Conclusions and recommendations
1. The Department has set itself an ambitious
programme for reforming NHS dentistry. Some key milestones have
been missed, and the planned introduction of the new base contract
was deferred by six months, to October 2005.
The Comptroller and Auditor General's report drew particular attention
to concerns that Primary Care Trusts lacked the necessary skills
and resources to undertake their new commissioning responsibilities
effectively. The Committee are extremely concerned that in this
vital area of services to the public the Department required Primary
Care Trusts to take over the management of the new contracting
arrangements without ensuring that they had the necessary expertise
and resources. The Department acknowledged that they needed even
more time to implement the new contracting arrangements, and have
now delayed their introduction for a further six months. They
have also established a support team to provide advice and guidance
on commissioning dental services. Primary Care Trusts will need
to give high priority to developing sufficient expertise in dentistry
if the Department is to meet its new target of April 2006.
2. The Department is proposing to move from
patient charges for 400 different items of treatment, to a small
number of price bands. This radical upheaval to the historical
system of charging may have unintended consequences both for dentists'
willingness to provide treatment and for patients' willingness
to pay. The details of the new patient
charges, which were submitted to Ministers in April 2004, are
now to be the subject of public consultation in the summer
2005, followed by affirmative resolution. The Department will
need to play close attention to the results of their consultation
on dental charging if they are to emerge with a system which commands
the assent of all parties. The charging system will also need
to avoid creating incentives to offer private treatment to registered
NHS patients at a lower cost than the NHS charge, leading to a
fall in the costs recovered by the NHS from patient charges. The
Committee is concerned that the time needed for the consultation
and ministerial debate will leave little time for convincing
dentists to agree to the new charges by April 2006.
The Department will need to manage the risks inherent in this
to prevent an exodus from the NHS at the eleventh hour.
3. Dentists will no longer have a financial
incentive to try and collect debts from patients who fail to pay
the correct NHS charges for the treatments they receive because,
under the new system, dentists' income is guaranteed for three
years and is not dependent on the level of charge income.
Primary Care Trusts will need to monitor outstanding debt to see
whether dental practices are as rigorous in collecting payments
under the new system as they were under the old system, and take
appropriate action to ensure that similar levels of fee income
per dentist are maintained.
4. The move away from a system where dentists
are paid per item of treatment will mean that the Dental Practice
Board will no longer be able to monitor dentists' performance
by collating information on treatments carried out.
The Department has acknowledged the need to introduce alternative
monitoring arrangements, and has revised the role of the Dental
Reference Service accordingly. The new arrangements being introduced
by the Dental Reference Service will need to provide effective
accountability arrangements, including clinical audit and evidence
based quality assurance arrangements which monitor levels and
quality of treatment.
5. Indicators of oral health, which have tended
to focus on children, show that children in England average lower
levels of decay than their European neighbours, but with strong
regional variations in the extent of dental decay in adults and
children. Children in some parts of northern
England have on average twice the level of dental decay of children
in some other parts of the country. Adults in northern England
are twice as likely to have no natural teeth as those in the south.
6. Poor oral health tends to be associated
with social deprivation, and some deprived areas have relatively
few dentists as it can be difficult to attract them to set up
practices in these areas. People in areas
of social deprivation are likely to have greatest need for dental
services but be least able to access them. The Department should
consider whether initiatives such as using access centres and
mobile dental units to target areas of need have been given a
sufficiently high priority under the new system. Primary Care
Trusts will need to use their new commissioning responsibilities
for dentistry to influence dentists to provide NHS dental services
in areas of greatest oral health need.
7. The Department has not attempted to assess
demand for NHS dentistry, although it estimates that currently
there are about two million people who would like to register
with an NHS dentist but are unable to do so.
Even in more affluent areas patients may experience difficulties
registering for NHS treatments as dentists have reduced their
commitment to NHS dentistry. If they are to commission dental
services effectively, Strategic Health Authorities and Primary
Care Trusts need to improve their understanding of both need and
demand for local NHS dental services through modelling the requirements
of their local health economies.
8. Matching demand and supply of NHS dentists
over the long term is dependent on the Department and Primary
Care Trusts developing a clear understanding of dentists' reasons
for switching to PDS contracts in advance of the new contracting
arrangements. The Department should undertake
a survey of dentists who have moved to the PDS contracts to understand
more fully their reasons and determine whether the expected increase
in commitment is being realised.
9. England has one of the highest ratios of
people to dentists of all the European Union and G7 countries,
and in 2002 the Department estimated that in 2003 there would
be a shortage of 1,850 dentists. The shortfall
in dentists is being met in the short term by international recruitment
initiatives. In the long term the Department is increasing the
number of dental training places by 25% and is quadrupling the
number of dental therapist places. The Department needs to explore
options for incentivising these additional dentists to commit
to the NHS.
10. The Prime Minister's pledge that everyone
should be able to see a NHS dentist by phoning NHS Direct requires
up to date information on dentists' capacity, but the data provided
to NHS Direct by Primary Care Trusts is often out of date.
Moreover NHS Direct do not follow up to determine whether callers
were successful in locating a suitable dentist. Primary Care Trusts
need to work with their local NHS Direct to develop a more accurate
system of providing the necessary data. NHS Direct should introduce
a feedback system so that it can track the accuracy and effectiveness
of its advice.
11. The National Institute of Clinical Excellence's
2004 advice on changing the dental recall period, from the 6 months
used by most dentists to between 3-18 months depending on clinical
need, should also help free up capacity.
There is however a risk that the existing incentive for dentists
to see their patients too often will be replaced by an incentive
to reduce patient visits to below the optimum frequency for oral
health. The Department should provide posters and leaflets to
be displayed in dentists' surgeries which explain the rationale
for the change, so that patients understand any proposed variation
in their recall period.
12. There is a lack of consensus on suitable
measures of oral health. The new contract
provides remuneration to dentists for meeting their patients'
oral health needs, so a common approach to monitoring oral health
will be needed. The National Audit Office used an Oral Health
Index devised by the University of Birmingham in preparing its
report. The Department should consider adopting this index, or
agree on a more suitable oral health measure.
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