Further supplementary memorandum submitted
by the Department of Health
I attach the notes promised at the hearing.
In addition, Sir Nigel would like to amend the estimated figure
of 1,100 he gave to question 159 at the hearing to 960. A total
of 80 training places in the UK were lost with the closure of
the Edinburgh and University College London dental schools. The
schools were run down to complete closure by 1992. In the 12 years
from 1993 to 2004, therefore, some 960 additional dentists would
have trained but for the closures.
Question 73 (Jon Trickett): Will the NHS
find a person, who perhaps owed significant money to a dentist
or to the NHS, another dentist without first of all securing the
money that they owe?
Under the present patient charge arrangements,
dentists are responsible for bad debts if patients fail to pay
the correct NHS charges for treatments they receive. Generally,
dentists are well practised at minimising the risk of bad debts,
for example by requiring patients to pay as they go if their treatment
extends over more than one visit. If a dentist is unwilling to
treat a particular individual, they also have the ultimate right
to refuse to treat that patient.
Whilst the incidence of bad debts can undoubtedly
be a nuisance and irritant, the profession have not brought forward
evidence to suggest that the scale of loss is a serious financial
burden, or that it is large enough to justify maintaining a centralised
system to track patients with a record of bad debts. Therefore,
a patient who approaches their primary care trust (PCT) or NHS
Direct for assistance in finding NHS dental care would not necessarily
be identified if they had an outstanding bad debt arising from
a previous NHS treatment.
We have given guarantees that where patient
charge revenue falls because of the new ways of working (ie not
where patients have just simply not paid), practices will not
lose out financially. We will expect dental practices to be as
rigorous in the new world as they are now in collecting patient
charges.
Question 96 (Mr Field): Could you give the
breakdown for the four constituencies on the Wirral, because I
guessed there might be differences where these new patients were
picked up?
Patient registrations (or on practice lists)
with general dental service or personal dental service, dentists
on 30 September 2004 in the four constituencies within Wirral
are as follows:
| Adult registrations/listed
| Children's registrations/listed |
| Birkenhead | 36,431 |
11,368 |
| Wallasey | 44,149 |
15,520 |
| Wirral West | 33,121 |
10,364 |
| Wirral South | 35,628 |
10,427 |
| Total | 149,329 | 47,679
|
| | |
The registrations/listings are with the dentists in these
areas. The figures will include some patients who are resident
in other areas. Similarly, some patients from these areas will
get dental treatment in other areas. Therefore, the figures for
small areas should be treated with caution.
The registration period in the general dental service is
15 months. Patients who have not seen a dentist in the past 15
months eg some occasional attenders will not be counted in these
figures. In the personal dental service, the registration/listing
periods can be different; a longer period increases the numbers
because occasional attenders are counted for longer after their
last attendance.
The registration/listing rates for the area covered by the
four constituencies are 68.8% for children and 61.1% for adults.
Separate rates cannot be calculated for the individual constituencies
because population figures are not available. However, for adults,
using the electoral roll numbers in individual constituencies
to estimate adult populations for the individual constituencies
gives the following registration/listing rates:
| Adult registration/listing rates 30 Sept 2004
|
| Birkenhead | 62.8% |
| Wallasey | 68.3% |
| Wirral West | 53.3% |
| Wirral South | 59.6% |
| These rates are affected by the particular locations of dentists.
|
| |
Question 99 (Mr Field): Is not collecting bad debts part
of the treadmill you are trying to get dentists off?
The "treadmill" in NHS dentistry usually refers
to the Item of Service approach to remuneration, whereby a dentist
is paid more for providing more operative dental treatments where
these are permitted in the Statement of Dental Remuneration.
Dentists will still be expected to be the initial collection
point for NHS charges, because that is the most convenient arrangement
for patients. However, by moving away from the "treadmill"
of an item of service approach to remuneration for dentists, which
in turn has given rise to the nearly 400 different treatment charge
rates, it should be possible to introduce a far simpler system
of patient charges which will be less onerous and bureaucratic
for dentists to administer.
Question 100 (Mr Field): Did you look at whether nursing
mothers and young children were the two most deserving groups
if we were going to exempt groups en bloc from charges? Are there
no more deserving groups like diabetics or others who perhaps
ought to be given free treatment?
The issue of NHS patient charge exemption categories is wider
than the modernising dentistry programme. Current exemptions from
dental charges are based in primary legislation, and were only
recently reconfirmed in the Health and Social Care (Community
Health and Standards) Act 2003. In his Written Ministerial Statement
on NHS dentistry reforms on 10 January 2005, the Secretary of
State confirmed that new regulations for dental charging will
be published for consultation in the summer of 2005.
Promoting dental health care towards nursing and expectant
mothers may still have benefits as preventable oral diseases can,
and do start, in children as young as 0-5 years of age.
Question 117 (Mr Steinberg): What is "a short distance"
(ie distance between caller and dentist recommended)?
Primary care trusts have developed local distances standards
between the location of a caller to a helpline (either local or
NHS Direct) and the location of the dentist recommended to them.
For example, the local distance standards for Durham and
Chester-le-Street (Mr Steinberg's PCT) are as follows:
In urban areas, routine care five miles, urgent care 15 miles
and emergency care 15 miles. In the case of rural areas, agreed
distances are generally greater: routine care 25 miles, urgent
care 35 miles and emergency care 35 miles.
Question 139 (Mr Bacon): Can you summarise the position
for dentists in the UK as to income and numbers, including information
on all the dentists in the UK, let us know how many there are,
how many of them work purely in public practices, in the NHS,
how many of them work purely in private practice, that is, purely
for themselves privately, and how many operate what you call a
mixed economy, and what the income levels are for these different
types of dentists, showing also regional variations, so a public/private
mix, showing also the difference between income for the practice
and the actual income for a dentist?
Number of Dentists
The number of NHS dentists in Great Britain can be broken
down by dental service as follows:
| Number of dentists (headcount)
|
| General Dental Service (GDS) | 20,800 at Sept 2004
|
| Personal Dental Service (PDS) | 3,500 of whom 700 also work in the GDS
|
| Community Dental Service (CDS) | 1,940 some of whom also work in the PDS
|
| Salaried Dental Service (SDS) | 200
|
| Hospital Dental Service(HDS) | 2,245
|
| |
Very few practising dentists do no NHS work at all. The Office
for Fair Trading Report reported that only 210 practices out of
11,000 in the UK are wholly private.
Dentists' Income
Self-employed dentists
Dentists working in the General Dental Service (GDS) are
largely principal dentists who are qualified to work unsupervised.
These dentists are self-employed. They are free to vary the amount
of NHS work they do. These dentists receive both capitation payments—monthly
payments for each registered patient—and payments for treatment
carried out. The fees are a national set of fees and are set out
in a Statement of Dental Remuneration. The payments are gross
and are intended to cover a dentist's practice expenses as well
as their personal income. Dentists in PDS who are self-employed
will also be paid using various combinations of capitation, treatment
or fixed rate service payments.
Gross fee income of GDS dentists
Average gross GDS fee income of a GDS dentist for GDS work
in 2003-04 was £101,000 in England. Gross fee income of a
NHS dentist includes both their personal remuneration as well
as business expenses such as staff salaries, laboratory charges
and dental consumables. The average net GDS income after expenses
would be about £45,000.
The income distribution is very wide reflecting the large
differences in the amount of GDS work done by individual dentists.
Principal GDS dentists do not have a standard working week. They
are self-employed and choose the amount of GDS work they do. Most
dentists have other income either from private dentistry or from
other NHS work.
Gross fee income of dentists with a reasonable commitment to
the GDS
Average gross GDS fee income for dentists with a reasonable
GDS commitment was about £143,000 in 2003-04. The average
excludes dentists with gross fee income of less than £57,300
which excludes dentists doing two days or less each week. Taking
into account estimated expenses, average net fee income of a GDS
dentist with a reasonable GDS commitment was around £66,700
in 2003-04. This is equivalent to about £69,000 this year,
2004-05.
Earnings split
In 2003-04, dentists' fee income accounted for about 92%
of total earnings as follows:
— Child capitation payments—13%;
— Child item of service—13%;
— Adult continuing care payments—7%;
— Adult item of service—59%.
Dentists' other payments make up a further 8%. This includes
Continuing Professional Development, commitment payments, seniority
payments, training grants, business rates etc.
Distribution of gross fee earnings
There is a wide distribution of gross fee earnings, which
reflects many variations in the amount of GDS work done. A significant
number of dentists now do relatively small amounts of GDS work.
Table 1 below shows the distribution of gross fee earnings
in £50,000 bands, 2003-04, this is also illustrated graphically
below (figure 1)—
| Gross earnings | Men
| Women | Total
| % of total |
| Under £50,000 | 3,255 |
1,704 | 4,959 | 34%
|
| £50,000—£99,999 | 2,024
| 1,283 | 3,307 | 23%
|
| £100,000—£149,999 | 2,574
| 950 | 3,524 | 24%
|
| £150,000—£199,999 | 1,438
| 240 | 1,678 | 12%
|
| £200,000—£249,999 | 496
| 65 | 561 | 4%
|
| £250,000—£299,999 | 190
| 26 | 216 | 1%
|
| Over £300,000 | 208 |
20 | 228 | 2% |
| Total | 10,185 | 4,288
| 14,473 | 100% |
| | |
| |
Figure 1—Earnings distributions of dentists (in £5,000
bands, adjusted to 2003-04 feescale): England and Wales, 1993-94
and 2003-04
GDS earnings by region
Average gross GDS fee earnings are highest in the Yorkshire
region. Figures by region are shown below. The higher figure in
Yorkshire will be due to dentists in that region doing more GDS
work.
Table 2 below shows the distribution of gross fee earnings
by region, 2003-04—
| | |
|
| Region: | Number of
Principals
|
Gross Earnings | Average Gross
Earnings
|
| | |
|
| | |
|
| Yorkshire | 1,206 | 146,349,525
| 121,351 |
| South West Thames (excluding London) | 1,753
| 200,668,969 | 114,472 |
| Northern | 1,692 | 189,156,837
| 111,795 |
| Wessex | 1,422 | 156,696,885
| 110,195 |
| South East Thames (excluding London) | 1,350
| 148,111,319 | 109,712 |
| Wales | 806 | 86,736,573
| 107,614 |
| Oxford | 2,244 | 219,754,839
| 97,930 |
| South Western | 2,542 | 217,267,166
| 85,471 |
| West Midlands | 1,458 | 119,640,692
| 82,058 |
| | |
|
| Total | 14,473 | 1,484,382,806
| 102,562 |
| | |
|
| |
| |
Private and GDS earnings
Information is available from the Inland Revenue for reported
schedule D earnings covering both NHS and private work. The information
is for average gross income, expenses and net income after expenses.
For the tax year 2002-03, the results are available for 3,000
single-handed dentists. Average gross income for these dentists
from both NHS and private work was £167,300 for the tax year
2002-03. On average 56.6% of their income was allowable as expenses.
This left £72,550 for average net earnings. The averages
cover all dentists whether or not they are working full-time or
part-time. An analysis by sex and age group is Table 3 with separate
figures for the Thames regions and elsewhere.
Average gross income of £167,300 covering both NHS and
private work can be compared to the GDS gross income for these
dentists in the financial year 2002-03 of about £97,500.
This indicates that GDS income accounts for almost 60% of total
income on average.
The average of £72,550 for net income after expenses
for both NHS and private work covers all dentists whether they
work full-time or part-time. For full-time dentists the average
would be higher.
Average net income of £72,550 covering both NHS and
private work compares with the assessment of £63,000 for
the average GDS income in 2002-03 of a dentist with a reasonable
commitment to GDS. Since GDS income is almost 60% of total income
on average, this implies that a full-time private dentist will
earn an average of over £90,000 a year in order for the overall
average for NHS and private work to be £72,550.
Table 3: Gross income, expenses ratio and net income
from NHS and private dental work for the tax year 2002-03: Great
Britain
| | |
| | | |
|
| | |
Number in
Survey
|
Gross
Popn | Average
Gross
Earnings
|
Expenses
Ratio (%)
|
Average Net
Earnings |
| | |
| | | |
|
| Men | |
| | | |
| |
| Single-handed | Aged under 35
| Thames regions | 42 | 78
| £167,765 | 60.67 | £65,990
|
| | Elsewhere
| 126 | 237 | £175,634
| 58.66 | £72,606 |
| Aged 35-44 | Thames regions
| 169 | 276 | £207,628
| 58.20 | £86,791 |
| | Elsewhere
| 559 | 847 | £185,966
| 56.08 | £81,675 |
| Aged 45-54 | Thames regions
| 208 | 324 | £192,589
| 60.18 | £76,697 |
| | Elsewhere
| 767 | 1,041 | £167,234
| 55.56 | £74,327 |
| Aged 55 and over | Thames regions
| 134 | 212 | £162,605
| 55.95 | £71,625 |
| | Elsewhere
| 343 | 464 | £145,694
| 54.48 | £66,326 |
| In partnership | All ages |
Thames regions | 13 | 28
| £189,805 | 56.43 | £82,702
|
| | Elsewhere
| 158 | 245 | £158,017
| 52.12 | £75,663 |
| All men | |
| 2,519 | 3,752 |
£173,806 | 56.37
| £75,833 |
| Women | |
| | | |
| |
| Single-handed | Aged under 35
| Thames regions | 14 | 40
| £130,868 | 64.71 | £46,181
|
| | Elsewhere
| 54 | 102 | £153,834
| 62.70 | £57,377 |
| Aged 35-44 | Thames regions
| 42 | 82 | £137,818
| 55.93 | £60,742 |
| | Elsewhere
| 156 | 258 | £156,089
| 59.79 | £62,758 |
| Aged 45-54 | Thames regions
| 38 | 64 | £137,642
| 58.65 | £56,910 |
| | Elsewhere
| 104 | 178 | £130,935
| 55.55 | £58,203 |
| Aged 55 and over | Thames regions
| 15 | 24 | £117,078
| 50.05 | £58,479 |
| | Elsewhere
| 37 | 49 | £100,111
| 55.19 | £44,860 |
| In partnership | All ages |
Thames regions | 8 | 16
| £141,684 | 51.97 | £68,052
|
| | Elsewhere
| 52 | 74 | £125,997
| 51.96 | £60,535 |
| All women | |
| 520 | 887 |
£139,706 | 58.00
| £58,675 |
| | |
| | | |
|
| All dentists | |
| 3,039 | 4,639 |
£167,286 | 56.63
| £72,552 |
| | |
| | | |
|
| | |
| | | |
|
Salaried dentists
Dentists working in the CDS, SDS and HDS and some dentists
in PDS are salaried dentists and are paid on salary scales recommended
by the Review Body (Doctor's and Dentist's Review Body DDRB).
The Community Dental Officer salary scale payable from the 1 April
2004 ranged from £30,313 to £48,016. The Senior Dental
Officer scales ranged from £43,721 to £59,422.
Question 176: The money going to PCTs, will this be ring-fenced
to stop the PCTs stealing dentists' money for other things?
Primary care trusts' additional dental allocations will be
"floor funded" for the initial three-year transitional
period, requiring them to spend at least that amount on primary
dental services. Primary care trusts will be free to supplement
these allocations with additional funds for dentistry from their
devolved resources if they consider this necessary in the light
of local needs and priorities.
Question 176 (Chairman): I would like to have a note please
on paragraph 2.8, where the National Audit Office notes that "it
is still not clear what services dentists will be contracted to
provide, what services patients can expect or what charges patients
will pay and on when you intend to provide dentists and the public
with this information?
It is proposed to carry forward broadly the same definition
of "treatment" as used in the NHS (General Dental Services)
Regulations, Regulation 2, except for orthodontic treatment and
sedation, which will be subject to separate agreements with the
primary care trust. The GDS definition would, therefore, read:
"treatment" means all proper and necessary
dental treatment, which a dentist usually undertakes for a patient
and which the patient is willing to undergo, including examination,
diagnosis, preventive treatment, periodontal treatment, conservative
treatment, surgical treatment, the supply and repair of dental
appliances, the taking of radiographs, the supply of listed drugs
and the issue of prescriptions.
Under a general dental services contract in the new arrangements,
practices will have to provide dental treatment that is clinically
necessary.
There will be a contractual requirement to submit data to
the Dental Practice Board or its successor body for verification
of patient charges due and activity carried out under the contract.
The Dental Reference Service will also have functions in relation
to quality assurance of the new system. Information for contract
monitoring by the primary care trust will be reported on a monthly
basis.
Ministers are considering Harry Cayton's report. What is
clear is that any new system will be simpler to understand and
administer and more transparent, and we have given a guarantee
that practices will not bear any financial risk from any possible
fluctuations in charge revenue.
We can also confirm our intention to publish for consultation
the new regulations for local commissioning of primary dental
services and dental charging in the summer of 2005.
How confident are you that the proposed expansion in training
places is sufficient to meet the longer term projected future
need for dentists (ref para 1.43 of the NAO Report)?
We provided additional funding for 170 extra training places
for dental undergraduates—a 25% increase which, by 2010,
will result in some 850 additional dental students under training.
But, because the course takes five years, the first cohort of
new dentists will not qualify until summer 2010. As an interim
measure, we are recruiting the equivalent of 1,000 more dentists
by:
— encouraging dentists taking career breaks to return
to work;
— providing incentives for dentists with mixed private
and NHS practices to increase their NHS commitment; and
— recruiting overseas dentists.
We are confident the new contract will revitalise NHS dentistry
and reverse the drift of dentists into private practice, but later
this year we will check the assumptions upon which our expansion
of the dental workforce are based.
As patients will be moving from a system of paying for each
item of treatment to paying for improved oral health, what is
the expected impact on income from charges?
The remit of the patient charge working group was to devise
a system that could raise the same proportion of service cost
as the current system of patient charges. It is intended to publish
the new regulations for local commissioning of primary dental
services and dental charging, for consultation, in the summer
of 2005.
|
