Select Committee on Health Appendices to the Minutes of Evidence


Memorandum by The British Association for the Study of Community Dentistry (D28)


  1.1  This document forms written evidence to the Health Committee from the British Association for the Study of Community Dentistry (BASCoD) on whether the Government's proposals made in Modernising NHS Dentistry, will improve access to NHS dentistry into the long term. The present document outlines the key issues that BASCoD argues will be important in determining whether the population can have access to NHS Dentistry, in particular, into the long-term. This response is divided into two sections: the key issues that we believe will determine access and a brief supporting commentary.

  1.2  We would argue that there are a number of issues that will affect the developments of NHS oral health care services as outlined in Modernising NHS Dentistry and, subsequently will determine whether the proposals made will improve access into the long-term. They are:

    —  The contractual mechanisms operating within the primary dental care system. The current contract with a requirement to visit a dentist within a 15-month period is fundamentally different from that in primary medical care. Furthermore the contractual arrangements in primary dental care have both a patient charge for adults and for the mixing of NHS and non-NHS work. We argue that the issues will influence how people will use the services, and in consequence, identify whether access to NHS care will be affected.

    —  Changes in the oral health needs of the population. Given the charges involved disease patterns are likely to influence service usage. We would argue that two factors will influence oral health needs and in consequence, service requirements: first, the changing epidemiology, with a reduction in disease levels in the younger age cohorts, and, second, advances in technology, which could lead to a more specialised series of treatments and may increase need.

    —  Changes in general health care delivery in the United Kingdom. The development of care delivery systems with an increased emphasis on provision within the primary care sector will also influence oral health care provision. The integration of primary dental care and primary medical care has in the past been weak. The proposals outlined in Modernising NHS Dentistry highlight the potential to bring the two sectors together. However, any modifications to the funding and scope of work commissioned under a state funded system in total are likely to impact on both arrangements within the NHS oral care system and any arrangement outside of the NHS.

    —  The weakest component in Modernising NHS Dentistry centres on the lack of content surrounding workforce planning. Changes in oral health needs and the terms and conditions of service would alter the number and type of personnel, an important determinant of access.


2.1  Barriers to dental care

  There is considerable literature on the reasons for attending at a dental practice, although the emphasis is on the identification to barriers of care. Studies have identified cost and fear as major barriers to attendance. Satisfaction with care has also been associated with regular attendance: those satisfied with the dental care are likely to attend regularly. Possible explanations offered for the low uptake of care include that individuals were satisfied with their current dental health and had confidence in their own ability to prevent dental disease.

  Researchers examining the supply and utilisation of dental services in the Netherlands identified that areas with a higher density of dentists had higher attendance levels. Attendance was also influenced by the type of insurance; individuals with private insurance arrangements attended more often.

  However, this appears to assume that an individual's judgement as to the appropriate use of services is made by reference to the profession's judgement of service usage, the normative need. What is absent is discussion of the possibility that those not registered, those not having attended a dentist within the last 15 month, are doing so on a basis of their own judgement of need, felt need. This judgement will, in part, be based upon the individual's own perception of the likelihood of problems, their perceived risk.

  The Committee will need to recognise that reasons for not attending, ie accessing NHS dental care, are not simply based on service availability. The impact of the decline in disease levels on the perceived needs for oral treatment in patients creates considerable uncertainty in answering whether access will be a problem into the long-term.


  The present contractual arrangements of General Dental Practitioners (GDPs) within the NHS are different to that of their medical counterparts. Perhaps most importantly is the issue of registration. When registered with a General Medical Practitioner (GMP) a patient remains on the doctors list until either party actively seeks to alter the arrangement. There is no necessity for the patient to actively seek re-registration to remain within the care system. This is not the case for dental services. At present, to remain within the NHS care system, the patient needs to attend a dental practice within 15 months. Failure to attend within the time frame would mean that the patient is de-registered, and in consequence, he or she would be excluded from the system.

  Less than 55 per cent of the population aged 18 years or above and 70 per cent of children are registered within the NHS system although wide variation exists for differing age groups. For example, approximately 20 per cent of children aged between nought and two years are registered, while 80 per cent of 10-14 year-olds are.

  However these figures are cohort data: although the percentage of adults may remain the same in total, there is substantial change within the group. Indeed figures from the Dental Practice Board indicate that there are approximately one million changes in registration status on average each month. The million changes may be the same patients re-registering with the same GDP, registering with another GDP, or new patients entering the care system. Reasons for the change in patients' registration status are unknown.

  Yet these issues are critical in determining whether the proposals outlined in Modernising NHS Dentistry will address any perceived problem in access. The patients may be making a rational decision not to use services within a 15-month period, and in consequence, become deregistered. Alternatively patients may not understand the requirements of visiting a dentist to remain within the system: the organisation of NHS medical practice being totally different.

  Modernising NHS Dentistry contains proposals to improve access through the creation of access or drop-in centres. Under the proposals there is no requirement to register within the NHS system. Providing personnel can be found to work within the centres such a move may solve any temporary access problems if they are due to availability. However, into the long-term the consequences of such a policy must be considered. There are implications for monitoring service usage and considerable probity issues.

2.3  Workforce issues

  The current balance in the provision of NHS and non-NHS dental care is very different to that, say, of 10 years ago. There has been a shift from care provision in the NHS to the non-NHS sector. Although precise data are unavailable, the most recent estimates would suggest that approximately 25 per cent of care is provided outside NHS care arrangements. However, reasons for the situation are unknown. These could include that the patient wishes to have non-NHS treatment on the one hand or the dental care provider only offering non-NHS care on the other. Unless an understanding of why the current distribution of care provision has developed, predictions of whether access to NHS remain guesswork. Furthermore, data suggest that the workforce requirements for a service provided outside of the NHS are considerably greater than that should the service be provided within the NHS. In consequence, should any substantial change occur in the balance of non-NHS provision, there will be major implications for the size of the workforce. A shortage will create access problems.

  Modernising NHS Dentistry contains little information on proposals for identifying the appropriate workforce. Although anecdotal comments suggest that at present there is a shortage of personnel, and in consequence, creates access problems, changes in the system as a whole could alter the numbers required. The Health Committee should reinforce the necessity to undertake a thorough examination of workforce planning to ensure that any long-term problems with access are not due to shortfalls in personnel.


  3.1  Access to NHS Dentistry is dependent upon a considerable number of factors. These include the size of the workforce, its geographical distribution and the extent to which the system operates as a "market". Additional factors will also need to be taken into account. These include the perceptions that the public make of the risk of oral problems and the costs of care.

  3.2  Modernising NHS Dentistry deals with the issues in a superficial way that while potentially solving short-term problems through the creation of access or drop-in centres, provides little indication of the long-term consequences.

  3.3  A key issue that the present proposals fail to address is that of the workforce. Having a suitable sized workforce will be critical in ensuring access is maintained. Workforce requirements however will need to be estimated in the context of likely care arrangements. A growth in non-NHS care provision will make access to NHS care more difficult. Vulnerable groups or those who find meeting costs of dental care a problem would be likely to suffer disproportionately.

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Prepared 27 March 2001