House of Commons - Health

Select Committee on Health First Report

ACCESS TO NHS DENTISTRY

Quality of care

27. The issue of access to NHS dentistry is closely linked to concerns about the quality of care provided. Modernising NHS Dentistry says that NHS dentistry must provide a high quality service. There is, however, evidence that the pressures under which the profession works impact on the quality of care. The GDPA express concern that Modernising NHS Dentistry does not take quality seriously. They point out that the strategy focuses mainly on the organisational framework needed to achieve high quality care, i.e.:

clearer information for patients about their rights
strengthening self-regulation of the profession
the implementation of clinical governance
continuing to tackle fraud

rather than on standards of treatment. We have described above dentists' concerns that their heavy and increasing workload affects the quality of care they can provide. We received evidence that they cannot afford—under the GDS contract—to purchase high quality materials.[69] We also heard how important support staff are to providing quality care; we discuss this further at paragraph 34. In written evidence one GDS dentist gave us details of the low success rate of NHS endodontic (root canal) treatment (10%), as measured against European radiographic standards. He noted the additional costs to the service this sub-standard care imposed and discussed the reasons why it occurred, which he ascribed to the lack of time and the use of ineffective and out-dated techniques and materials. His comment sums up the problem:

28. The DoH did not accept that there was hard evidence to suggest that the quality of NHS dentistry is not up to the standard they expect.[71] They pointed to the regulatory system: the comprehensive inspections undertaken each year by the Dental Reference Service, and the introduction within the GDS of clinical governance and clinical audit.[72] In response to the evidence quoted above, Dame Margaret Seward, the Chief Dental Officer, told us:

WORKFORCE

29. In 1985, there were 24,500 dentists on the Dental Register. By January 2000 there were 31,000.[74] In March 2000, 20,842 dentists were providing care and treatment under the GDS in Great Britain. This is three per cent higher than the previous year.[75] But this increase in numbers has not resulted in any improvement in access to NHS dentistry because:

the composition of the workforce has changed;
the commitment of dentists to GDS has decreased;
numbers entering the GDS are declining; and,
the distribution of dentists around the country is uneven.

The BDA estimate that a further 1000 dentists are needed to meet the DoH's target of giving access to a further 2 million people.[76]

Workforce Composition

30. The dental workforce is getting older.[77] Older dentists are generally less productive—men aged over 60 have an average gross income of less than two thirds the average of dentists in their twenties and thirties. The number of women dentists continues to grow. So does the number of dentists working part-time within the GDS. Women comprised 23% of the GDS workforce in 1991 and 30% in 2000; the proportion of women among dentists under 30 is now 50%.[78] The average gross income for women is two thirds the male average. The combined impact of these changes in the age and sex of the workforce has been to reduce average gross income by 0.5% per year.[79] In June 2000, the DoH commissioned Dame Margaret Seward (subsequently appointed CDO) to undertake a new study of the experiences and ambitions of women pursuing careers in dentistry in a bid to encourage more women to join the NHS. A report is due in March 2001.

Commitment to the NHS

31. The shift to part-time or private sector working is evidenced by the increased number of GDS dentists in the lower income bands.[80] The situation varies between different regions of the country; in the North and Midlands dentists have on average a greater commitment to the NHS.[81] We also heard that the UK now registers more European and overseas graduates to practise dentistry in the UK each year than UK graduates (899 compared with 810 in 1999[82]). These sources of workforce can vary. So does the commitment of these dentists to the UK, creating additional uncertainty about long term access. The UK has no control over either of these factors.[83]

Numbers entering the GDS

32. The number of dentists completing vocational training and applying to the Dental Vocational Training Authority (DVTA) for the "vocational training number," which enables them to work in the GDS as an associate or a principal, has fallen from 590 in 1998-99 to 557 in 1999-00. Yet there were more vocational training schemes available (see also paragraph 36 below).[84] The DDRB summarised the position: recruitment to dental schools remains good but retention within the GDS and motivation do not appear to be improving.[85] In 1998 the BDA noted that the CDS was also experiencing difficulties recruiting dentists: 44 whole time equivalent dental officer posts remained unfilled despite advertising, vacancies varying from two months to four years.

Geographic Distribution

33. Access problems are also related to the geographic distribution of GDS dentists. New dentists going into general practice tend to go to areas where they can, over the long term, establish a viable business. For many this points to the South and East of the country. Judith Husband put the point concisely:

"There are definite limits as to where we can set up our businesses and do well. I would choose to set up a business in the South now, having experienced both working up North and in the South. It makes more business sense to set up a practice in an area where the demographics suggest that we have socially got people who will want to come and see us. ... It is not simply that there are not enough dentists, which there are not, and it is not simply that people want to go to dentists and they cannot, it is that there are lots of dentists in some areas and not in others. When we have got free choice as individuals, why should we work in an inner city where we have got junkies shooting up in the bathroom when we could have a nice life? I am sure we would all choose to live somewhere that is nice and pleasant, just the same as where we choose to work."[

Professions Complementary to Dentistry

34. There is an ongoing debate about the role of dental therapists and dental technicians within the dental team. Representatives of these professional groups suggested to us that an increased role for their members—the right to work within GDS practices (dental therapists), the right to work independently of dentists (technicians)—would ameliorate access problems.[87] Modernising NHS Dentistry notes that there are plans to extend the duties of dental therapists and dental hygienists and introduce new classes of professionals complementary to dentistry such as clinical dental technicians and orthodontic therapists.[88] But the NHS fee structure raises the same problem for the employment of dental therapists in GDS practices as it does for dentists themselves. With regard to the role of clinical dental technicians, the BDA argued that any patient with teeth must be seen by a dentist not just someone providing dentures. They also believe that patients without teeth ought to be seen by a dentist, and that, anyway, the number of fully edentulous patients is falling rapidly.[89]

35. We asked whether there had been any studies examining the roles of dental team members. The BDA told us that "There is very little evidence to support it one way or another. I am not saying it is not a good idea but the evidence is relatively poor. The studies around the world do not point in one direction or another."[90] The CDO, however, pointed to The Nuffield Foundation report in 1993 which looked at the whole contribution of the dental team and, the DoH's Service of all the Talents that focused on the need to look at the skill mix.[91] She also noted that part of the remit of her study into women dentists "was also obviously going to impinge on the therapists and the hygienists and their work patterns because 99 per cent of therapists are women."[92]

36. There are a number of other workforce issues which have a bearing on access. Primary care specialist working can increase access to specialist dental services. Access to secondary and tertiary care is not however addressed specifically in Modernising NHS Dentistry. One particular difficulty is that current DVTA regulations make it difficult for specialists to gain the vocational training number they need to work in the GDS.[93] This can prevent practices offering a full range of dental services. The DVTA would like to see the regulations changed.[94] Without good support staff high quality dental care is unachievable. But the levels of pay affordable out of NHS fees are not attractive, especially in high-cost areas such as the South East. We received evidence of problems with recruitment and retention of good support staff.[95] We were also informed that salaried dentists (in PDS and CDS) were less productive than their GDS counterparts.[96] This is reflected in the return from the capital and revenue costs of PDS schemes compared with the return from GDS grants (in Cornwall £65 per registration compared with £40 per registration). The health authorities, however, told us that it was not appropriate to compare directly the workload of the CDS and PDS with that of the GDS, since the services were designed to meet different needs.[97] The CDS's role in treating patients with special needs does make such a comparison inappropriate. But such a comparison is not, we believe, inappropriate when applied to the common role of providing access to unregistered patients per se.

37. John Renshaw summarised the problems around the issue of the dentistry workforce:

38. We believe that it is now imperative that a review of the workforce is undertaken. The DoH agrees. It has established a new National Workforce Development Board, which, inter alia, will address the planning of the dental workforce, including dentists and professions complementary to dentistry, to meet the future staffing implications of the dental strategy.[99] We welcome the planned review of the dental workforce. We recommend that it should:

take account of discussions about remuneration between the profession and the Government;
cover the whole dental team and take account of the findings of the CDO's review of women dentists' working practices;
look at the composition and distribution of the workforce as well as its current size, and at anticipated trends, recommending incentives to encourage dentists to work in areas which are presently poorly served; and,
advise on the frequency of subsequent workforce reviews.

The Role of Health Authorities

39. Prior to 1997 NHS general dental services could only be delivered by GDPs via a national contract with a nationally negotiated scale of fees. Within this framework health authorities had a statutory duty to ensure the provision of dental services for their population.[100] Their responsibilities included holding GDPs' contracts and managing the arrangements under which they provided general dental services, maintaining a list of dentists, overseeing dentists' pay (the operational responsibility of the Dental Practice Board), and liaising with the Local Dental Committees (the body representing dentists' interests in each health authority).[101] Complementing these arrangements, the NHS (Primary Care) Act 1997 allowed for the voluntary establishment of personal dental service (PDS) pilot schemes to test alternative ways of delivering dental services, in particular general dental services, through local contracting arrangements between health authorities and one or a group of dental providers. These pilots are currently being evaluated.[102]

40. Modernising NHS Dentistry now aims to move dentistry up the NHS agenda, expanding health authorities' influence.[103] Access to NHS dentistry is now specifically included in the National Priorities Guidance for 2000-01 to 2002-03, to ensure a new and long-term prominence in health authority planning and activity.[104] Every DoH Regional Office has nominated a lead director to assume responsibility for implementing the dental strategy and health authorities have been asked to do the same. Modernising NHS Dentistry describes the new partnerships with providers of dentistry which the Government expects health authorities to develop. Specifically, health authorities will be expected to:

ensure fair access to NHS dentistry, including work with local dentists to support commitment to the NHS, making sure that out of hours and emergency coverage is effective, and negotiating arrangements for referral of unregistered patients from NHS Direct;

finance necessary developments in local dental services from the growth in their general funding;

work through Health Improvement Programmes, Health Action Zones, Healthy Living Centres and Sure Start to improve oral health, especially of children. Health authorities will be encouraged to instigate schemes aimed at increasing visits to dentists by children from black and minority ethnic communities;

ensure effective and efficient delivery of appropriate Trust-led salaried dental services, either through the Community Dental Service or Personal Dental Services pilots (including Dental Access Centres[105], of which to date there have been two waves [eight projects in total] tackling the worst local access problems. A third wave will be up and running by March 2001.[106])

plan and implement the modernisation of the practices of significantly committed NHS dentists. Up to £35m has been made available for 2001-02; and

provide accurate and up to date information to NHS Direct on which dentists are accepting NHS patients and to work with NHS Direct to maintain the accuracy of this information.[107]

41. We were concerned that health authorities might not have the resources to take on this new role competently. The health authorities who gave evidence told us they felt that they were well prepared to deliver the changes expected of them. We received evidence about the staged development of the 1998 PDS pilot in Cornwall, the plans to support existing CDS and GDS roles in Birmingham, and about the positive interactions both authorities had had with NHS Direct. These health authorities saw Modernising NHS Dentistry as a first step in improving dental health in the round, not as an end in itself. They saw the new PDS schemes complementing the GDS, not competing with it, and were clear about the need for a mixed economy in which the GDS continued to play a key role.

42. However, we also heard how some health authorities are much better prepared than others, and that there was, therefore, an important need to share good practice.[108] The levers currently available to health authorities are limited. The improvements in oral health they are charged to deliver cannot be achieved without the help of the GDS. Health authorities can control the development of salaried services within the PDS and intend to use this to develop local services to address local needs, working with Primary Care Trusts. But they have little influence over the GDS, which is a national system based on piece-work whose fee structure is nationally determined. While the health authorities who gave evidence are clearly determined to use what influences they have as imaginatively as possible, we believe that this lack of leverage is a paradox at the heart of Modernising NHS Dentistry.

43. The health authorities outlined various actions needed to take the strategy forward. These reflect the difficulties they face. They stressed their role in protecting the existing functions of the CDS, developing the PDS, and exploring links between Primary Care Trusts and NHS dental services. They also emphasised the need to work constructively with their local GDS dentists, and, in the absence of local levers, the need for a national review of the dental workforce, its distribution and the current system of remuneration.

44. Modernising NHS Dentistry aims to bring dentistry into the mainstream of the NHS and reduce inequalities in oral health. We welcome this and the key role it gives to health authorities. However we are concerned that they do not possess the levers they require to meet the objectives of the strategy. We recommend that, with the help of health authorities, a study should be undertaken of the levers (formal and informal) which health authorities are currently able to apply to fulfil the objectives of Modernising NHS Dentistry. This should examine the limitations that impede the achievement of these objectives and, in conjunction with findings from the remuneration and workforce reviews, advise on how these limitations might be addressed. We recommend that in all these exercises the profession and the patients it serves should be fully consulted in a timely fashion. However we reiterate that such consultation should be a prelude to action rather than an excuse for inaction, and should follow a strict timetable for implementation.

Conclusion

45. During this inquiry various concerns have been voiced to us about the Government's strategy. The BDA considered that Modernising NHS Dentistry had helped put dentistry on the agenda and that this, after years of neglect, was in itself welcome. But they felt that, although the strategy offered opportunities for both dentists and their patients, it concentrated too much on short-term solutions for the unregistered patient who does not attend regularly. The BDA felt that the opportunity to address the root causes of the problem of access—the GDS remuneration system, and the size, composition and distribution of the dental workforce—had not been grasped.[109] John Renshaw told us: "it is not really a strategy, it is more of an action plan to sort out the access problem."[110] A recent survey of BDA members suggests that the drift out of NHS dentistry would continue and that the incentives designed to keep GDPs in the service would have little impact.[111] The GDPA similarly commented that Modernising NHS Dentistry merely "tinkers at the edges." They argued that more complex problems, such as access for exempt patients or access to advanced conservative treatment within the NHS, were ignored. In addition the perverse incentives created by the remuneration system were not addressed. There were also concerns about the lack of consultation on the strategy.[112]

46. The Government maintain that commitment payments, the dental care development fund, and health authority grants for practice improvement will have a positive effect on the motivation and retention of dentists in the GDS. But we were also told that these incentive schemes would not benefit all dentists working in the NHS and were not always perceived as equitable.[113] The BDA, while welcoming these measures, noted that selective incentives could have a negative impact on the morale of those dentists who did not benefit. The overall effect might be to drive more dentists into the private sector.[114]

47. We also heard concerns that emphasis on Dental Access Centres might create a two-tier service: a health authority-led relief-of-pain NHS service and a private GDS, and that they would prove expensive to run and would face recruitment problems because the work they provided would not be sufficiently varied to attract high-quality staff.

48. As we have said this was a very brief inquiry based on a single oral evidence session, but we have received extensive written evidence and we are quite clear that urgent action is required. We consider that dentistry has never been fully integrated into the NHS and as a result major health inequalities exist. We believe that the present arrangements for accessing NHS dentistry are inequitable, uncertain and getting worse; patients do not know where they stand. Unregistered patients find it hard to get any form of care. Registered patients can lose that status without redress and often without knowing they have done so. Patients do not always get the advanced conservative treatment they need (crowns, bridges, implants etc) through the NHS even when they are registered. Certain very vulnerable groups of patients, such as elderly people and those with dementia, face particular problems. We agree with the Eastman Hospital, that "there should be greater clarity and honesty regarding availability of NHS treatment."[115] Modernising NHS Dentistry aims to address immediate problems of access. But these are, as the BDA told us, multi-faceted long-standing problems to which solutions will not be found overnight. There are widespread concerns that the proposals in the document merely provide a quick fix and do not go to the root of the problems. There are also concerns about current workforce levels and distribution, about which at present we have little detailed information. We believe these are serious concerns and that Modernising NHS Dentistry lacks the weight to alter fundamentally what is a deteriorating situation. We would suggest that a longer term strategy for dentistry within the NHS is still badly needed.