Memorandum by the General Dental Practitioners
Association (D 29)
MODERNISING NHS DENTISTRY—IMPLEMENTING
THE NHS PLAN—THE DENTAL STRATEGY SEPTEMBER 2000
1. INTRODUCTION
The General Dental Practitioners Association
(GDPA) is one of the two Trade Unions in Dentistry. The GDPA was
founded in 1954 to represent, only, the General Dental Practitioner
(GDP)—the high street dentist.
2. WILL THE
DENTAL STRATEGY
WORK?
2.1 This document had been awaited for several
years and the wait only resulted, for the most part, in the expected—doing
nothing of significance. What is most surprising about it is the
manner in which it differs, so markedly, from the overall NHS
Plan which contained admissions of long-term underfunding and
the promise of monies to rectify this.
2.2 The overriding principle for judging
the value of this document is:
Does it propose measures that will achieve the
prime directive which is to entice a majority of general dental
practitioners to increase their commitment to the dental NHS?
The present access problems stem entirely from
the steady reduction of the time GDPs are prepared to donate to
the dental NHS and it is only a reversal of their attitude that
will bring about the desired rectification of the problem.
2.3 GDPs know that 100 per cent NHS dentistry
is not economically viable and that the rewards pale into insignificance
when compared with those they experience in private practice.
Not jut financial, although these are paramount, but mental and
physical—which come from the ability to provide treatment
to a standard that enables GDPs to get satisfaction from, and
have pride in, the work they do.
2.4 Does this strategy deal with the problems?
No!
Will it succeed in the prime objective? No!
2.5 It does make some admissions, some of
which deal with fairness and equity which have been the cornerstones
of GDPA policy for many years. The GDPA has maintained that the
principle of a national fee scale, which takes no cognisance of
local conditions and results in financial punishment for those
whose dedication is of the highest, cannot be just. Therefore,
both Equalisation of Expenses Ratios—[which means that where
local costs are above the average (such as in London as an example)
resulting in reduced reward for the same item of service carried
out elsewhere]—and Deprivation Payments—[concerns
the fact that although the item of service fee applies to a specific
treatment classification, the work involved is not the same in
areas of social deprivation, where caries, for example, is gross
and extensive and the treatment involves a much greater expenditure
of time]—require incremental payments to bring nearer the
goal of parity of reward.
2.6 The Dental Strategy document offers
a "loyalty bonus" as a solution but this has already
been achieved via the Review Body on Doctors and Dentists Remuneration
(DDRB) and does not address the problem properly. The previous
Select Committee understood the issues well as shown by their
Report of 1992-93. We draw attention especially to paragraphs
198, 200, 201, 202 and 203.
2.7 We regarded these increments for pay
parity to be a partial, temporary solution whilst awaiting the
arrival of a strategic plan which would tackle the underlying,
root cause and, preferably, offer a totally new system. A plan
which would do away with the twiddling and fiddling with a system
that was initiated as an interim measure in 1948. As the Secretary
of State for Health writes in his foreword: "NHS dentistry
has served the country well for over 50 years. Just like the rest
of the NHS, it now needs to modernise".
This is that plan and it does not even mention
the primary areas for modernisation which are in its methodology
and the levels of practitioner reward—and, in honesty, the
strategy can only be classed as a failure and a waste of all our
time!
2.8 Through political eyes it would seem
that the key objective, feature No 1 is to keep the Prime Minister's
September 1999 commitment "NHS dentistry shall be available
by September 2001, to everyone if and when they need it".
2.9 This does not mean that dentistry, as
an entirety, is to be available, but that the relief of pain shall
be the prime criterion. Thus a great deal of emphasis (and of
the money too) is aimed at the formation of "dental access"
"drop in" centres. We, along with all other dental organisations,
have demonstrated in the past, that the only financially efficient
provider of primary dental health care is the "ordinary"
GDP.
3. ANALYSIS
3.1 The GDPA submitted to this Government,
on its accession, an extensive briefing paper and also a "think
piece" entitled "If the NHS had not been invented would
it be created today—and in what form?"
In these papers we suggested:
(a) that circumstances today leave the public
with the view that government's obligation is only needed for
those of the socially deprived; and
(b) that nobody, and that includes government,
can have what they are not prepared to pay for.
3.2 The responses to the Bloomfield Report
all echoed this latter feeling and the General Dental Services
Committee's response suggested that if no additional monies were
to be provided then prioritisation, by class, for treatment should
be instituted. It was envisaged that there would not be sufficient
money to pay for those who did not receive relief from statutory
payments.
3.3 As previously commented above, the institution
of Equalisation of Expenses ratios, Deprivation Payments and Loyalty
Payments were needed:
(a) to reward and retain those GDPs working
in the high cost, socially deprived areas—but only if no
overall restructuring of the dental NHS was carried out; and
(b) to enable government to carry out its
obligations to the poor and needy.
3.4 The Nuffield Group published an unsolicited
paper on the subject of the use of ancillary staff for dentistry.
Even though they themselves inserted several
caveats including that the introduction of ancillary staff could
not be countenanced without radical change of the system of remuneration
for NHS GDPs and that there was no proof, whatsoever, that there
would be any money saving by their introduction this was seized
upon by Government as "dentists are too expensive to do dentistry"
and costs could be brought down by their employment.
Nobody would claim that the dilution of the
profession by this means would lead to a raising of quality yet
this plan includes this as part of a chapter which states that
its target is that of the NHS being "more clinically effective
and more cost effective".
3.5 There is a mass of statistical evidence
which proves beyond doubt, that the most efficient and cost effective
method of providing treatment to patients is via the general dental
service provided by GDPs. Most of this evidence the Departments
of Health have ignored, denying the fact of the immense capital
costs outlay that is involved in the provision of a dental practice.
It is, in fact, only of very recent times that DDRB have appreciated
its extent and have expressed some concern when we showed that
sum to be in excess of £150,000.
3.6 In advocating the foundation of 50 "drop
in" centres, the Government, in this plan, is expecting a
cost of between £500,000 and £1 million each. This excludes
the revenue costs which will also be much greater than they expect.
It would appear to be a lesson Governments have yet to learn—the
hard and expensive way. It is going to prove to be very expensive
window dressing—so much more could have been achieved with
the money if it had gone to the right place and with the right
spirit.
3.7 Mr Blair, the Prime Minister, stated
in the House of Commons when introducing The Plan for the NHS
as a whole "that it suffered from years of underfunding"
and that he was "going to increase spending by a third over
the next five years".
If this were to be applied to the dental NHS
this would correspond to at least an additional £500 million.
3.8 As the GDS is provided by GDPs who are
independent, private sub-contractors without any governmental
funding as to their practice capital and revenue costs this should
have, reasonably, resulted in paying GDPs 33 per cent more (even
if this low level figure of underfunding was accepted by reducing
the level of dental underfunding to that of the NHS in general).
3.9 This plan ignores any mention of paying
all GDPs more via a raised item of service fee-scale. In fact
it offers nothing to GDPs in general except peer review, clinical
governance mandatory postgraduate education and re-registration.
It mentions only some local incentives and loyalty
pay (whose existence has already been established and which accounts
for £20 million of the total figure of £100 million
mentioned in the document).
3.10 There is no mention of any goal which
involves increasing the fee-scale by an amount that would be of
significance and which would stand any chance of enticing those
GDPs (who comprise 90 per cent of profession) to increase their
dental NHS commitment despite the admission of the great fall
in the commitment of GDPs to the NHS.
Nor does the plan call for an order of increased
spending that would be in the same ballpark as that which Mr Blair
stated to be necessary.
Nor does it meet with the Secretary of State
for Health's foreword ". . . and makes sure that the development
of dental services in England will be consistent with, and a core
part of, the NHS plan".
3.11 There is no mention of the important
subject of standards of treatment nor, more importantly, of the
question of raising them. Chapter 4 "Improving Quality"
concerns itself with:
(a) clearer information for patients as to
their rights;
(b) strengthening self regulation of the
profession (although the "self" part seems destined
to be diminished (4.22) by re-organising the GDC to have more
lay members;
(c) the implementation of clinical governance;
and
(d) continuing to tackle fraud.
3.12 We feel it would be appropriate to
include some of the comments from Chapter 1 of the very recently
published 30th Report of the Doctors' and Dentists' Review Body
on Remuneration.
— "We particularly welcome the
acknowledgement in the Plan (NHS Plan) of the underfunding and
staff shortages the professions have raised with us over recent
years."
— "With the exception of the retention
of dentists in the NHS we see no evidence at present of major
retention problems among our remit groups."
— "We are glad to see that the
Health Departments have acknowledged that, increasingly, GDPs
are reducing their commitment to NHS work."
— "The retention of GDPs in the
NHS and their motivation do not appear to us to be improving.
We consider that in order to meet the commitments in Modernising
NHS Dentistry it is important to encourage GDPs' retention
in the GDS and introduce measures to increase their motivation."
— "It seems to us that the survey
[DDRB commissioned BMRB International to carry out a survey on
its behalf] into GDPs hours of work and workload support some
of the concerns the profession has raised with us about GDPs'
workload and its subsequent impact on GDPs retention in the NHS
and on their morale. We believe that the survey's findings tend
to support the professions' assertion that the GDPs' reducing
commitment to GDS dentistry stems, in large part, from a desire
to alleviate the pressures under which they are working in the
GDS."
— [Research done by the GDPA shows
that GDPs in most of the civilised world have a workload of 10
to 12 patients a day, four and a half days per week (against 30
to 40 per day for a UK, NHS GDP) for a standard of living much
higher than that which NHS GDPs enjoy today.]
— "We continue in the belief that
a comprehensive fee relativity exercise is long overdue and that
such an exercise should re-evaluate treatment timings having regard
to quality objectives, clinical developments and patient expectation."
This is a précis of part of what the
DDRB diagnoses as being wrong with the dental NHS and anyone who
reads the dental strategy document will readily see that nothing
is done to redress the ills.
4. CONCLUSIONS
4.1 To make the NHS (and by implication
the dental NHS) something "to be proud of and the envy of
the world" was Mr Blair's stated intention. To do this a
great deal more money is required—most of it for substantially
increasing what GDPs are paid for the treatment they provide—and
it is obvious, the Government has no intention of so doing!
The plan, both by its contents and its omissions,
make this abundantly clear. Rather, it would seem, the Government
would prefer to redefine its role and commitment on the lines
that its obligation is to provide treatment only for emergencies
and for those unable to afford the private fees.
4.2 That the service is to be of a "first
aid service" type is clearly demonstrated not only by the
lack of mention concerning standards of treatment, which figured
so loudly in Mr Blair's Commons statement, but also by the intention
to establish, at great cost, NHS Direct (the dentists finding
bureau) and NHS Dental Access centres. The declared purpose of
Access centres is to provide treatment for unregistered patients
(3.18) and thus defeating the other declared objective of improving
the nation's dental health by continuing care and prevention.
The remainder of the money is aimed at local
incentives primarily to deal with the areas of social deprivation—in
an effort to retain manpower, partially compensating for the effects
of high costs and higher time expenditure that those GDPs suffer.
4.3 There is also the intention (4.30) to
tighten "prior approval" for advanced and complex treatments
for such "treatments are sometimes given when they are not
justified". Additionally, in respect to orthodontics, (4.34)
"This will concentrate valuable NHS resources more on the
cases of greatest clinical need and less on purely cosmetic work".
Some abnormalities are more important than others and, despite
the effect they may have on the body and person as a whole, should
not be classed as treatment worthy, it would appear—even
by the new Professionals Complementary to Dentistry (PCDs).
The emphasis for the widespread use of "cheaper"
ancillaries who will, no doubt, be used as the main manpower source
for these centres, compounds this evidence (4.44).
4.4 By these methods, and by the lack of
any effort to tackle the root cause of the problem, the main body
of the dental NHS will be allowed to wither and perish.
4.5 Examining the inferences, suggests that
Government will, in its second term, seek to have a "nationalised"
dental health service with its emphasis on pain eradication—to
the detriment of the existing sub-contracted service.
It will accept a minimal obligation, such as
exists for Ophthalmics, carried out by and run by employees of
local Primary Care Trusts, in conjunction with Health Authorities,
in their own premises and will leave the "private sector"
to deal with the bulk of the population.
In the socially deprived areas, where demand
and obligation will be greatest, we believe that local authorities
will arrive at individual contracts of a purchaser/provider nature
or may even acquire existing practices, converting the incumbents
to a salaried basis or place a contract with a group owned practice
probably on a sessional basis.
4.6 This document suggests that patients
are called for check-ups too frequently and that many scale and
polishes (at a gross cost to the NHS of £122 million) are
provided without clinical justification (4.37 and 4.38). It goes
on to say—"It is possible that this treatment could
be provided more clinically effectively and cost effectively—and
both patients' and dentists' time better spent—by recalling
patients at intervals which match their individual needs more
closely."
Many patients need to be seen four or six times
a year (example: cases of poor gum conditions) and as GDPs cannot
claim for this the DoH assumes that it does not happen.
In paragraph 4.39 it suggests that there should
be discussions which "will cover the question of how to make
the best use of the time freed up—for example by treating
more new patients".
4.7 Whilst we appreciate that Government
has an obligation to scrutinise public expenditure dentists resent
this lack of trust.
This destroys morale and drives GDPs to reduce
their NHS commitment.
5. REMEDIES AND
ALTERNATIVE SYSTEMS
5.1 More money, in adequate amounts, made
available from central public funds would solve the problems virtually
absolutely. Rewarded at a proper level (not an outrageous one)
most of the problems would be managed within the compass of whatever
system was to be operated.
5.2 We would suggest that an net income
of the order of £65,000 per annum for an agreed, designated,
workload liability would see a huge reversal of the trend of haemorrhage
of personnel from the dental NHS.
This can be brought about in a number of ways:
(a) to bring the fee-scale nearer to that
which applies in the private sector. This should give an incentive
for those already remaining to stay as well as those who are beginning
to start therein.
(b) The acquisition of ownership of the practices
(as was the original intention) and placing GDPs into a similar
contract to that of GMPs.
(c) An alteration in the methodology and
level of financial reward. If some of the Bloomfield and Select
Committee recommendations were activated—such as the reimbursement
of fixed and staff costs—then reward for actual labour can
be made nearer to equal.
(d) The possibility of the introduction of
an adequately funded and remunerated, sessionally based scheme
should not be discounted.
If this were coupled to some further direct
reimbursement, say of rent, as already existing with rates, plus
Deprivation Pay increments (similar to Jarman Index) the goal
could be achieved. It was an ill sold previous idea—too
nebulous and supposedly cost neutral ever to have found the support
of the profession. It did not mean that it was totally unacceptable—for
it is the system by which consultants are paid!
5.3 However, if no further monies are to
be forthcoming then the maxim must be:
ONE CANNOT HAVE WHAT ONE IS NOT PREPARED TO
PAY FOR!
5.4 It must be accepted that the dental
NHS cannot offer a full range of treatments if it wishes to stay
within its financial limitations. GDPs cannot go on subsidising
the dental NHS.
(a) In its response to the Report of Sir
Kenneth Bloomfield the profession, accepting the implied reality,
suggested that the available monies be targeted to produce a "core
service" either by population type or by treatment type or
by a combination of both.
The profession expressed its willingness to
discuss this, in depth, further although its tendency was to population
type. This was defined as prioritising with children at the head
and then the poor etc.
(b) Some monies must be made available to
rectify the inequalities of high deprivation and high costs so
that a targeting of available money goes to the areas of population
most in need of treatment and the retaining of the manpower to
provide it.
(c) Alternatively, the GDPA has for many
years advocated a "Grant in aid" solution. The title
is misleading but the core of its suggestion is that of a credit
system whereby very basic treatment costs are provided for everyone
but that the patient is given the option to pay an additional
sum towards the cost of higher quality or more advanced treatment.
It can be exampled by Ophthalmic provision today.
The patient (if eligible) can pay additionally for better frames
or "varilux" lenses. The GDPA recommendation is that
all are eligible to a basic degree and can opt to pay extra.
This system is similar to that which pertains
in France.
5.5 The list above refers to alterations
to the status quo but other alternatives exist.
(a) Government could redefine its obligations
to the NHS.
If the NHS did not exist would it be invented
in its present form? Circumstances and social conditions have
changed considerably since 1948 and it is extremely unlikely that
the dental NHS would have included a format that included availability
to all—just as "free at the point of delivery"
no longer exists. The latest NHS Plan hints that the Government
may have this in mind with a service provided by state owned practices
(Access Centres and Drop in Centres) assisted by local contracts
with selected practices concentrating on the areas of social deprivation.
(b) An alternative methodology one could
consider is the institution of a totally private arrangement for
treatment with the patients being able to claim a refund from
public funds, in varying degrees, according to their tax code
number. This is the principle of the German Health Service.
(c) Another alternative would encompass a
scheme for compulsory insurance for dental treatment with the
public purse liable only for the premiums of those unable to pay—such
as those on income support.
Whether this compulsory insurance is provided
by the private sector or by the government itself is a political
decision. As can be seen from the figures in Appendix 1 there
is little difference. Similarly, the who should pay is a political
decision.
Should those in work pay the premium for their
families? Should others pay partially depending on their ability
to pay? Should a liability to pay be allied to their tax code
number? Should it be tax deductible?
The answer to such questions is not for us.
5.6 At first sight these proposals might
seem impractical, but closer examination reveals an impressive
logicality. Let us look at some of the bullet points for solutions
5.5(b) and (c).
— Why should there by any necessity
for government to be involved in the provision of health care
other than to make certain that all have the wherewithal to achieve
it?
— Why should government involve itself
in the vast costs of administration at both national and local
levels, quality checking and anti-fraud investigations when this
can be easily left to others including the patients themselves?
— In short, why should the provision
of dental health care be nationalised?
5.7 Which ever way that it is decided, government
should be involved (but only as a less than major partner) in
the regulation of the fee-scale which should be negotiated by
the profession and the insurers on an annual basis. There is now
a third party—corporate dentistry—involved in dentistry
whose existence would act as a market regulator.
The level of the premium should also be subject
to government control.
5.8 If a negotiated fee-scale level is determined
at an acceptable basic level and the treatments allowable specified,
then patients would be free to choose their preferred provider
and what level of quality of treatment they require a long as
they are prepared to shoulder the excess liability.
Governmental responsibility, in this scheme,
is reduced still further—and more of the onus is put where
it should belong—with the patient.
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