During the first 40 years of the NHS General Dental
Service dentists (GDPs), working as independent practitioners,
provided all NHS dental care on a fee-per-item basis. Initially
fees were set on the basis of the time spent providing services.
But already in 1949 this had led to unsustainably high earnings
as dentists responded to the huge demand for free services. Fee
cuts and charges for some forms of care were imposed.
Addressing the problem in 1960, a Royal Commission
noted that, although the number of treatments had risen, the amount
of time dentists spent providing them (a measure of effort) had
not changed correspondingly. Advances in technique and technology
had allowed greater productivity without greater effort. The Commission
recommended that the fee-per-item of service approach should stay,
but that simple increases in the number of procedures undertaken
should no longer, of themselves, result in dentists earning more.
This laid the basis for the current GDS remuneration
system. This is a "process of negotiation, forecast and calculation"
in which 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, given practice expenses.
It works as follows:
- The Doctors and Dentists Review Body examines
the work of the profession annually and recommends a level of
remuneration for the average dentist. Since 1994 this has
been expressed as a percentage of the fees.
- Given this advice and taking into account the
overall amount of resource available for NHS dentistry, the Government
sets a level for that remuneration.
- The Dental Rates Study Group then forecasts the
likely average practice expenses of GDS dentists in the coming
year, adjusts the figure for previous under- or over- payments
of expenses, and sets a fee scale that will provide average net
remuneration at the level set by the Government. The forecast
of expenses is, in part, based on the likely incidence of particular
treatments in the coming year.
In theory dentists as a group can thus be rewarded
for increased productivity, an increase distributed to all through
the fee scale. But to get that increase, based on forecast
levels of activity, an individual dentist has to match those activity
levelsor beat them if he/she wishes get a higher than average
increase. Moreover adjustments because of, for example, previous
forecasting inaccuracies, mean that in practice fee levels are
either "declining or increasing very slowly"a
further incentive to increase turnover.
The result is as follows:
- In the current year forecast levels of activity
are exceeded as individual dentists attempt to beat the forecast
average to increase their income
- For the coming year the DDRB recommends a level
of remuneration based on the increase in the workload of GDPs
evidenced by their increased output
- The DRSG sets the fee levels for the coming year,
based on the same output that prompted the DDRB's
recommendation in the first place, plus an expected percentage
productivity rise, plus any adjustment for previous under- or
over-payments in previous years. The net result: fee levels rise
imperceptibly if at all
- GDPs, knowing that their reward for increased
activity is related to the average level of activity for the whole
profession, are encouraged yet again to beat the forecast levels
This system is known to the profession as the treadmill.
In 1991 the remuneration system was described by
the then Secretary of State for Health as "this discredited
funding system". It was further criticised in the 1993 review
undertaken by Sir Kenneth Bloomfield, who cited a number of inherent
- the concept and practical effect of a system
based on the arithmetic notion of the average dentist;
- the lack of prioritisation;
- the incentives and effects of a system based
on a fee for item of service approach.
Reporting in the same year the then Health Committee
also commented that:
"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," and that "the productivity
incentives in the current system exert pressure on the quality
The 1994 DoH document Improving NHS Dentistry
proposed two alternatives:
i) sessional fees
with the treatments available categorised along lines suggested
by the Health Committee Report, i.e.:
- diagnostic and preventive services (free to all)
- maintenance services (free to those who attend
- advanced treatments (100% charge to those who
can afford to pay)
ii) a fee-based system
with a fee for every procedure carried out on adult patients and
an amended capitation fee for children. DoH noted that 'this option
has the disadvantage of retaining many of the disincentives and
failings identified by Bloomfield and the Select Committee'.
However, it is this second alternative that persists
today. The remuneration system therefore 'still rewards quantity
and not quality.'
116 Material in this section is sourced from HC (1992-93)
264 and Sir Kenneth Bloomfield: Fundamental Review of Dental Remuneration,
HMSO (1992) Back
HC (1992-93) 264. Back
HC (1992-93) 264. Back
HC (1992-93) 264, paras 103, 114. Back
BDA News, December 2000. Back