Memorandum by the British Dental Association
(D 7)
EXECUTIVE SUMMARY
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.
INTRODUCTION
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.
EXTENT OF
THE ACCESS
PROBLEM
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.
3. ISSUES ARISING
FROM ACCESS
PROBLEMS
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.
4. HOW WELL
DOES THE
GOVERNMENT'S
DENTAL STRATEGY
ADDRESS ACCESS
PROBLEMS?
There are three main areas in which the Government
has made proposals to improve access to NHS dentistry:
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.
5. EFFECT OF
STRATEGY ON
ORAL HEALTH
AND SERVICE
DELIVERY
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.
6. SOLVING THE
ACCESS PROBLEM
IN THE
SHORT TERM
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;
— 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.
7. SOLVING THE
PROBLEM OF
ACCESS TO
NHS DENTISTRY IN
THE LONGER
TERM
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.
8. THE PRIORITIES
OF THE
BDA
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
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