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
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
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. ISSUES THAT
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.