APPENDIX 6
Memorandum by Denplan Limited (D22)
1. SCOPE
The remit of the Committee is to enquire whether
the provisions of the Government's Dental Health Strategy, published
in September 2000, will address in the long term problems of access
to NHS dentistry.
We conclude, as set out below, that it does
not appear likely to us that they will do so effectively.
2. THE PROPOSALS
A principal objective of the Strategy, as foreshadowed
by the Prime Minister's speech to the Labour Party Conference
in September 1999, was the intention to ensure that everyone who
wished would have access to primary NHS dental care by September
2001. Amongst the means set out to achieve this goal, the Strategy
includes:
— Including dental access in the remit
of NHS Direct from April 2001;
— The establishment of about 50 Dental
Access Centres;
— The Introduction of Commitment Fees
to dental practitioners on HA lists;
— A Dental Care Development Fund for
dental practice development;
— Additional funding available through
HAs to committed NHS dentists;
— Further Personal Dental Service,
Community Dental Service and Salaried service developments.
Although wide ranging, expansive—and expensive—none
of these approaches, in our view, strikes at the fundamental and
ongoing reduction in availability of NHS primary dental care to
which the Prime Minister's speech was a reaction.
3. THE PROBLEM
We characterise the difficulty which has faced
primary dental care in four ways:
(1) The basis of the payment system;
(2) A long-term failure of the relationship
of trust between the profession and the Government.
(3) A perceived unwillingness of the NHS
and Private Sector to engage in constructive dialogue about the
long term support and future of dental care.
(4) An increased drive towards "consumerism"
whereby the balance of trust and access to information will gradually
empower and enlighten the patient viewpoint.
3.1 The Payment System
As long ago as 1963, the Tattersall Report2,
commissioned by the British Dental Association, proposed a capitation
system for the delivery of primary dental care. This option was
also reviewed by Sir Kenneth Bloomfield3 and was supported in
evidence before the then Health Select Committee in 19934.
Capitation was given only passing consideration
in the White Paper "Improving NHS Dentistry" in 1994,
but as recently as this month, a scientific paper authored by
Professor Nairn Wilson, President of the General Dental Council
and others stated:
"it is suggested that ways need to be identified
to remunerate dentists for saving, rather than replacing restorations...5"
Denplan's founder, Dr Stephen Noar, gave evidence
before the Health Select Committee in 1993 and we do not propose
to repeat all that he then said in description of the Denplan
Care capitation system. However, since then, patients registered
under Denplan Care have risen from 400,000 to over 1 million and
today some 6,250 dentists are involved throughout the United Kingdom.
In 2000 alone, over 95,000 patients opted for a Denplan Care contract
with their dentist.
In essence, the operation of Denplan Care has
continued essentially unchanged—although with some developments—since
Dr Noar addressed the Select Committee. Dentists enter individually
into contracts with patients to provide all their routine dental
care for a regular monthly capitation fee. The fee is arrived
at by assessing each patient's oral condition at the outset. Fees
vary from dentist to dentist according to the hourly cost of providing
care in that surgery, although advice is available from Denplan.
Denplan administers the collection of payments and their transmission
to dentists monthly, in addition to providing on the dentist's
behalf a supplementary insurance against oral trauma or emergency
dental care worldwide including the provision of a 24 hour Helpline.
In 1948, a fee-for-item system was an understandable
choice at the outset of the General Dental Services. Half a century
later, with the opportunities afforded by improved social conditions,
availability of fluoride in different forms, and most of all,
a good scientific understanding of the aetiology of dental diseases,
its wholesale retention is a dis-service to patients and the profession.
No satisfactory trial comparing fee-for-service
and capitation-based dental care for an adult population has been
conducted in the UK, although a recent paper by Krasse and co-workers
(in press) describing such a comparison in Sweden suggests that
the benefits in health, cost and professional terms are in favour
of capitation6.
3.2 Relations Between Government and the Profession
The profession has, since the 1980s, perceived
that spending on primary dental care has declined year on year
both in proportion to health spending generally and to the costs
of running a modern and compliant dental practice. The "New
Contract" of October 1990 promised much, but is principally
remembered for the consequent 7 per cent fee cut in July 1992.
The prevailing view is that a policy of passive decline has been
in place since then. To offer additional incentives by means of
sporadic programmes such as Investing in Dentistry, or the current
proposals, is seen by the profession—and reported by the
British Dental Association—as a thin crust on an inadequate
pie.
The majority of dentists who adopt Denplan Care
do not, according to our research, do so with the primary intention
of raising their income7. They correspondingly increase their
time with each patient, reduce or manage more effectively (through
the use of complementary professionals, for instance) their patient
throughput and significantly, they raise the quality of their
care through the availability of improved materials, more Continuing
Professional Development, and investment in their practices.
The knowledge that a proportion of their income
is guaranteed on a monthly basis engenders a security in planning
for the future which they have not experienced in their dealings
with the NHS.
4. THE PROPOSED
SOLUTIONS—SHORTCOMINGS
4.1 NHS Direct and Dental Access Centres
These initiatives address chiefly the problem
of irregular, un-registered and emergency patients. There are
already reported instances of NHS Direct sending patients to practices
some distance away when nearer practices were available8, and
it has been observed that the distribution of Access Centres does
not accord with data on the availability of NHS dentists or reported
access problems9. It must be questioned whether the cost per episode
will compare favourably with care for these patients in general
practices, where the opportunity to develop continuing preventive
attendance can be encouraged. At this time, we remain unconvinced
that the locations of Dental Access Centres are being determined
according to "dental need" and questions whether their
siting is determined according to key variables such as:
In a number of locations it appears that a Dental
Access Centre has been sited in an area which already enjoys a
relatively high penetration of both NHS and private dentists.
4.2 Commitment Fees and Other Funding Initiatives
As noted above (3.2) such initiatives have a
scattered impact and are not always perceived as equitable. The
management of professional expectations is not always addressed
in their announcement and their long-term benefit is not established.
A risk exists that these proposals will continue a process of
superficial, although nevertheless expensive in overall terms,
reactivity.
4.3 Personal Dental Services, CDS and Salaried
Services
There will always be a need for local and regional
variations in approach. The needs of specific communities and
certain patient groups will always require particular attention,
for instance, long-term in-patient dental care. Where such a need
is established then appropriate provision measured against clear
objectives should be made. Patients exempt from treatment charges
or on low incomes should however, continue to be treated in general
dental practices with appropriate subsidy from Health Authorities.
4.4 Partnerships
The establishment of Primary Care Groups and,
in future, other commissioners or providers of primary dental
health care carries the danger of making more complex and bureaucratic
a service which is presently carried out efficiently by independent
dental practitioners. Whilst the growth of dental corporate bodies
may well, in time, bring economies of scale, the wholesale devolution
of clinical responsibility to commercial interests may require
the introduction of a new dimension to professional regulation.
5. ACCESS CANNOT
BE CONSIDERED
IN ISOLATION
Although it is recognised that the Select Committee
has a specific scope in its present remit, we believe that it
is dangerous to consider the issue of access purely in isolation.
Within any system such as health care, access (or throughput)
is only one axis of a three-dimensional model:
The measures outlined in the Strategy do not
adequately address either resources (human or financial), or quality
of output.
In resource terms, it has been pointed out that,
for the first time in 1999, overseas-qualified entrants to the
Dentists Register exceeded the UK-qualified entrants10. As, given
the six year training period (including vocational training) of
dentists, there is no immediate solution to the problem by this
route, the committee should carefully consider the necessity to
expand the training of dental hygienists and other professionals
complementary to dentistry (PCDs), who should form part of a practice
based, team approach to continuing and preventive care.
We believe strongly that continuing preventive
care is best delivered in general practice by developing the roles
of dental nurses, dental hygienists and dental therapists, both
within dentist-co-ordinated teams and in time, in outreach or
independent practices.
Additional financial resource is undoubtedly
required, but a capitation-based approach to care in this manner
would maximise the impact of incremental investment by government.
Quality of care is the third dimension and arguably,
from the patients' viewpoint, the most significant. Again, Denplan's
research shows that patients are generally appreciative of the
rewards, in terms of quality of care, which Denplan Care can provide11.
Quality is not a commodity in health care which is amenable to
simplistic measurement. Amongst the initiatives currently undertaken
by Denplan within its own measurement are included the following:
— Self-assessed and independent review
of practice structure, process and clinical provision.
— Provision of Oral health Scores K,
and Patient Feedback Surveys within the Denplan Excel Accreditation
Programme
— Provision of—and recording
of—Continuing Professional Development
— A practice-centred dispute resolution
service including informal complaints handling and an independently
administered Arbitration Scheme
— Explicit criteria and standards based
on dynamic professional standards
— Advice and support on clinical and
practice issues.
Evidence from other countries shows that quality
of care is not a function of its delivery solely by dentists themselves
and that the quality of care delivered by PCDs stands equal.
6. CONCLUSIONS
The measures outlined in "Modernising NHS
Dentistry—Implementing the NHS Plan" will not address
the problems of access to NHS dentistry. As outlined in the Demos
Report "Futures for Dentistry—The Changing Environment"12
there are genuine concerns that the current focus on access may
lead to a scenario called "NHS fragments". This scenario
outlines the following circumstances:
"The access strategy does however, start
to create problems. Although fees are increased for some procedures,
they are not for all treatments. In response, more and more dentists
are not willing to carry out all possible treatments which arise
from the initial consultation on an NHS fee scale. In the end
the Government is unable to fund the widespread increase in fees
needed to bring sufficient dentists back into the NHS to cover
the whole population. Nor do attempts to increase fees locally
in deprived areas succeed in encouraging enough dentists to move
into these areas in the long run."
In the short term, a statistically argued improvement
may be achieved, but only at the cost of a further lost opportunity
to promote dental health through continuing, high-quality preventive
care based on dental practices.
In the longer term, problems of access will
intensify. Whether this will be in spite of, or indeed in part
because of, the advocated measures will remain to be seen.
In order to provide a constructive framework
for debate, Denplan would wish to engage in dialogue about access
to quality dental care and to focus particularly on the following
four key points:
— A constructive discussion between
the NHS and private sector regarding local dental needs and their
satisfaction via a coherent mix of NHS and private provision
— Addition of the axis of quality of
patient care to be considered within the debate on access and
the opportunity for an open analysis of Denplan's research in
this area
— A review by the National Institute
for Clinical Excellence of the efficacy and benefit of the regular
dental examination, since much of the strategy appears to challenge
the "six-monthly" approach. Further review of comparative
benefits of a regular preventive regime against those of an occasional/symptom-led
regime is also needed.
— A review of current plans for the
expansion of PCD training and for the development of their role
and remit both in and without practice teams.
January 2001
REFERENCES
1 Modernising NHS Dentistry, implementing the
NHS Plan. HMSO (2000)
2 The Report of the GDSC Ad-Hoc Sub-Committee
on Methods of Remuneration. BDA (1964)
3 Sir Kenneth Bloomfield: Fundamental Review
of Dental Remuneration HMSO (1992)
4 Health Select Committee, fourth report, Dental
Services, volume II, p186 et seq (1993)
5 Deligeorgi, Mjor and Wilson. An Overview of
Reasons for the Placement and Replacement of Restorations. Primary
Dent Care 8;1:5-12 (2001)
6 Zickert, Klock, Krasse & Jonson; Disease
activity and need for dental care in a capitation plan based on
risk assessment (2000) (in press)
7 Denplan Research (1998)
8 Report, Hebden Bridge Times, 15 Dec 2000,
p12
9 BDA Research Unit: Quarterly Bulletin Jan
(2001)
10 The Dentists Register, General Dental Council
(1999)
11 Denplan Tracking Research: BDRC Ltd Q3, 2000
12 Futures for Dentistry—The Changing
Environment Demos, (2000)
| 
