to better access will be. However, in the Review Body's last report, they made several recommendations that will bring much needed stability and continuity to this scheme. The BDA is now in constructive negotiations with the Department of Health to see how the scheme can be improved from April 2001.

  A Modernisation Fund of £35 million will also be available to those dentists who are committed to the NHS to improve the fabric and equipment of their practices. The details of the scheme are still being worked out but it would appear that they will provide much needed capital and may encourage dentists to continue to work in the NHS.

  The Review Body also recommended payments for dentists taking part in Continuing Professional Development and Clinical Governance. These payments, if implemented, will be very welcome and exceed those outlined in Modernising NHS Dentistry. Although we are still engaged in negotiations on their implementation, it is too early to say what their effect will be on keeping dentists committed to the NHS.


  Improving access is the Government's top priority for NHS dentistry. Most of the strategy and almost all the additional resources are directed towards that objective. This is in contrast to the Scottish Executive's Dental Plan, which makes its first priority improvements in oral health. The BDA believes that concentration on access should not be at the expense of other health care objectives.

  The BDA is disappointed that the Strategy places such a low priority on reducing inequalities in oral health. We have been pressing for the introduction of water fluoridation in areas where there is poor oral health for many years. We believe that there must be improved services for those in socially deprived areas and among minority ethnic groups. We were, however, pleased to see that in the Dental Modernisation Steering Group a sub-group has been set up to look at these issues and we look forward to working on this with the Department of Health.

  Members of the BDA working in the Community Dental Service have voiced concerns that the concentration of their role on access can lead to fewer resources being directed toward their traditional role of treating patients with special needs as a result of physical or mental disability. We have given evidence to the Review Body that, in some Trusts, those dentists caring for such patients are at a financial disadvantage compared with those who have been recruited to improve access.

  Those patients who use the Community Dental Service are not the same patients who use the General Dental Services, nor have they ever been. These patients are often vulnerable and their needs can be overlooked when others are more vocal. If the Community Dental Services were to be reduced, the impact on such vulnerable patients would be very considerable.

  Access to specialist and secondary (hospital) care is largely ignored in the strategy. A survey of our consultant members working in the field of orthodontics (straightening teeth) last year showed considerable variations across the country for both waiting and treatment times. In the worst instance this amounted to four years, with another two years for the treatment to be completed. The 1993 Child Dental Health Survey showed that 28 per cent of 15 year olds needed orthodontic treatment. The problems of orthodontics are addressed in paragraphs 4.32 to 4.36 of Modernising NHS Dentistry. The BDA is working with the Department of Health to improve such services. The BDA recommends that action be taken towards an integrated specialist care service in dentistry.

  Improving high quality NHS dental care is an objective of the strategy, but in terms of resources applied it very much takes second place to that of access. The Review Body recommended better rewards for those who take part in continuing professional development and, in the future, Clinical Governance. This, to some extent, remedies some of the deficiencies of the Strategy.


  The BDA will work with the Government to try to fulfil the Prime Minister's pledge that, by this September, anyone who wishes to will be able to find a dentist to provide NHS care. A key to this solution is NHS Direct, which will need systems in place from 1 April to enable it to identify those Dental Access Centres, clinics and practices able to meet this demand.

  Crucial to achieving this objective will be the role of Health Authorities, whose responsibilities in this respect include:

    —  keeping NHS Direct informed on available facilities;

    —  disbursement of funds through the Dental Care Development Fund;

    —  the Modernisation Fund to improve practices;

    —  Dental Access Centres;

    —  new partnerships with dentists, groups of practices and Primary Care NHS Trusts;

    —  Personal Dental Services and Salaried Dental Service; and

    —  monitoring the work of the Community Dental Service in reducing health inequalities and providing access for disadvantaged groups.

  In the past Health Authorities have complained that there was little they could do to address the access problem and improve primary care dental services, because they had no levers or management control over the general dental services. Although dentists will remain as independent contractors, Health Authorities have local responsibility to improve access. To do this they will need to work in close partnership with local dentists, especially Local Dental Committees and Oral Health Advisory Groups. The BDA is working to keep these groups informed about opportunities for closer working.


  Modernising NHS Dentistry focuses on the patient who is not registered with a dentist and probably does not seek treatment on a regular basis. The BDA believes that the main function of the General Dental Services is to offer care on a continuing basis to patients who attend the dentist of their choice regularly. We also believe that dentists working in the Community Dental Services have developed the speciality of caring for patients with physical and mental disabilities and have an important role in providing access to care for those who would not register with a GDS practitioner.

  We believe that nothing should be done in the short term to jeopardise these important functions, indeed, access to these traditional services also needs improving. The problems of access for patients with poor oral health, perhaps living in socially deprived areas and in minority ethnic communities and for the older housebound patient need to be further addressed. Access for patients in an emergency and out of hours care is mentioned in Modernising NHS Dentistry, but progress in these areas must be carefully monitored to prevent time and money being wasted.

  We will be closely following progress in the Dental Modernisation Steering Group in the areas of workforce, quality, education, IT and oral health inequalities, and will be contributing to their work. We will also be making progress on a fundamental review of the system of dentists' remuneration.


  The BDA has published a five-point plan for the improvement of NHS dental care provision. This is:

    —  an end to the postcode lottery of NHS dental provision, where access in some areas is much worse than in others;

    —  incentives to ensure dentists continue to work in, or return to, the NHS;

    —  investment in services and equipment of £100 million in real terms each year for the next five years;

    —  improved quality within NHS dental services, through training, both for dentists and other oral healthcare professionals; and

    —  a comprehensive oral health improvement programme, through targeted water fluoridation and oral cancer screening.

January 2000

previous page contents next page

House of Commons home page Parliament home page House of Lords home page search page enquiries index

© Parliamentary copyright 2001
Prepared 27 March 2001