House of Commons - Public Accounts

Select Committee on Public Accounts Thirtieth Report

1 Supply and demand for NHS dentistry services

1. Most dentists are not employed by the NHS. They are independent contractors running their practices as small businesses. Primary Care Trusts have no powers to compel dentists to take on NHS patients as they have for general medical practitioners. Traditionally NHS dentistry in England has been provided largely through the General Dental Service, the dental practices located throughout the country. They chose where to locate their premises and how much, if any, NHS treatment to provide. Since 1998, the Department of Health (Department) has been piloting Personal Dental Service contracts aimed at giving the NHS more influence over location of dentists and extent of NHS treatment.[2]

2. In 2002, the Department published its Options for Change report proposing a radical reform of NHS dental service in England which builds on the Personal Dental Services pilots. The "Options" paper suggested that any new system should be voluntary and would operate alongside the existing piece work system. In 2003, the Health and Social Care (Community Health and Standards) Act paved the way for major changes to dentistry. Each Primary Care Trust will be responsible for commissioning dental services "to the extent that it considers necessary to meet all reasonable requirements". Dentists will be paid for delivering local contracts where they provide NHS dentistry to meet patients' oral health needs, rather than for each item of treatment. The Department initially set an April 2005 target date for implementation but, in response to consultation, announced in July 2004 that the changes would be implemented from October 2005. Subsequently the Secretary of State for Health announced that full implementation would be deferred until April 2006 but that in the meantime dentists will be encouraged to move over to a Personal Dental Services contract.[3]

3. As at September 2004 there were some 20,800 dentists working under the GDS and 3,500 under the PDS. In addition the NHS funds other dental services, and in 2003-04 two million patients were treated in hospital and community dental services (Figure 1). The net cost to the NHS of providing these dental services was some £1.8 billion, with £0.5 billion funded through patient charges.[4] Figure 1: The numbers of different types of NHS dentists

Type of NHS dentistry Number of dentists as at September 2004

General Dental Service (GDS) 20,800

Personal Dental Service (PDS) 3,500

Hospital Dental Service 2,245

Community Dental Service 1,940

Salaried Dental Service 200

Note: 700 Personal Dental Service dentists also worked in the General Dental Service and some Community Dental Service dentists also worked in the Personal Dental Service

4. Figure 2 details some of the key facts about the current and proposed systems. Figure 2: Key facts about NHS Dentistry

·  There are around 21,000 dentists in primary care, more than in previous years, but many spend a lower proportion of their time on NHS work which has left some people unable to get the routine treatment they want on the NHS, unless they are prepared to travel.
·  Some 17 million adults (45%) and 7 million children (62%) are registered with an NHS dentist. Between 1994 and 1998, adult registrations fell by 5 million but for the last few years have decreased only marginally.
·  Everyone is entitled to see an NHS dentist for emergency or urgent treatment, whether registered or not.
·  NHS dentists currently operating under the General Dental Services contract receive a capitation fee for each registered patient and a fee per each item of treatment.
·  All treatment necessary to maintain oral health is available on the NHS, although some are only provided through the hospital dental service. Overall there are some 400 items of treatment.
·  Patients liable for dental charges currently pay 80% of the dentist's fee, ranging from £3.50 for one X-ray to £297.70 for a fixed brace. The maximum charge is £378 for one course of treatment. Full exemptions from fees apply to all patients under 18 years of age and expectant and nursing mothers; full remission of fees applies to adults in receipt of tax credits, job seekers allowance and income support. Additionally, some patients on low incomes are entitled to partial remission of fees.
·  NHS treatment does not include purely cosmetic procedures such as tooth whitening. Complex tooth-coloured fillings on back teeth are generally not permitted, primarily because they are generally less reliable than silver amalgam.
·  Some treatments are provided free to all patients. These include denture repairs, arrest of haemorrhage, removal of sutures, home visits and attendance to open the surgery in an emergency.
·  From 2005-06 spending on NHS dentistry is set to increase with Primary Care Trusts set to receive an increased allocation of £250 million a year (a 19.3% increase over the equivalent spend in 2003-04).
·  The NHS Workforce is set to increase by the equivalent of 1,000 dentists by October 2005. Some 3,500 dentist have already moved over to the Personal Dental Services contract and by April 2006 dentists will no longer be paid per item of treatment but will be paid an annual contract to provide treatment to patients on the basis of clinical need.

5. In 2003-04 17 million adults and 7 million children were registered with an NHS dentist, representing 45% of the adult population and 62% of children. Over the ten years to March 2004 the number of adults registered with the General Dental Service fell by 5.5 million (Figure 3). In areas with high levels of social deprivation there are relatively few dentists and consequently high levels of registration per dentist. In more affluent areas patients may experience difficulties registering for NHS treatment as dentists have reduced their commitment to the NHS.[5]

Figure 3: Fall in the number of adults registered with the General Dental Service of 5.5 million between April 1994 and March 2004

An increasing number of adults are unable to access routine dentistry services on the NHS

6. In order to access routine treatment such as check ups on the NHS a patient must be registered with an NHS dentist. The Department acknowledged that in some parts of the country it was difficult to get registered with an NHS dentist and that it was not delivering guaranteed routine treatment to people across the country.[6] The Department estimated that there were around two million people who needed to register with a NHS dentist but were currently unable to do so. Its intention was that all these people would be able to register by October 2005.[7]

7. In 1999 the Prime Minister pledged that by September 2001 anyone would be able to see a dentist just by phoning NHS Direct.[8] The Department explained this pledge as meaning that anyone phoning NHS Direct could get urgent or emergency dental treatment, not that they could register with an NHS dentist.[9] The Department told us that around 19,000 people ring NHS Direct each month to try and access emergency and urgent dental treatment, and that around 94% are referred to a dentist within a short distance from their home.[10] Primary Care Trusts have developed local distance standards between the location of a caller to a helpline and the location of the dentist recommended to them. For example, the local distance standards for Durham and Chester-le-Street are shown in Figure 4.[11] The Department does not subsequently monitor whether the dentists to which these patients are referred provide treatment and therefore cannot say whether the Prime Minister's pledge is being met.Figure 4: Local distance standards for Durham and Chester-le-Street Primary Care Trust

Urban areas Rural areas

Routine care 5 miles Routine care 25 miles

Urgent care 15 miles Urgent care 35 miles

Emergency care 15 miles Emergency care 35 miles

Encouraging existing NHS dentists to increase or maintain their NHS commitment

8. In the early 1990s, following cuts in fees, many dentists reduced their provision of NHS services and developed their private work. Since then the General Dental Services (GDS) per capita spending has increased by only 9% compared with a 75% increase in overall NHS funding per capita. Currently, around 66% of dentists do 70% or more of their work for the NHS. However, there is a wide variation in total gross fee that dentists earn from the NHS which reflects the amount of GDS work performed; a significant number of dentists now do relatively small amounts of GDS work. The percentage of dentists earning less than £50,000 in gross fee earnings from GDS work increased by two percentage points between 2002-03 and 2003-04 (Figure 5).[12]Figure 5: The distribution of gross NHS fee earnings for Principal Dentists in £50,000 bands in 2002-03 and 2003-04[13]

Gross NHS Earnings 2002-03 2003-04

Total Percentage distribution Total Percentage distribution

Under £50,000 4,688 32 4,959 34

£50,000 - £99,999 3,572 25 3,307 23

£100,000 - £149,999 3,484 24 3,524 24

£150,000 - £199,999 1,564 11 1,678 12

£200,000 - £249,999 576 4 561 4

£250,000 - £299,999 230 2 216 1

Over £300,000 335 2 228 2

Total 14,449 100 14,473 100

Notes:
Principal dentists are those who are contracted to provide general dental services and have worked for a full year.
The table excludes those dentists who worked for a body corporate, assistants and dentists on Vocational Training.

9. Dentists can earn more working in private practice than providing treatment for the NHS. For example, a dentist with a reasonable commitment to the GDS would have earned around £63,000 in 2002-03 after expenses whilst a dentist undertaking solely private work would have earned over £90,000.[14] Both the Department and the British Dental Association told us that most dentists undertake private work because it allows them to move off a treadmill system of working and spend more time performing preventive work, rather than because of the additional money then can earn.[15] The British Dental Association warned that unless those dentists currently offering NHS services in England could be persuaded to continue then there was a strong possibility of the almost total demise of the provision of dentistry on the NHS.[16]

10. In July 2004 the Government announced that from 2005-06, there would be additional funding of £250 million a year for NHS dentistry, an increase of 19.3% compared with 2003-04 spending.[17] The British Dental Association was concerned that the majority of this money would be used to fund the recruitment of additional dentists from overseas and the dentists' annual pay review. Of the additional £250 million it estimated that only £60 million would be used for the expansion and growth of the existing service.[18]

11. England has a ratio of 1 dentist to 2,276 people, which is one of the highest ratios of population to dentists of all the European Union and G7 countries. The Department considered that it was misleading to consider only the ratio of dentists to members of the population without considering other members of the dental team. The Department's approach to workforce planning differs from some other countries, and in England a higher proportion of dental hygienists and dental nurses are employed as part of the dental team. There are however also shortages of dental hygienists, therapists and nurses in England which result in qualified dentists performing basic work which could be done by other dental professionals.[19]

Recruiting additional dentists

12. The Department had undertaken some limited attempts at manpower planning in the 1980s which led to the closure of 80 dental training places. In July 2004 the Department published a workforce review based on analyses undertaken in 2001-02. The review concluded that in 2003 there was a shortage of 1,850 whole time equivalent dentists and that, without additional resources, by 2011 the shortfall would increase to between 3,640 and 5,100 dentists. There were also shortages of dental hygienists, therapists and nurses. If the dental schools had not been closed in the 1980s then an additional 960 dentists would have been trained to date.[20]

13. The Department announced in July 2004 that it needed 1,000 additional whole time equivalent dentists to meet England's short term dentistry needs. It has launched a return to NHS dentistry campaign and expects to recruit additional dentists from overseas, aiming to increase by the equivalent of 1,000 the numbers of dentists providing NHS treatments by October 2005.[21] A first group of dentists from Poland have now arrived in England and started work in January 2005. Further tranches of Polish dentists will be starting work before October 2005, and the Department has also commenced recruitment in other countries including Spain, and Germany and India.[22]

14. The additional dentists will be commissioned to provide NHS dentistry services in the areas of most need, though the Department recognised the risk that at the end of their contracts these dentists would transfer from providing NHS dentistry to more lucrative private practice. It intended to respond by making NHS dentistry more attractive.[23]

15. To increase the supply of NHS dental services in the longer term, the Department is increasing the number of dental training places by 170 (a 25% increase) and quadrupling the number of dental therapist places. If the increase in the provision of NHS dentistry services accounted for by the additional training places and the dentists recruited from overseas is to be sustained, the Department needs to be able to demonstrate to dentists and other dental professionals that the NHS is an attractive place for them to work.[24]



© Parliamentary copyright 2005	Prepared 14 July 2005