Select Committee on Health First Report

FIRST REPORT

The Health Committee has agreed to the following Report:—

ACCESS TO NHS DENTISTRY

Introduction

1. In 1999 the Prime Minister announced that by September 2001 anyone who wanted NHS dental care would be able to receive it, and the DoH subsequently affirmed its commitment to improving access to NHS dentistry in the NHS plan.[8] This was followed in September 2000 by Modernising NHS Dentistry: Implementing the NHS Plan.[9] This strategy aims to improve access to NHS dentistry, and to improve the quality of dental care and ultimately, oral health. There remain, however, substantial concerns that access to NHS dentistry is poor and not improving, and that Modernising NHS Dentistry does not deal with the fundamental problems. In view of this, we felt it would be useful to conduct a short inquiry into the strategy. We published a major report on Dental Services in 1993[10] and this brief inquiry does not attempt to replicate that one. Rather it aims to: describe the current problems of access; explore why these have been created; and highlight the key concerns of the dental profession and others about the Government's strategies to deal with this.

2. We announced our decision to undertake this inquiry on 14 December 2000 with the following terms of reference:

"To examine whether the Government's strategy, Modernising NHS Dentistry, will improve access to NHS dentistry in the long term."

We took oral evidence on 15 February from: the British Dental Association (BDA), the General Dental Practitioners'Association (GDPA), Dr Clive Bosley and Dr Judith Husband, General Dental Practitioners (GDPs);[11] Cornwall Health Authority, and Birmingham Health Authority; Lord Hunt of Kings Heath, Parliamentary Under-Secretary of State, Department of Health and Dame Margaret Seward, Chief Dental Officer. We also received over 30 written memoranda from individuals and institutions. We are very grateful to all those who presented evidence, written and oral, to us. We would also like to thank our Specialist Adviser, Bryony Soper, whose expertise has helped us enormously.

MODERNISING NHS DENTISTRY

3. Modernising NHS Dentistry is designed to improve: access to NHS dentistry; the quality of dental care; and the information that dentists give patients about the full range, quality and cost of NHS dental treatment. The measures in the dental strategy for improving access can be categorised under three broad headings:

(a)  Incentives to encourage independent practitioners to remain in the GDS:[12]

• commitment payments to dentists who have shown long-term, high-level commitment to the general dental service;
• practice grants for modernisation and expansion through the Dental Care Development Fund[13] (a follow-up to the 1997-99 Investing-in-Dentistry Scheme), and through health authority grants to improve the practices of significantly committed NHS dentists;
• additional inducements to see un-registered patients;

(b)  New partnerships between health authorities and potential providers of dentistry and new arrangements involving salaried practitioners:

• Personal Dental Services, including Dental Access Centres for non-registered patients;
• involvement of corporate practices, run by dentists or private companies such as Boots and governed by the rules for corporate bodies in dentistry.

@These arrangements will be complemented by changes in:

• the Community Dental Service, which currently provides care to people with special needs (such as those with learning disabilities), screens school children, and promotes dental health;
• the responsibilities of health authorities and primary care trusts for salaried dentists.

(c)  Better information for patients and prospective patients through NHS Direct.

Present Situation

4. Problems with access to NHS dentistry for some patients have been reported since the early 1990s. In our 1993 report we heard that "there is a clearly defined haemorrhage of dentists away from the NHS" and were told by the Association of Community Health Councils of England and Wales of concern about the number of patients being de-registered by dentists.[14] This situation appears to have worsened. In 1996 the BDA carried out a survey which found that 35% of people said it was difficult to find an NHS dentist in their area.[15] In their memorandum, the Department of Health (DoH) acknowledged the access problem, although it thought the scale needed to be kept in perspective.[16] Modernising NHS Dentistry notes that last year about one third of health authorities reported serious problems in finding dentists for at least some of their residents. It estimates the unmet demand for NHS dentistry at two million people.

5. The amount of time general dental practitioners (GDPs) spend working in the NHS has also declined. In a 1993 BDA survey 75% of GDS dentists said that they received at least three quarters of their earnings from the NHS and just 12% received less than one quarter. By 1999 those figures had changed to 58% and 18% respectively.[17]

WHERE ARE THE ACCESS PROBLEMS?

6. We have received evidence of geographic differences in access to NHS dentistry. The 1996 BDA survey confirmed our earlier findings that problems were particularly bad in the South.[18] But, as we had also discovered,[19] problems have also become apparent in other parts of the country. The National Association of Citizens Advice Bureaux told how, in recent months, they had received reports of difficulties in accessing NHS dentistry from Cheshire, Cornwall, Hampshire, Kent, Lincolnshire, Oxfordshire, Shropshire, West London, and Yorkshire.[20]

WHO HAS PROBLEMS ACCESSING NHS DENTISTRY?

7. Our written evidence pointed to the presence of particular access problems for specific groups of patients, such as elderly people and those with disabilities, including deaf people, those with dementia, and people living in care homes.[21] It is not clear whether this is a new problem, or an old problem getting worse as the numbers of elderly people, and, particularly, the number with extensively restored teeth that require maintenance, increases. Dental services for these groups are provided, mainly, by the Community Dental Service run by the local health authority. The Alzheimer's Society described how people with dementia may experience difficulties with access due to problems with communication and mobility.[22] They also reported that "80% of carers said they were worried about problems a person with dementia has with eating and drinking; and that oral health was the most frequently cited factor associated with such problems."[23] However only eight per cent of carers had sought help from a dentist.[24] This was attributed to carers' lack of awareness of the community dental services and possibly suggests a need for community dental teams to improve their outreach services. Difficulties in obtaining dental care can be exacerbated by living in a care home, a point which was supported by Age Concern.[25] Age Concern noted that problems accessing financial assistance for dental care also acted as a barrier for the elderly.[26]

8. Modernising NHS Dentistry focuses mainly on improving access for unregistered patients who are seeking immediate treatment. Unregistered patients have a particular problem in areas such as Stafford where a great many dentists are not taking on new NHS patients. Such patients may have to travel long distances to find care, a problem for elderly people or where public transport is poor.[27] One of the Government's proposed solutions—Dental Access Centres (which we discuss below)—will provide emergency "drop-in" care; but they will not necessarily provide comprehensive regular care for unregistered patients.

9. The BDA commented that people registered with an NHS dentist had little difficulty in gaining access to NHS dental care.[28] We, however, have received evidence which suggests that even registered patients can experience problems.[29] In its evidence to this year's Review Body on Doctors' and Dentists' Remuneration (DDRB), the DoH noted the wide variation in the types of treatment given across the country, particularly in the percentage of adult courses of treatment that involve no intervention.[30] One possible explanation is that even registered patients are being denied access to some treatments on the NHS as dentists selectively decide to ration what care they will provide within the service and what privately. The Eastman Dental Hospital reported that "with more advanced treatment, such as implant treatment, there is virtually no option other than private treatment if the patient is not accepted for the very limited number of NHS treatments."[31]

10. Access is not just an adult problem. Although children on the whole are covered either by registration within General Dental Services (GDS) (68% of children) or by Community Dental Services (CDS) or Personal Dental Services pilots (PDS),[32] those children whose parents experience difficulty accessing NHS care can also have problems.

ARE THERE PROBLEMS WITH ACCESS TO PARTICULAR SERVICES?

11. Modernising NHS Dentistry, as we have said, mainly deals with patients seeking immediate treatment, for example for pain relief. This could indicate that access problems are actually problems with the provision of emergency care. Clive Bosley described how "the NHS defines emergency treatment ... very often ... as just being a dressing, so you can get rid of the pain by doing a dressing but then the patient has to go and find somebody else to put the filling in and

this is nonsense. To put the filling in you have to register the patient. If you are full up, what do you do?"[33] He argued therefore that access to emergency care had been reduced by registration.[34] A BDA survey showed that "only a small percentage of patients seen under the present emergency arrangements could accurately be defined as emergencies."[35] This could therefore mean that there is a problem with out-of-hours services, rather than emergency care per se.

Causes of the Problems

BACKGROUND

12. Prior to 1990 General Dental Service dentists, working as independent practitioners, contracted to provide NHS dental care on a fee-per-item basis for all their patients.[36] There were no formal arrangements for continuing care. Each course of treatment represented a short-term contract between dentist and patient. In practice, however, practitioners built up lists of regular patients to whom they had an on-going commitment.

13. A new dental contract in 1990 introduced capitation payments for children, and the registration of adult patients—whose treatment continued to be remunerated on a fee-per-item basis. The declared intention was to shift the emphasis from individual dental treatments to the purchase of continuing dental care. The underlying principles of the 1990 contract, essentially a move away from remunerating dentists for the amount of work they did to a more preventative approach, were broadly welcomed by the profession.[37] But its implementation was widely opposed because of fears among dentists that its net effect would depress their incomes.[38] To protect their incomes they worked harder (by a factor of 8.5%), increasing the payments due to them and leading to an overspend on the GDS in 1991-92 of £190 million. As a result the DoH made unilateral cuts in the fee scale for 1992-93 of 23%, later reduced after negotiation to 7%. This furore led to a breakdown in relations between the DoH and dentists, and compounded existing dissatisfactions among the profession about remuneration and the problems of providing high quality care. GDPs continued to reduce their commitment to the NHS and the DoH acknowledges in Modernising NHS Dentistry that the access problem stems from the reduction of GDPs time spent working for the NHS.

14. Examining this situation in 1993, we concluded that the difficulties some people were having in gaining access to NHS dental care were not the transient effects of the dispute over pay but the results of inherent contradictions within the system of remuneration that had been highlighted by, but not caused by, the dispute:

"the present system of remuneration for dentists seems to have an inherent leaning towards instability which threatens to undermine the commitment of dental practitioners to the NHS."[39]

This situation has not improved. John Renshaw, Chairman of the Executive Board of the BDA, told us that the 1992 fee cut is still seen as "a scar running through the profession that has never been put right".[40]

REGISTRATION

15. According to the BDA, registration levels have been relatively static over the last three years. NHS dental registration figures for adults in Great Britain between 1992 and 2000 are listed below.[41] There were few changes to registration figures for children in that time; in September 2000 7.9m children were registered.

Date	No. Registered (million)
Dec 1992	24.4
Dec 1993	24.8
Dec 1994	24
Dec 1995	23
Dec 1996	22.7
Dec 1997	22.3
Dec 1998	19.7
June 1999	19.7
July 2000	19.6
Sept 2000	19.8

16. The length of registration is 15 months for both adults and children. Registration lapses if patients do not return during that time.[42] We were informed that some patients were unaware of the limit on the length of registration and had dropped off the list unwittingly.[43] We also found that previous registration with the NHS is no protection if a practice decides to go private or if a patient moves house into an area where access is difficult.[44] We heard how this causes problems for those unable to afford private dental care; a problem particularly affecting the elderly who may face very expensive treatments.

17. Registration of adult NHS patients was introduced in 1990 to shift the emphasis from individual treatments to the provision of continuing dental care, including preventative care. As we described in paragraph 13, it was well-supported by the profession. In the first year 24.4 million adults were registered. Alan Ross, Chairman of the GDPA, commented: "the registration system was a huge success in 1990. We registered millions more patients than the Government at the time expected and they had to pay out for it. We were rewarded with what? Another fee cut. It sent out exactly the wrong message."[45]

18. The DoH notes that at the peak of registration in 1993 only just over 50% of the population were registered.[46] Modernising NHS Dentistry comments that the number registered has come to be seen as the benchmark of access to NHS dentistry and therefore an end in itself.[47] The Government considers that "what really matters is that everyone can get NHS dental care when they need it, not that everyone is registered."[48] However, the BDA supports registration as a measure of access to routine care. They also comment that its early promise as an innovative approach towards continuing dental care, rather than the "drill and fill" ethos encouraged by the GDS contract, has never been realised. This is reflected in the current fees for registration, which are set at the very low level of 54p per adult per month.[49] Yet the registration scheme has potential: its basis, regular care for a fixed amount of money, is, for example, used successfully by Denplan to support private dental care packages.[50]

REMUNERATION SYSTEM

19. For many, the remuneration system— that is the NHS fee structure— is flawed and it is this which is at the heart of the access problem.[51] A description of how the system works is attached as an Annex. In effect, it creates a tendency for dentists to increase the number of patients they treat year-on-year in order to receive an income above the notional average, the so-called treadmill. Worse still and despite the intentions of the 1990 contract, the remuneration system still does not reward preventative work. GDS dentists are not paid for time spent advising patients on preventative measures, only actual clinical interventions. As John Renshaw put it, "if you can't count it you don't get paid for it."[52] We heard about the difficulties caused for dentists by the remuneration system. Clive Bosley gave one example:

"The business sense of the National Health Service is to reward me with a fee of £11, total fee from the state and the patient, for extracting a tooth.... On NHS figures that gives me 11 minutes to greet, wash, treat, inject, take the tooth out, say goodbye and sterilise the surgery for the next one. I cannot do it in 11 minutes. My costings mean that £11 indicates that I should give the patient four minutes to remain solvent. That is why I do not do it for £11."[53]

20. Ros Hamburger of Birmingham Health Authority suggested that a package of incentives might encourage dentists to remain in the NHS:

" So [as a NHS dentist] you knew you could have access to occupational health services, you knew you could have access to proper information management and technology, you knew you could have access to some of the group discounts that could be organised. (In the health authority we have already done that for things like waste disposal.) If we could have that put together as a package, I think that would be quite attractive to people so people would know what it was they would get from being an NHS dentist."[54]

21. The DoH did not agree that access problems are caused mainly by the remuneration system. They pointed to the fact that the DDRB has found dentists' earnings to be broadly reasonable and in line with those of comparable professions.[55] The Government also believed that dentists' average annual earnings are fair. These are now about £60,000 (after expenses but before tax) for a full time dental principal (aged 45 or over) who does only NHS work.[56] The BDA challenged this figure, quoting the returns from the DDRB survey of workload to substantiate a figure of £54,000. They also noted that this figure did not apply to those dentists who worked as associates (more than half the GDS workforce) whose gross income was much lower.[57] However, despite the DoH's reluctance to accept remuneration as the major factor behind access problems, Lord Hunt told us that:

"[he understood] the dental profession does have concerns about the pattern of work which they have to undertake under the current GDS contractual arrangements. I have said that we are prepared to sit down with the profession to look at this over the next few months to see if there are any changes that can be made.[58]

We warmly welcome this commitment from the Government to review the GDS contract in consultation with the profession.

22. We consider that the GDS remuneration system is the heart of the problem. The fee structure encourages the move of dentists out of the NHS. It also discourages preventive dental care and the continuing maintenance of good oral health. The system has been reviewed comprehensively in the past,[59] and both this Committee[60] and the DoH developed options for alternative systems.[61] Yet it remains unchanged. In the light of this history we do not advocate yet more reviews for their own sake, but rather action: we believe the time for reform is ripe. We recommend that talks should take place immediately between the Government and the profession's representatives to revise the GDS contract, taking account of:

• previous reviews of the remuneration system;
• the current context in which GDS dentists are working, including the new remit of the health authorities to improve oral health;
• GDS incentives outlined in Modernising NHS Dentistry;
• GDS concerns about workload (including the DDRB study), standards of care in the NHS and levels of clinical indemnity;
• future arrangements for registration, bearing in mind its original purpose;
• exemplars provided by successful arrangements for the remuneration of private dental care developed by organisations such as Denplan.

WORKLOAD AND ITS EFFECT ON THE QUALITY OF CARE

GDPs workload

23. Despite the problems with the remuneration system, actual level of income is not the reason many dentists cite for leaving the NHS. Their concern is that providing comprehensive high quality dental care to appropriate standards has become increasingly difficult under the GDS contract. Alan Ross commented that:

"by and large it is the method by which we have to arrive at that remuneration [which is the problem]; it is the treadmill. Successive governments over 30-odd years have realised that dentists will work harder and harder and faster and faster for the same income and we are fed up with it."[62]

John Renshaw agreed:

"Dentists do not leave the NHS for ideological reasons, they leave because they are over-stressed and overworked and until somebody does something about that you are not going to turn this situation around."[63]

We heard that young dentists in particular are concerned about the amount of time they are able to spend with individual patients, and their inability to use the full range of the highly developed skills they acquire in training (for example, advanced crown and bridge work) within the NHS.[64] The BDA noted that list sizes rose by 2.2% between June 1999 and June 2000[65] and many of their members had told them that they were already working to full capacity and could not take on any more patients, with clear consequences for access.

24. The GDPA reported that their own research shows that GDPs in other Western countries had a workload of 12-15 patients per day, working a four and a half day week, compared with a workload of 30-40 patients per day in the UK for a five day week. This situation is not static; as we have described, the remuneration system has the effect of making dentists work harder and harder and faster and faster.

25. Last year, following longstanding concerns about the pressures under which the profession was working, the DDRB commissioned a survey which looked at the workload of GDPs.[66] This found that:

• about 70% felt rushed when treating NHS patients;
• about 60% said that their workload did not allow them to provide the professional standard of care with which they were comfortable;
• only 16% expected to be committing 90% or more of their time to the NHS in five years.

The survey also found that full-time dentists wholly committed to the GDS work on average 42.3 hours per week, seeing 139 patients. This is compared with 43 hours worked and 122 patients seen by full-time dentists doing some private work.[67] As the DDRB comment, the survey's findings tend to support the profession's assertions that 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.

26. Compounding this are increasing controls over the type and level of treatment that can be undertaken within the NHS, as we heard from the Eastman Hospital. Alan Ross highlighted this:

"I think there are access problems within the branches of dentistry itself because dentistry has changed and the NHS has not changed over 50 years. Dentistry has moved on from extracting teeth and replacing them with a bit of plastic to implants, whereas the NHS is taking away bits of dentistry. They have taken away crowns, they have taken away prevention and put in nothing, so there is a void there which private practice is having to fill."[68]

---

8   The NHS Plan: A Plan for Investment, A Plan for Reform, July 2000 (Cm 4818), para 12.8. Back

9   Modernising NHS Dentistry: Implementing the NHS Plan, DoH, September 2000. Back

10   Fourth Report from the Health Committee, Session 1992-93, Dental Services (HC 264). Back

11   Dr Husband is a member of the young dentists' committee of the BDA, although she appeared before us in a personal capacity. Dr Bosley is an experienced GDP who has worked in the NHS and in private practice.  Back

12   These are given on a selective basis, not of right to all GDS dentists. Back

13   Modernising NHS Dentistry, para 3.12. Back

14   HC (1992-93) 264, paras 91-92. Back

15   Ev., p.2. Back

16   Ev., p.131. Back

17   Ev., p.4. Back

18   Ev., p.4 and HC (1992-93) 264, para 94. Back

19   HC (1992-93) 264, para 95. Back

20   Ev., p.54. Back

21   Ev., pp.46, 49; D10, 17 (not printed). Back

22   Ev., p.47. Back

23   Ev., p.46. Back

24   Ev., p.47. Back

25   Ev., p.49. Back

26   Ev., p.49. Back

27   D3, 4, 5, 6, 8, 9, 12 (not printed). Back

28   Ev., p.1. Back

29   See eg. D4, 5, 6 (not printed). Back

30   Review Body on Doctors and Dentists Remuneration, Thirtieth Report 2001 (Cm 4998) para 7.8. Back

31   Ev., p.63; under GDS regulations these forms of treatment have to be approved by the Dental Practice Board. Back

32   NHS dental services are provided by General Dental Practitioners (GDPs) working in the General Dental Service (GDS); the Community Dental Service (CDS); hospital dental services; and Personal Dental Services (PDS).

Health authorities are responsible for making arrangements for Community Dental Services with NHS Trusts (including Primary Care Trusts). The CDS provides for patients who have difficulty getting treatment in the GDS.

Personal Dental Services pilot projects have been set up in two waves and a further fourteen will be set up during 2000-01. These projects represent new systems for the local development and commissioning of primary care dentistry. They are being evaluated by a team from Birmingham University. Back

33   Q25. Back

34   Q24. Back

35   Review Body on Doctors' and Dentists' Remuneration, Review for 2001: Written Evidence from the Health Departments for Great Britain, Sept 2000 Back

36   This is a complex payment system. The NHS fee is not a price for a particular treatment (as it might appear) but an element in an equation designed to deliver a certain quantum of net income. See Annex. Back

37   HC (1992-93) 264, para 40. Back

38   This suspicion was caused by a number of factors. The new administrative procedures and emergency cover commitments, the payment of maternity, sickness and post-graduate education allowances out of the existing pool of dental money and the targeting of capitation payments for children by their age, rather than their oral health status, were all cited by the dentists' representatives as being influential. (HC (1992-93) 264, para 74). Back

39   HC (1992-93) 264, para 103. Back

40   Q2. Back

41   Source: British Dental Association. Back

42   A dentist can remove an NHS patient from their list but a minimum of three months notice should be given (unless the health authority consents to a shorter time period). In many cases (if the patient agrees or if the patient threatens or is violent) it can be immediate.  Back

43   D12 (not printed). Back

44   D4, 5, 6, 8, 9 (not printed). Back

45   Q23. Back

46   Ev., p.31. Back

47   Modernising NHS Dentistry, para 3.3. Back

48   Ibid, para 3.4. Back

49   BDA News: NHS Fees Guide April 2000 - March 2001. Back

50   Q23. Back

51   Ev., pp4, 8, 48. Back

52   Q20. Back

53   Q21. Back

54   Q81. Back

55   Ev., p.35. Back

56   Ev., p.35. Back

57   Cm 4998, para 7.29. Back

58   Q101. Back

59   The Report of the GDSC Ad-Hoc Sub-Committee on Methods of Remuneration, BDA (1964); Sir Kenneth Bloomfield: Fundamental Review of Dental Remuneration, HMSO (1992). Back

60   HC (1992-93) 264, para 149. Back

61   Improving NHS Dentistry 1994 London: HMSO. Back

62   Q17. Back

63   Q64. Back

64   Q8. Back

65   Ev., p.3. Back

66   Cm 4998. Back

67   Cm 4998. Back

68   Q27. Back

---

Prepared 27 March 2001