House of Commons - Health - Minutes of Evidence

Select Committee on Health Minutes of Evidence

Memorandum by the Department of Health (D 1)

CONTENTS

EXECUTIVE SUMMARY

1. This memorandum describes the measures announced in Modernising NHS Dentistry—Implementing the NHS Plan for improving access to NHS dentistry and their expected outcome. These are:

— the new role of NHS Direct in helping patients to find NHS dentistry;

— the Dental Care Development Fund—grants to dentists allowing them to treat up to 250,000 more patients;

— rewarding dentists' commitment to the NHS, which has the potential to secure treatment for a third of a million more people;

— the capital Modernisation Fund—£35 million for modernising the practices of significantly committed NHS dentists;

— Dental Access Centres, offering high quality NHS care to half a million people unable to find a GDS dentist willing to register them;

— other Personal Dental Service pilot projects finding new and better ways of providing NHS dental care;

— modernising other salaried dental services so that they can make the maximum contribution to the provision of dental treatment;

— the enhanced role of health authorities and their new partnerships with providers of dental care, so that anyone who calls NHS Direct looking for a dentist can be referred to one;

— maximising the contribution of the whole dental team, including professions complementary to dentistry and women dentists who have encountered obstacles in their career paths; and

— the potential of long term improvements to working patterns—for example, more flexible intervals between routine dental examinations.

2. The memorandum concludes by looking at some relevant issues around the funding of NHS dentistry.

3. While a number of the measures in the strategy are targeted clearly on delivering immediate improvements to access, the strategy is designed just as much to raise the overall quality of NHS dental care and to provide a firm foundation for the future of NHS dentistry for decades to come.

4. The strategy signals the Government's willingness to work with the profession and find long term improvements to the working pattern of dentists. It also provides the basis of a new, much stronger partnership between the NHS and dentists at local level which will be crucial in ensuring a more effective and integrated NHS dental service for patients.

INTRODUCTION

5. In July 2000 the Government published the NHS Plan, which reaffirmed its commitment to improving access to NHS dentistry (paragraph 12.8) and put dentistry firmly on the NHS's future agenda. This was followed in September by a detailed strategy—Modern NHS Dentistry—Implementing the NHS Plan. This strategy expanded on the commitment and described how it could be achieved, as well as describing plans for improving the quality of NHS dentistry and of the nation's oral health.

6. The strategy acknowledges the nature and origins of the access problem and is realistic about its scale. It describes the measures and resources being devoted to improving access to NHS dentistry by September 2001 and to sustaining that improvement.

7. This memorandum avoids simply duplicating the content of the strategy (although some repetition is inevitable). It updates the strategy and describes the measures in more detail and in the context of the Committee's terms of reference:

Modernising NHS Dentistry

BACKGROUND

8. The current statutory structure for dentistry within the NHS has its roots in section 35 of the NHS Act 1977, which begins:

"It is every Health Authority's duty, in accordance with regulations, to make as respects their area arrangements with dental practitioners under which any person in the area for whom a dental practitioner undertakes in accordance with the arrangements to provide dental treatment and appliances shall receive such treatment and appliances."

9. The number of dentists working at least partly in the General Dental Service (GDS) in England continues to rise significantly year on year. At the last count there were 18,040, which is about 2,500 more than in 1992 when there was no perceived access problem.

10. Nevertheless, during the 1990s many more people began to have difficulty finding NHS dental treatment. The reasons for that are described in the strategy, but can be summarised as an ageing workforce, the increasing number of dentists working part-time and—most significantly—the increasing amount of time that GDS dentists devote to private practice.

11. The Government did not wait to publish its strategy before tackling problems of access to NHS dentistry. The measures described in Modernising NHS Dentistry—Implementing the NHS Plan to build on the important action already taken. The Investing in Dentistry scheme ran from 1997 to 1999. It is still bearing fruit and has the potential to deliver access to about two thirds of a million patients. In 1998 the Government introduced the Personal Dental Services, including the first two dental access centres.

12. While it will never be complacent about the access problem, the Government believes the scale of the problem needs to be kept in perspective. The most recent Office of Manpower Economics survey (based on hours worked) shows that two thirds of General Dental Practitioners (GDPs) do at least 80 per cent of their work in the GDS and nearly 60 per cent of them do 90 per cent or more. The recent Adult Dental Health Survey, quoted in the strategy, reported that nearly four out of five adults said that they had their latest course of dental treatment under the NHS.

13. In other words most dentists still spend most or all of their time on NHS work and most people who want it still get NHS dental treatment. This is despite the fact that currently fewer than half the population are registered with a GDS dentist (and even at the 1993 peak only a little more than half were registered).

14. GDS dentists are independent contractors, free to choose how to divide their time between the NHS and private work. The strategy does nothing to encroach on that freedom. It does, however, clearly demonstrate the Government's determination to make NHS dentistry available to anyone who wants it.

15. The measures in the dental strategy for improving access can be categorised under four broad headings:

— helping and ecncouraging GDS dentists to do more NHS work;

— providing NHS alternatives to the GDS where necessary, with an enhanced role for health authorities;

— making sure the entire dental workforce (not just dentists themselves) is operating at optimum strength and efficiency; and

— improving oral health and tackling inequalities.

16. The rest of this memorandum describes in more detail these measures and their effects on the availability of NHS dentistry, cross-referenced to the relevant paragraphs of the strategy document, and briefly considers some relevant issues around the funding of NHS dentistry more generally.

DEVELOPING THE GDS

NHS Direct (3.7-3.10)

17. A better exchange of information about what dental services are available and where is a prerequisite of improved access. It will benefit dentists and patients alike, helping to make maximum use of the capacity available and to eliminate any slack in the system.

18. NHS Direct is ideally placed to take on and develop health authorities' existing role of advising those seeking NHS dentistry. Currently two pilot projects—one in the south west, the other in the north east—are testing NHS Direct's ability to direct local callers to dental treatment. The Government expects to extend this nationally by the summer.

Dental Care Development Fund (3.11-3.12)

19. The £4 million DCDF has been allocated to health authorities. All HAs with any recognisable access problem—72 out of 99—received a share, weighted for the size of the authority and the severity of their problem. The allocations ranged from £15,000 to £125,000. The DCDF reflects the outcome of consultation with the British Dental Association, which has welcomed the Fund as an important initiative for NHS patients and welcomed HAs' role in making it work.

20. HAs are using the money to reimburse dental practices which expand and treat more NHS patients. The average level of return required is 100 extra patients treated per £1,250 of grant. HAs have considerable flexibility in deciding how to use their resources and many supplement the central allocation from their own funds. Nationally the Government expects this year's DCDF to make NHS dental treatment available to up to 250,000 more people by August this year.

21. Although the DCDF is designed to deliver quick results, it is more than a short term measure. Dentists who benefit from the Fund this year will have to maintain the agreed level of extra NHS capacity for at least three years. The Government is committed to extending the DCDF into 2001-02 if that is necessary, and will allocate up to £6 million more for that purpose. It will keep under review the need for similar funding in future years.

Rewarding commitment to the NHS (3.13-3.14)

22. The strategy announced the detail of a scheme rewarding the level of GDS dentists' commitment to NHS work at a cost of about £20 million for 2000-01 in England. This is a long-term commitment, and the Government has accepted the recommendation of this year's report from the Review Body on Doctors' and Dentists' Remuneration for increased rates of payment in 2001-02.

23. The total level of the scheme was originally recommended by the Review Body in its 2000 report and the Government agreed the scheme's current structure with the BDA. Its aim is to encourage more dentists to stay within the NHS and, where possible, to increase their present level of commitment to the NHS. The Government believes that these resources, together with the other significant new resources which the strategy offers to committed GDS dentists, can have a real and beneficial effect on the numbers of GDS dentists offering NHS treatment.

24. The Government is working with the BDA on a review of the structure of the commitment scheme to make sure that it remains consistent with the objectives in the strategy of rewarding loyalty to the NHS and helping up to a third of a million more people get and keep access to NHS dentistry. That review should be complete by April.

Modernisation Fund (3.15-3.16)

25. The Government is currently considering the distribution of £35 million from the Treasury Capital Modernisation Fund for the modernisation of committed NHS dental practices, and the conditions to be attached to it. It is doing so in conjunction with the BDA and will bear in mind the prevailing access situation at the end of this financial year before deciding what, if any, conditions relating to continuing or increased commitment to NHS treatment should be attached to the payments. The benefits for patients and dentists from modernised premises and equipment will last for some years.

Modernised working patterns (4.37-4.39)

26. The strategy indicates how it may be possible for the GDS to provide more, and more appropriate, treatment through improved working patterns. It quotes the example of the interval between routine dental examinations—many patients believe they should see a dentist every six months, many dentists now feel that most people need only attend every year at most. The potential for freeing up dentists' time is considerable, and the Government will work with the profession to explore that potential in full.

ALTERNATIVES TO THE GDS

Dental Access Centres (3.17-3.22)

27. Last November the Government announced the locations of the next wave of DACs. It expects DACs to be operating from about 60 principal sites across the country by April, able to treat about half a million patients a year. The Government is currently considering the need for further DACs to be established during 2001-02, taking into account the effects of its whole programme of action and any gaps which might arise.

28. DACs are by their nature long-term arrangements requiring a significant investment of resources in premises, staff and equipment. As Personal Dental Service pilot projects individual DACs will be formally evaluated after three years, but the early evidence indicates that they are an invaluable tool for making NHS dentistry available where GDS provision is inadequate.

29. DACs have been criticised for being unable to deliver access to everyone who needs it. The strategy is clear that most patients will continue to be treated within the GDS, which is why most of the new resources are being directed at the GDS. Access Centres will play a crucial part in providing access to NHS care in the parts of the country where they are needed most, but the Government's plans recognise that DACs alone cannot solve the whole problem.

30. Neither are DACs in competition with the GDS, either for patients or resources. DACs are established where the GDS is not meeting local demand for NHS care. They are not intended to treat patients registered with GDPs and will encourage patients to register wherever possible.

Other Personal Dental Services (3.26-3.28)

31. The Government has written to health authorities inviting expressions of interest for a fourth wave of Personal Dental Services pilot projects. These projects will also focus on access, supplementing the direct improvements offered by DACs. This might be through:

— trust-led pilots addressing access issues, both of unmet need for services and unmet demand;

— GDS projects addressing access in areas of dental need, including through the skill mix of the dental team; or

— service reconfiguration and modernisation of existing Trust-led salaried services.

32. Fourth wave projects are expected to be up and running from summer 2001 onwards. Like DACs, all PDS projects will be evaluated formally after three years but—again like DACs—the Government expects them to make a significant contribution to improved access both in the short term and for years to come.

Modernising other salaried dental services (3.32-3.34)

33. There is already a significant investment in the Community Dental Service in many places, over and above that in any local Dental Access Centres. The Government believes that the way HAs have commissioned CDS can be improved and so fulfil the potential of the service for addressing local dental needs.

34. HAs have been asked to appraise the scope for enhancing existing CDS services through additional investment of capital or revenue. This could mean better use of existing clinical facilities, increasing staff numbers, better support for management and investment in improved premises and equipment.

35. None of this should affect adversely the services and functions which are already being provided by the CDS. The aim is for a permanent enhancement of the whole performance of CDS, not a shift of resources which reduces the ability of the CDS to fulfil its existing functions.

New partnerships and HAs' role (3.23-3.25)

36. The Government believes that its centrally-funded initiatives will have a major impact on access problems. Working in parallel, health authorities must also monitor the local situation and be ready to intervene in new ways, making sure that NHS dental care is available to everyone who needs it.

37. The dental strategy describes the sort of new partnerships with providers of dentistry that the Government expects HAs to enter into if they are required. HAs are benefiting from the largest sustained increase in funding in the history of the NHS, and the Government is making it clear that this provides an opportunity to move dentistry up the local NHS agenda permanently.

38. The NHS Executive's performance management arrangements now reflect that. For example, every regional office of the Executive has nominated a lead director to take responsibility for implementing the dental strategy and health authorities have been asked to do the same. Any authority experiencing problems will be identified and offered advice and assistance.

39. The Government is currently preparing detailed guidance for HAs on how the new partnerships should work. It envisages Personal Dental Service contracts between HAs and providers, creating reliable and stable mechanisms for offering NHS dental treatment to anyone referred by NHS Direct even where no local GDS dentist is accepting new registrations and there is no convenient Dental Access Centre.

WORKFORCE ISSUES

40. The last review of the requirement for dentists was completed in 1987 when a quota of 805 undergraduate admissions to dental schools per annum was set. In fact, due to the popularity of dentistry as a career and the high calibre of applicants for places in dental schools, this quota has regularly been exceeded in recent years. In the 1999-2000 session 877 students entered UK dental schools. There were 4,185 students in training in January 2000, of whom some 95 per cent were from the UK. This figure is similar to the 4,193 students in training in January 1999.

41. The Dental Advisory Sub-Group of the Medical Education, Training and Staffing Committee (DAGMETs) initiated a new review in 1998. At the time of the 1987 review the number of dentists on the Dental Register was projected to grow by 14 per cent, from 24,500 in 1985 to 28,000 by 1995. The actual increase was very close to this. There has been a marked change in the proportion of male to female dentists and, with the more flexible working patterns adopted by some women dentists, it has been estimated the whole-time equivalent of the Dentist Register in 1995 was about 19,000. By January 2000 the number on the Register had increased to 31,000, equivalent to about 21,000 whole-time dentists.

42. On the demand site, population growth has exceeded the 1987 estimate. In 1987 the population of the UK was expected to reach a total of 58.1 million by 1996, but it had already reached 58.8 million by 1996 and further divergence from 1987 projections is expected.

43. The fall in the percentage of adults without natural teeth was underestimated. In 1987 a UK rate of 16.8 per cent was predicted by 1995 (compared to a rate of 23.2 per cent in 1985) but the actual 1995 level was 15 per cent. There also seems to have been a change in attitudes to dental care. People have become more health-aware, and also more aware of what dentists can do for them cosmetically. The proportion of adults with natural teeth claiming to see a dentist for a regular check-up has increased by some 6 per cent since 1987.

44. Future plans to extend duties of dental therapists and dental hygienists and introduce new classes of professionals complementary to dentistry such as clinical dental technicians and orthodontic therapists will expand and enrich the skills mix of the whole dental team. The potential of the extended role of professionals complementary to dentistry needs to be considered before final conclusions on workforce requirements are drawn (paragraphs 4.41-4.46 of the dental strategy).

45. In April 2000 the Department of Health published a consultation document A Health Service of all the talents: developing the NHS workforce which proposed a more integrated approach to work force planning and the creation of a new National Workforce Development Board to oversee the new arrangements. A sub-group of the Board will take forward the DAGMETS review by addressing the planning of the dental workforce, including dentists and professionals complementary to dentistry, to meet the future staffing implications of the dental strategy.

46. Also, to achieve a better understanding of the career aspirations and working patterns of women in NHS dentistry the Chief Dental Officer, Dame Margaret Seward, is carrying out a study of barriers to women making the fullest contribution to dentistry, with a view to improving employment opportunities for women dentists. Dame Margaret expects to complete her report by 31 March.

47. In summary, the Government feels there are three major issues to be addressed before reaching firm conclusions about whether the overall dental workforce is of an appropriate size to meet the population's dental care needs:

— the development of team working in which the skills of all dental professionals are used to full effect;

— the potential of better rewarding commitment to the NHS to increase the proportion of time dentists work in the NHS; and

— a better appreciation of the career ambitions of dentists, including any changes in terms and conditions necessary for them to accommodate domestic responsibilities within their chosen career pattern.

IMPROVING ORAL HEALTH

48. Much of Chapter 3 of Modernising NHS Dentistry—Implementing the NHS Plan 1 is about meeting unmet demand for dentistry. Chapter 5 of the strategy addresses the related, but not identical, issue of unmet need through measures aimed at improving oral health and reducing inequalities.

49. Experience shows that relatively small schemes can be effective in introducing large numbers of children to good oral health practice (paragraphs 5.11-5.13 of the strategy). In the current financial year the Government is making available about £0.5 million to fund schemes where children's oral health is poorest.

50. The oral health of black and minority ethnic groups can be relatively poor, for a number of reasons (2.8). The Government and the NHS will continue to address this issue and work with the National Transcultural Oral Health Centre (5.19-5.21).

51. Because there is no single cause of oral health inequality the strategy describes how the problem will be tackled on a number of new fronts—for example Health Action Zones, Healthy Living Centres and the Sure Start initiative (5.23-5.28). The strategy also announced the Government's intention to set new targets for oral health, for both children and adults (5.7).

Fluoridation

52. The York University review into the effects on health of fluoridation clearly shows that fluoridating water helps to reduce tooth decay. In areas where overall health is lower than average, dental health is much higher if the water is fluoridated. The report also identified the need for more good quality research and we are asking the Medical Research Council to suggest where it is possible to carry out further research to strengthen the evidence currently available to us.

53. The Government will encourage health authorities with particular dental health problems to consider fluoridating their water as part of their overall oral health strategy. We will be having further discussions about this with the water companies and local authorities.

FUNDING ISSUES

54. It is sometimes alleged that access problems are a result of under-funding of NHS dentistry and that access cannot be improved as long as private practice is more profitable than NHS work.

55. The NHS fee scale which comprises dentists' income from NHS work falls within the remit of the independent Review Body on Doctors' and Dentists' Remuneration, whose recent reports have concluded that dentists' earnings were broadly reasonable and in line with those of comparable professions.

56. Average annual earnings (after expenses but before tax) of a full time dentist who does only NHS work are now about £60,000. The Government believes that is fair. Most dentists also do at least some private work which takes their earnings higher. Earnings now include the scheme rewarding dentists' commitment to the NHS, which has added up to £4,500 a year to dentists' NHS income.

57. The Review Body also commissioned a survey into dentists' hours of work and workload. According to that, a full time, wholly committed GDS dentist works on average 42.3 hours a week and sees 139 patients while the average for all dentists (including those who do private work) is 43 hours and 122 patients. The Government's consideration of the dental workforce, the Personal Dental Service pilot projects looking at new ways of delivering dentistry and remunerating dentists, and other possible changes to working patterns all indicate the Government's willingness to keep workload issues under constant review.

58. Most of the £100 million in the strategy will be paid to GDS dentists to improve their working environment and treat NHS patients. Expenditure on the GDS in 2000-01 is projected to reach a level 8 per cent higher in real terms than in 1997. Meeting the Government's target of treating another two million people will add about £80 million a year to DGS spending. There are PDS projects testing alternative ways of remunerating dentists (para 3.26 of the strategy) which will be evaluated in due course.

CONCLUSION

59. The Government knows it has set an ambitious target for access to NHS dentistry but is determined to meet it. The commitment to developing NHS dentistry will not end there. The Government will continue to work closely with the profession and the NHS, who both have crucial roles in meeting the target for improved access and sustaining the improvement for the future. The new resources and mechanisms that the Government is making available, and the drive for better working patterns it is setting in motion, represent a golden opportunity to change the delivery of NHS dentistry for better and for good.

January 2001



© Parliamentary copyright 2001	Prepared 27 March 2001