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.
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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]
2 C&AG's Report, HC 25, Session 2004-05, paras
2, 1.5 Back
3
ibid, paras 3, 5-7; Ev 23-24 Back
4
C&AGs Report, HC 25, Session 2004-05 paras 3, 1.18; Ev 25-28 Back
5
C&AG's Report, para 1.14 Back
6
Q 58 Back
7
Qq 152, 155 Back
8
C&AG's Report, Executive Summary, para 12 Back
9
Q 56 Back
10
Qq 114-117 Back
11
Ev 25 Back
12
C&AGs Report, para 29; Qq 61, 67-70, 112, 136-138 Back
13
Ev 25-28; C&AG's Report, Figure 5 Back
14
Ev 28 Back
15
Qq 10, 67 Back
16
Q 58 Back
17
C&AG's Report, Executive Summary, para 18 Back
18
Q 44 Back
19
C&AG's Report, para 1.41 and Figure 25; Q 160 Back
20
C&AG's Report, para 1.41; Q 159 Back
21
C&AG's Report, para 1.41; Qq 152-156 Back
22
HC Deb 10 January 2005, cc 7-8 WS Back
23
Q 60 Back
24
C&AG's Report, para 1.43 Back
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