Evidence submitted by the Dental Practitioners'
Association (WP 20)
INTRODUCTION
1. The Dental Practitioners Association
(DPA) has produced this response to the House of Commons Health
Committee's inquiry into Workforce needs and planning for the
health service.
2. The DPA was formed in 1954 to advise,
represent and support high-street dentists. Currently, the DPA
is the largest dental organisation that specialises in general
practice, representing over 1,200 practices (3,000+ dentists)
in the UK and produces the Industry-standard Private Fees and
Wages Guide.
3. To maintain contact with the profession,
the 15 members of the principal executive committee, and the Chief
Executive, must all be dentists.
4. The Dental Practitioners Association
would welcome the opportunity to contribute to the work of the
Health Committee by giving oral evidence. This is particularly
important as the DPA is not consulted by the Department of Health.
EXECUTIVE SUMMARY
5. The Health Committee has chosen a difficult
time to review dental workforce needs.
6. Substantial changes to registration groups
and revalidation requirements are imminent.
7. Dentists are self-employed subcontractors
which sets them apart from the NHS workforce as far as planning
is concerned.
8. After 1 April 2006 Primary Care Trusts,
who have very little experience of dental contracting, will determine
NHS employment patterns.
RESPONSE
9. The Committee has set a very difficult
task for itself in reviewing the dental workforce at this time.
10. Unlike doctors, dentists are independent
practitioners who provide and pay for all facilities, equipment,
materials and staff in their surgeries out of fees received. With
the exception of rates rebates, dentists receive no other support
for costs.
11. This is a very different situation to
General Medical Practitioners and is frequently misrepresented
to the public. Recently the DPA brought a successful complaint
to the Press Complaints Commission, against the Sunday Times
for misrepresentation of dentists' earnings.
12. It is a time of considerable change
in dentistry at present. Perhaps all we can best do is to suggest
some of the difficult questions that will need to be answered
before proper workforce planning can be undertaken.
13. There is no real shortage of dentists.
Even in an emergency, one will find a dentist with reasonable
ease, perhaps not everywhere on the NHS but if patients wish to
pay privately there is access. Access to an NHS dentist is not
easy.
14. Registration, which caused much of the
bad press for dentistry, is a recent concern in dentistry. It
was imposed along with the previous contract in 1990. Prior to
that, the concept of being on a dentist's list did not exist.
Recent workforce concerns have been prompted by it. The new contract
greatly changes the emphasis on registration.
15. The other factor that highlights access
difficulties within the NHS is emergency care. This is an area
which, although an essential service, is very poorly rewarded
and it still will be under the new arrangements.
16. It is a laudable desire for the NHS
to provide a comprehensive service for all. It never has done.
Less than 50% of the population are regular attendees. There was
never sufficient funding for this 50%. The year October 2004 to
September 2005 used to measure funding for the new contract, reflects
this level of existing funding and therefore does not accurately
represent the cost of providing the desired service. Even with
the introduction of NICE recall guidance, the funding will go
little further. Workforce requirements will be guided by this.
But it is not only dentists who will be providing the service.
17. The timing of this investigation is
difficult because:
17.1 A new dental contract is
to be imposed in two weeks time.
17.2 The Review Body on Doctors'
and Dentists' Remuneration has a remit to took at workforce retention
and motivation as well as pay. Their report for this year has
not been released before dentists must sign the new contract.
17.3 Well over 1,000 new dentists
have entered the country. In the last 18 months.
17.4 Primary Care Trusts are just
coming to grips with dentistry. Their resources are limited. Provision
of dentistry in PCTs will evolve to match resources and local
need, dictating the workforce.
17.5 There are many changes
at the General Dental Council broadening the workforce.
17.6 New training places and
methods are coming on-stream.
17.7 The Department of Health's
strategy is unclear.
18. The NHS, by poor manpower management
in every respect and constant cynical manipulation of payments
to attempt to create the most productive dental service, has cast
a shadow over dentistry and dentists.
19. The workforce has bled away and the
pace of that haemorrhage is quickening. The new contract will
do nothing to staunch it. It will never be possible to deliver
the present level of service again.
20. The new contract is a fiasco. It sets
all its stakeholders against each other. Many dentists, perhaps
the majority, will sign the new contract, but this will be only
to give them control over their exit.
21. The contracts are valued in Units of
Dental Activity (UDAs). The monetary value of a UDA for each dentist
is different. A dentist may have a UDA value twice that of his
colleague who works in the same street or even the same practice.
22. Conscientious dentists with a list of
healthy patients will receive the lowest payments. Of, before
the new contract, they have worked on annual recalls as per NICE
guidance, instead of six-monthly they will find that they have
to see many additional patients for the same money.
23. New patients cost considerably higher
amounts to make healthy than do healthy patients. There is no
additional payment to compensate.
24. For example, a dentist working in the
NHS may have 700 child patients. When calculating his UDA target,
each child has been deemed to have visited twice, so 700 additional
UDAs have been added to his list. Although the DoH says that he
has had a 5% reduction in workload, his figures including the
extra 700 UDAs show an increase of 2%. His UDA vatue is £16.50
against a national average of £19-£20. He will sign
the contract but only to leave at time of his choosing.
25. He will move to private practice or
join one of the third-party modified capitation schemes such as
Denplan. Over 600 dentists joined Denptan in 2005. This is an
indication of the rapid move to private practice. There are other
companies like Denplan and many dentists do not privatise through
such companies. The extent of the drift away from the NHS can
not be accurately stated yet.
26. Although over 1,000 extra dentists joined
the NHS in the year to September 2005 there was no increase in
productivity.
27. It must be asked what beneficial effect
the NHS involvement in dentistry has brought.
28. A properly designed NHS dentistry service
could succeed.
29. A well-designed dental public health
programme could automatically reduce dental disease and therefore
the need for additional dentists. The workforce of the future
will be very different if the strategy is right. Dentists will
not be necessary to deliver such a programme.
30. Currently the political strategy is
unclear.
31. The GDC is about to register Dental
Care Professionals (DCPs). There are training programmes in place
and plants to increase the numbers in these groups. The pace of
training hygienists for example has been too slow to match the
need. This has served to increase their value in the market place.
They are more likely to be found working in the private sector.
32. The current buzzword is Teamwork. But
the new members of that team are seeking to establish independence.
There is already a growing desire amongst DCPs to be able to work
in their own businesses and therefore to have the right to examine,
diagnose and prescribe for patients.
33. The position of the dentist is becoming
unclear and appears under attack from DCP interest groups.
34. On the one hand, Dental Schools are
considering fast-track training for graduates while on the other,
groups are pressuring for dental nurses to be permitted to diagnose.
Can the training for dentistry be made shorter than the time it
takes to fast-track train a graduate?
35. The roles of the new imembers of the
Dental Team need to be defined. These new groups will have important
roles to play in a dental public health strategy.
36. Measuring workforce requirements for
the NHS must await a clear strategy from Government, it must await
also the evolution of PCTs and their requirements in dentistry.
37. Currently PCTs are learning about dentistry.
They have yet to understand their budgets. The number of fee-paying
patients is a great concern to PCTs because if the income from
these patients drops, funding is lost. The budget is therefore
unpredictable and will be for some time.
38. PCTs wait have to decide what treatment
they need to deliver in their area. Having decided this they will
decide who will best deliver that treatment; will they need dentists
or DCPs? At this point, a suitable workforce will be in urgent
demand.
39. Until now a dentist could move into
a district of his/her choosing, find a premises, equip it, open
a dental practice and send forms to the Dental Practice Board
for payment. Under the new arrangements this is no longer possible.
PCT funding is all that is available.
2004 WORKFORCE REVIEW
40. The first workforce review since 1987
was published in July 2004 by the Department of Health. It covers
dentists and DCPs in primary care (not hospital or community dental
services) in England. Biennial update reviews will be undertaken.
41. The Dental Practitioners' Association
(which represents the views of 72% of dentists in the target group)
was not consulted by the DoH.
42. The Variable used in the study was "clinical
time", that is direct contact between patient and dental
professional. Dentists are expected to have less clinical time
in future due to an increase in bureaucracy, which multiplies
the number of dentists required.
43. Demand modelling suggested a slight
increase for adults between 2004-11 followed by a levelling-off
between 2011-21. Child demand showed no significant change over
the next 20 years.
44. Demand is estimated at 30 million clinical
hours, rising to 31-33 million in 2011 and 30-33 million in 2021.
45. The number of whole-time equivalent
(WTE) dentists in England is expected to fall by 2,400 between
2001 and 2021, however there will be 870 more therapists and 330
more hygienists.
46. THE PROJECTED UNDERSUPPLY
| Undersupply
in hours
| Undersupply
(dentists) | Undersupply
as % of demand
| |
2001 | 1.5 |
1,050 | 5% | |
| 2003 | 2.7 | 1,850
| 9% | |
| 2011 lower projection | 5.0
| 3,640 | 16% |
|
| 2011 (upper projection) | 7.1
| 5,100 | 21% |
|
| |
| | |
47. How much work dentists will do on the NHS will have
a greater impact on the supply side, than the actual number of
dentists. This is why it is not relevant to quote the number of
dentists with NHS contracts or the number qualifying each year.
48. Even if more dentists qualify, due to student debt
in view of the length of the dental course, it is unlikely that
many of them will stay in the NHS.
49. These figures do not include any meaningful structural
changes such as a large-scale preventive approach.
50. Workforce considerations preclude a serious attempt
to attract the 50% of the public who do not have regular dental
care.
Derek Watson
Chief Executive, The Dental Practitioners' Association
14 March 2006
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