APPENDIX 7
Memorandum by National Association of
Citizens Advice Bureaux (D23)
SUMMARY
1. Access to NHS Dentistry has been a significant
issue of concern reported by CABx since the early 90's. The CAB
Service therefore welcomes the terms of reference of the Health
Committee's enquiry into NHS dentistry "to examine whether
the Government's strategy will improve access to NHS dentistry
in the long term".
2. We are concerned that the target in Modernising
NHS Dentistry appears to be focused on making it easier to access
information rather than on making it easier to access the service
itself. The key concern raised by CABx is not in accessing information,
but that there is no NHS dentistry provision in the local area,
so that clients have either to face the cost and inconvenience
of lengthy journeys by public transport, or go without. Although
there is provision within the health benefits scheme for help
with travel costs to hospitals, there is no provision for help
with travel costs to access NHS dentistry.
3. In our view a more relevant and challenging
target would have been to adopt the approach used in the Government's
Rural White Paper Our Countryside the future (Nov 2000) which
sets out minimum standards and targets covering access to and
delivery of public services in rural areas. These include "geographical
access standards" which specify "the maximum distance
or time which people should be expected to travel to reach a service
outlet".
4. Some of the initiatives outlined in Modernising
NHS dentistry are designed to address the immediate patient need
for care but do not guarantee access to treatment in the longer
term. In our view the long-term aim should be to ensure that people
can choose whether they receive NHS dental care through the registration
system or via a more flexible route.
5. But issues of choice are not confined
to the patient. More immediately, there is a need to take steps
to end certain practices which effectively enable dentists to
choose whom they will accept as patients, either on the basis
of their dental needs or by making acceptance conditional on a
child's parents agreeing to be treated privately.
6. It is regrettable that the Government's
strategy paper does not examine whether the current level of charges
is causing hardship, or is actually deterring people from obtaining
appropriate treatment. It seems likely that the level of patents'
concern about charges will become more visible in future as a
consequence both of the greater availability of NHS dentistry
for adults if the Government's strategy is successful, and of
the new requirement to give all patients a fully costed estimate
in advance of treatment.
7. Other areas of concern include cancellation
charges and the charging of deposits in advance for access to
NHS treatment. Where patients are on low incomes and would be
entitled to NHS treatment, this can prevent access to NHS treatment.
INTRODUCTION
8. The CAB Service welcomes the terms of
reference of the Health Committee's enquiry into NHS dentistry
"to examine whether the Government's strategy will improve
access to NHS dentistry in the long term". Access to NHS
dentistry has been a significant issue of concern reported by
CABx since the early 90's, and it is clear from our evidence that
NHS dentistry has in recent years failed to meet the Government's
manifesto commitment for the NHS that "access to it will
be based on need and need alone—not on your ability to pay,
or on . . . where you live".
9. Despite previous Government initiatives
such as Investing In Dentistry, which have improved access in
some areas, CABx have continued to report a reduction in the accessibility
of NHS dentistry at the local level. This is reflected in figures
from the Dental Practice Board which show a steady decline in
the number of adult patients registered for NHS dental treatment
over the last decade.
10. In recent months CABx in many parts
of the country including in particular Lincolnshire, Yorkshire,
Oxfordshire, Cheshire, Shropshire, Kent, Hampshire, Cornwall and
West London have reported difficulties in accessing NHS dentistry
in the local area.
11. In most cases the central problem is
not in accessing information. CABx are able to obtain information
about the nearest alternative NHS dentist from the local health
authority or help line. The key concern raised by CABx is that
there is no NHS dentistry provision in the local area, so that
clients have either to face the cost and inconvenience of lengthy
journeys by public transport, or go without. This has particular
implications for people on low incomes, pensioners and people
with disabilities or in poor health, who may find such journeys
present an insuperable barrier. Although there is provision within
the health benefits scheme for help with travel costs to hospitals,
there is no provision for help with travel costs to access NHS
dentistry.
— A CAB in Kent reported two clients
in two weeks who were concerned that their dentists were no longer
offering NHS dentistry. One was a pensioner. The CAB commented
that it is very difficult to find a dentist in the local area.
— A CAB in Yorkshire reported a pensioner
who had been a patient of the local dentist for 30 years. The
practice has now gone private and there is no other NHS practice
in the local area.
— A CAB in Oxfordshire reported a client
who needed emergency treatment but was unable to get an NHS appointment
for six weeks. The local Helpline revealed that all the local
NHS dentists were fully booked. She therefore attended the local
hospital where she was given painkillers. The hospital doctor
was annoyed that she had to use the busy hospital facility because
of the shortage of NHS dentists.
12. The CAB Service therefore welcomes the
Government's decision to invest £93 million over the next
two years and we are pleased that the availability of dentistry
is now seen as a clear priority for the NHS.
ADEQUACY OF
THE TARGET
13. The target in Modernising NHS Dentistry
states:
"By September 2001 everybody who needs NHS
dentistry will be a phone call away from finding it. Information
for patients about dentistry will be better and easier to get."
14. We are concerned that this target appears
to be focused on making it easier to access information rather
than on making it easier to access the service itself. In our
view a more relevant and challenging target would have been to
adopt the approach used in the Government's Rural White Paper
Our Countryside the future (Nov 2000) which sets our minimum
standards and targets covering access to and delivery of public
services in rural areas. These include "geographical access
standards" which specify "the maximum distance or time
which people should be expected to travel to reach a service outlet".
15. Without clear standards, there must
be a danger that gaps in the availability of NHS dentistry will
remain. For example Romsey CAB in Hampshire recently contacted
their health authority following publication of the Government's
dental strategy to ask whether this increased investment would
mean that there would again be NHS dentistry in their local market
town. At present the waiting list of the only NHS dentist in the
town is closed and residents have to make journeys of at least
5-6 miles to neighbouring towns, to which there is no direct regular
public transport. But the CAB was told that, although they recognised
that Romsey was not well served, there were no plans for additional
provision in the town as there were other localities which were
in greater need. The bureau was also told that no local geographical
targets were being set which took into account public transport
provision.
16. Cornwall is quoted in Modernising NHS
Dentistry as an area where access problems have been resolved
through the provision of a Dental Access Centre. But Liskeard
CAB reported that significant access problems remain. They were
informed by their health authority helpline that the service provided
through the Dental Access Centre was mainly for emergency dental
treatment. The service is provided through 21 clinics throughout
Cornwall which operate part-time on a rota basis. Apparently the
Liskeard clinic is particularly busy so it mainly accepts high
priority emergencies such as severe pain and swelling, or dental
pain from children who have been crying all night. People with
mild toothache or who had lost a filling were likely to have to
wait or travel many miles to another clinic. The emergency treatment
only provides temporary fillings which therefore have a limited
life.
17. The helpline stressed the importance
of getting on a waiting list for registration with an NHS dentist
for longer-term care. However there were no vacancies for NHS
treatment at any practice in south-east Cornwall. There was a
two month waiting list to register with an NHS dentist in Truro
(40 miles away) and a five month waiting list to register with
a dentist in Fowey (20 miles away). Both towns require long complex
journeys by buses, trains and in the case of Fowey a ferry, making
dental services inaccessible to most residents in south-east Cornwall
without their own transport.
18. The precise nature of the target is
also somewhat unclear as, in contrast to the target specified
in Modernising NHS dentistry, the Rural White Paper states that
"NHS dentistry will be made available to everyone who needs
it, no matter where they live, by September 2001". Whilst
this still falls short of defining geographical access standards,
it would appear to imply that the Government's commitment goes
beyond access to information.
19. In Modernising NHS dentistry, a key
role is envisaged for NHS Direct in disseminating accessible and
up to date information about the availability of NHS dentistry.
However it also needs to be recognised that there will be many
people seeking the service who will not use NHS Direct for this,
maybe because they are unaware of the service, or because they
do not have access to a telephone, or because they choose instead
to rely on word of mouth. People who are already socially excluded—through
language, disability or poverty for example—may risk having
their exclusion compounded unless this information is made more
widely available. It will be important that other outlets such
as health centres, CABx and other advice agencies, and community
outlets such as libraries are also provided with regularly updated
information about the local availability of NHS dentists.
20. Clearly the feedback from the NHS Direct
service in terms of the extent to which it is able to meet demand,
will be a useful means of measuring the extent to which the Government's
target is met. However for the reasons outlined above, it is important
that it is not used as the only measure. It will be important
that, in addition to reacting to data from the NHS Direct service,
health authorities also adopt a pro-active approach to the issue
and undertake comprehensive mapping of NHS dentistry provision,
setting local targets which reflect local travel patterns and
the availability of public transport.
21. Again it is noteworthy that the Rural
White Paper commits the Countryside Agency to monitor average
population distance from GPs and dentists. We would hope this
evidence will be an integral part of the overall monitoring of
the success of the Government's dental strategy.
MEETING PEOPLE'S
NEEDS
22. Understandably in the first instance
the Government's priority must be to ensure everyone who wants
to be treated by a NHS dentist is able to do so. However in the
longer term it will be important that NHS dentistry develops in
a way that meets people's needs. CAB evidence suggests there are
several key issues that need to be addressed if this is to be
achieved.
Continuity of care
23. Some of the initiatives outlined in
Modernising NHS dentistry are designed to address the immediate
patient need for care but do not guarantee access to treatment
in the longer term. For example sessional contracts with individual
GDS dentists will not provide longer term care. The next time
the patient needs dental treatment, s/he will again have to first
search for a dentist, and may well be directed to a different
provider. Dental Access Centres also appear to be focussed on
dealing with emergency rather than on-going routine treatment.
24. Many patients value highly the continuity
of care provided by their local dentist over many years. It will
be important that in the longer term people are again able to
access such a service throughout the country under the NHS.
— A CAB in Cheshire reported an elderly
client who had been a NHS patient with her local dentist for 35
years. When she recently attended for treatment, she was very
distressed to be informed that NHS treatment was no longer available.
25. Patients who had stayed with their dentist
but moved to private treatment when the dentist gave up NHS provision,
are particularly distressed to find that, should they become entitled
to remission of NHS charges, (for example if they lose their employment
or become pregnant) they are forced to seek an alternative dentist
at a point in time when they are already dealing with other significant
changes in their lives:
— A CAB in Surrey reported a client
who had been a patient with the local dentist all her life, originally
under the NHS but more recently as a private patient paying through
Denplan. She has now become pregnant and so is entitled to free
treatment under the NHS but has been told she will have to go
elsewhere for the treatment as the surgery only provides NHS treatment
for children.
— A CAB in Hampshire reported a client
who was forced to register with a private dentist when she moved
into the area because there was no NHS dentist available. She
has now become pregnant but her dentist will not provide her with
free NHS treatment.
26. The 15-month registration period can
also work against continuity of care, as the Government's strategy
paper notes (paragraph 3.4). People who leave a gap of more than
15 months between visits, will find that their registration has
lapsed and their dentist may refuse to re-register them. On the
other hand attendance within the 15 month period provides no guarantee
that dentists will not remove NHS patients from their lists if
they decide to move out of NHS provision. It is regrettable that
the NHS strategy does not include a reconsideration of the value
of the time-limited registration period. From the patient's perspective,
time-limited registration appears to be of little benefit as compared
with the open-ended registration with GPs Too often its main impact
appears to be that patients who unintentionally allow their registration
to lapse, find that their dentist refuses to re-register them.
It can also be confusing for patients to have two different systems
in operation.
27. CAB evidence suggests that pensioners
may be particularly affected by this problem, both because they
may not feel they need to make regular visits if they have a full
set of dentures and because some dentists appear particularly
reluctant to undertake denture work under the NHS:
28. A CAB in Cornwall reported a pensioner
in receipt of disability living allowance mobility component,
who had not felt the need to visit his dentist for some time because
he had no problems with his dentures. He then broke the lower
plate and went to his dentist to seek a repair. He was told that
he should have visited at least once a year, that he was now no
longer registered and that he could not re-register. The nearest
NHS dentist where he can register is around 30 miles away.
— A CAB in Oxfordshire reported a patient
who was told that his NHS dentist would no longer accept him as
a patient as he had not been attending regular check-ups. He did
not think this was necessary as he had a full set of dentures.
— A CAB in Lincolnshire reported a
pensioner who had been to the same dentist all her life. Three
years ago she had NHS dentures fitted and has not needed to go
to the dentist since. As a result of an accident she now needs
new dentures and was very distressed to find she could no longer
get NHS treatment from her dentist.
Choice
29. In our view the long-term aim should
be to ensure that people can choose whether they receive NHS dental
care through the registration system or via a more flexible route.
It will also be important that there is a number of local GDS
providers, both to avoid a local monopoly situation and so that
patients may be able to exercise real choice.
— A CAB in Shropshire reported a client
who was concerned about the service he was receiving from his
NHS dentist. However he was unable to move to another dentist
as there were only two in the local area and both had full lists.
The CAB commented that new patients faced a 15-mile journey to
the nearest town, with the usual public transport difficulties.
30. But issues of choice are not confined
to the patient. More immediately, there is a need to take steps
to end certain practices which effectively enable dentists to
choose whom they will accept as patients, either on the basis
on their dental needs or by making acceptance conditional on a
child's parents agreeing to be treated privately:
— A CAB in Wiltshire reported a couple
who had recently moved to the area and wanted to register with
a NHS dentist. They had difficulties in walking, were in receipt
of disability benefits and did not have a car. There was only
one dentist in the local town who would take on NHS patients,
and then only if they were assessed as dentally fit.
— A CAB in Essex reported a woman over
pensionable age who needed replacement dentures as her current
set was giving her ulcers. She was entitled to full exemption
from charges and her current dentist undertook NHS treatment.
However the dentist said she would not do denture work on the
NHS because the remuneration was insufficient.
— A CAB in Surrey reported a client
whose husband was accepted as a NHS patient by the local dentist.
He was told he required two half-hour appointments. Subsequently
he was told that he would not be taken on as a NHS patient because
too much work was needed on his teeth.
— The same CAB reported another client
with a three year old daughter who was told that her child would
only receive NHS treatment if the parents registered as private
patients.
31. It is particularly disappointing that
the Government's Modernising NHS dentistry paper acknowledges
the existence of dentists declining to accept children unless
their parents register as private patients (para 4.9) but merely
states that it will "consider whether it represents a significant
barrier to treatment for all". We would question the ethics
of such a practice, which in our view should have no place in
the National Health Service. We hope the Government will take
urgent action to end this practice and ensure that where dentists
undertake NHS work, this is made equally available to any potential
patient, without discrimination.
30. Charges
32. The level of charges for NHS dentistry
is not given any consideration in Modernising NHS dentistry. This
is a significant omission. In the last 10 years charges have risen
considerably, to the extent that they can now be a significant
barrier to accessing NHS services. Whilst the health benefits
scheme provides crucial protection for the poorest, the very high
maximum charge of 80 per cent of the total cost of treatment up
to a ceiling of £354 can leave many people on incomes above
the health benefits scheme threshold, in considerable difficulty.
There have been significant increases in this charge over the
last decade—in 1991-92 the maximum charge was 75 per cent
up to a ceiling of £200. Three quarters of adults receive
no help with the cost of dental treatment (Hansard, 19.6.00).
Pensioners can be particularly affected as the sudden one-off
cost of dentures is amongst the most expensive items of dentistry,
at a price which starts from £107.00.
— A CAB in Hampshire reported a pensioner
who was asked for a £300 deposit in advance for the provision
of NHS dentures.
— A CAB in Humberside reported a man
in low paid work who was told by his NHS dentist that he needed
root canal treatment at a cost of around £80. He could not
afford this and was therefore forced to have the tooth extracted
instead.
33. It is regrettable that the Government's
strategy paper gives no consideration as to whether the current
level of charges is causing hardship, or is actually deterring
people from obtaining appropriate treatment. It seems likely that
the level of patients' concern about charges will become more
visible in future as a consequence both of the greater availability
of NHS dentistry for adults if the Government's strategy is successful,
and of the new requirement to give all patients a fully costed
estimate in advance of treatment.
34. The lack of awareness about current
charges was clearly illustrated in research recently commissioned
by the BDA into patients' attitudes towards NHS dentistry. This
found that many people were not aware that patients paid 80 per
cent of the NHS cost. When they were informed of this there was
a widespread perception that this was unfair. Many felt that a
50/50 split or a reversal of the current ration to a 20 per cent
patient contribution was preferable. (User priorities for General
Dental Services, Land T and Herring L, York Health Economics
Consortium, 1998).
35. But it is not only the treatment charges
themselves which are of concern. CAB report that some dentists
are in effect charging for access to NHS treatment. Where patients
are on low incomes and would be entitled to free NHS treatment,
this can prevent access to NHS treatment:
— A CAB in Cambridgeshire reported
a single parent with three children who was in receipt of income
support. The dentist will only provide NHS dental treatment if
patients pay a £25 deposit which is refundable only after
the treatment is completed. The client cannot afford to pay the
charge for herself and each of her children and therefore is excluded
from access to what should be free NHS treatment.
— A CAB in Hampshire reported a woman
suffering from diabetes and mental health problems who was living
on the reduced rate of income support whilst appealing a refusal
of incapacity benefit. She would therefore have been entitled
to free NHS dental care. She needed urgent dental treatment and
her GP recommended a dentist in the same health centre. However
the dentist required a £20 refundable deposit before beginning
treatment which she could not afford. She telephoned several other
dental practices and found they made the same upfront charge.
The CAB telephoned the Health Authority which confirmed that such
charges were lawful and were common.
36. It is surely contrary to the principles
of the National Health Service to impose a charge for accessing
NHS treatment, as it effectively excludes the poorest people who
would be eligible for free treatment under the NHS. We would hope
that the Department will take urgent steps to end this practice.
37. A second area where large charges are
increasingly being reported is for broken appointments. Whilst
it is understandable that practitioners wish to impose some sanction
to prevent casual abuse of the system, it is clear that some dentists
are imposing charges for broken appointments with no regard either
for the reason the patient did not attend or for the patient's
ability to pay:
— A CAB in Wiltshire reported a single
parent in low paid work who was entitled to free treatment, who
was charged £30 for cancelling an appointment at short notice.
The reason for the cancellation was that her child was sick and
she could not find anyone to mind the child. The dentist was unwilling
for her to bring the child to the surgery.
38. The CAB Service considers that this
is an area where at the very least the Department of Health should
issue guidance, both on cancellation charges and on the circumstances
in which they might be appropriate.
CONCLUSION
39. The CAB Service welcomes the Government's
commitment to tackle what can only be described as a crisis in
the availability of NHS dentistry. We hope that the increased
investment will result in a significant improvement in access.
However without clear geographical access targets at the local
level, we are concerned that gaps in provision will remain. Any
gaps will have a severe impact on people on low incomes and others
for whom travel is difficult because of age, illness or disability.
40. There is also a need for the Department
of Health to address practices such as charging of deposits in
advance of treatment, and for cancelled appointments, which can
also act as barriers to dental services for people on low incomes.
41. In the longer term it will be important
that NHS dentistry develops in ways which reflect patients' preferences.
A modern, patient-centred NHS service should ensure that patients
are able to choose both how and from whom they receive their dental
care, in a convenient location and at a cost which is genuinely
affordable in all circumstances.
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