Select Committee on Health Appendices to the Minutes of Evidence


Memorandum by Denplan Limited (D22)


  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.


  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;

    —  New partnerships;

    —  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.


  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.


4.1  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:

    —  Disease prevalence

    —  Oral health status

    —  Local population needs

  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.


  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.


  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


  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)

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