Memorandum submitted by the British Dental
Association (CP 11)
1. The British Dental Association (BDA)
is the trade union and professional association for dentists practicing
in the UK, representing 22,000 members working in all aspects
of dentistry, including general practice, salaried services, the
armed forces, hospitals, academia and research. In September 2005
the BDA responded to the Department of Health's (DoH) Consultation
on the draft National Health Service (Dental Charges) Regulations
2006, which can be downloaded from the BDA website www.bda.org
2. The BDA would be pleased to offer oral
evidence to the committee on this subject.
BACKGROUND
3. NHS patient charges or co-payments are
a controversial area of healthcare finance. The Government has
been levying charges for NHS dental treatment since 1951 with
NHS dental charges in England currently raising revenue in the
region of £485 million each year.
4. Tax-financed healthcare systems (along
with insurance-based systems) commonly have the problem of potential
excess utilisation of healthcare services, and consequently patient
charges (or co-payments) are often, therefore, introduced to discourage
excess utilisation.
5. Economic evidence indicates that at the
level of the individual, introduction of a co-payment does lead
to a reduction in the utilisation of healthcare (relative to healthcare
that is free at the point of delivery). Most of this reduction
in utilisation is by people in lower income groups and even children;
further still demand for effective treatment is also reduced (ie
treatments that have an real impact on health outcomes).
6. A recent study by the British Association
for the Study of Community Dentistry (BASCD) 2005 has revealed
a widening gap in the levels of decay in children's teeth in the
poorest and richest parts of Britain. Areas with the lowest rates
of tooth decay are exclusively in the south of England and the
Midlands. The worst areas are restricted to parts of Wales, Scotland
and the north of England. Five-year-olds in some of the poorest
parts of the country, such as Merthyr in Wales, North Kirklees
in Yorkshire, and Argyll and Clyde in west Scotland, have an average
of almost four decayed, missing or filled teeth, while their counterparts
in Maidstone Weald in Kent, and Suffolk Coastal, near Felixstowe,
have an average of under 0.5.
7. Further still, the Adult Dental Health
Survey (1998) indicates that adults, where the head of the household
is from a higher social class, are less likely to be edentate
(ie with no natural teeth); 7% of adults where the social class
of the head of the household is I, II, or IIINM are edentate,
compared with 14% of adults where the social class of the head
of household is III M, and 21% of adults where the social class
of the head of household is IV or V. [1]
8. Further, and putting such inequality
issues aside, at the macro level of the healthcare system as a
whole, charging patients for care in high income countries is
very often unlikely to save overall healthcare costs if the healthcare
providers remain free to concentrate their demand-inducing abilities
(or practice cream skimming[2]
of patients) on those who can afford to pay.
Whether charges for treatments, including prescriptions,
dentistry and optical services; and hospital services (such as
telephone and TV use and car parking) are equitable and appropriate?
9. The proposed draft regulations on NHS
dental charges establish a three banded charges system (with an
urgent treatment charge band) which is to be introduced from 1
April 2006. Some treatments will be free of charge and there will
be guarantees that, should certain treatment be necessary within
a defined period, no further charge will be made.
10. However, according to the Government,
the NHS Plan has at its core a continued commitment to the founding
principles of the NHS. These founding principles can be summarised
as, the provision of care that:
— meets the needs of everyone;
— is free at the point of need; and
— is based on a patient's clinical
need not their ability to pay.
11. These core principles imply that there
should be no NHS dental patient charges, and that the proposed
charges system is therefore inappropriate and diametrically opposed
to the core principles of the NHS.
12. The BDA believes that the proposed NHS
dental charges system significantly hinders preventative care,
and encourages patients to delay treatments so as to maximise
value for money.
13. The polarised incentives that such a
system creates between patients and dentists will, the BDA believes,
be detrimental to the longer term quality of patient care. In
addition, the Government has alarmingly chosen not to pilot the
proposed new patient charges system in any of the much lauded
3,000 plus practices that have entered into Personal Dental Service
(PDS) arrangements. As such, neither the BDA nor the Government
have the evidence base to conclude fully on the appropriateness
or equity implications of such an untested system.
14. Under the proposed new patient charging
system access to NHS dentistry comes at an up front charge of
at least £15 to the majority of the population, with preventative
care no longer being free. In addition those patients from lower
socio-economic backgrounds, who have higher dental needs, will
continue to pay more for their treatments.
15. As with many co-payments in the NHS,
exemptions are absolute. Consequently, there will be a large proportion
of the population on the cusp of exemption criteria. The BDA does
not consider this an equitable approach for dental co-payments
and those who marginally fail to qualify for exemption are significantly
financially disadvantaged.
16. Finally, the increments between the
three bands in the proposed charges system are excessive. For
example, the patient charge increases by almost 175% between band
1 and band 2 and rises by almost 350% between band 2 and 3. The
BDA is convinced that such increments will prove to be a barrier
to accessing appropriate NHS dental care and as such is not equitable
and contravenes core NHS principles. The new charges system has
failed to address the impact on those people who will find the
new system unaffordable.
For example, an older person on a fixed income
who needs a partial denture will be paying significantly more
under the proposed patient charges system than under the previous
fee per item patient charges system. Concerns such as this seem
inequitable and need to be addressed immediately.
What is the optimal level of charges?
17. The BDA cannot comment on what the optimal
level of NHS dental charges should be. However, we would wish
to see a charging level that maximises oral health and minimises
oral health inequalities.
Whether the system of charging is sufficiently
transparent?
18. The proposed banding system for NHS
dental charges is significantly more transparent to patients than
the current system of 400 plus individual items of treatment.
However, the BDA has not been informed by the Government as to
how this new charging system, and its intricacies, is to be communicated
to the general public. For example, under the current system an
exam with x-rays incurs a patient charge of £9.84 compared
with £15.50 under the new system. The Government not only
needs to communicate the transparency of the new system to patients
but also needs to provide justification for why in many cases
the patient charge incurred has risen. It is also important to
make the public aware that these charges are not directly part
of the dentist's earnings nor do they reflect the full cost of
providing that particular treatment.
19. Underlying the reforms of NHS dentistry
is the Government's vision of an integrated NHS dental care system,
where patients can seamlessly move between the various components
of primary care as and when is appropriate for patient needs.
The proposed patient charges system does not explicitly define
the charging situation across the differing components of an integrated
NHS primary dental care system, particularly for Salaried Primary
Dental Care Services (SPDCS). Consequently, the lack of clarity
on the NHS charges is likely to result in different charges being
levied across the various components of an integrated NHS dental
care system. Such a situation is confusing for patients, creates
perverse patient incentives thereby leading to inefficient outcomes
and does little to promote an integrated primary dental care service.
The BDA believes that whichever patient charges system is finally
implemented that it be uniform and transparent across the whole
of NHS primary dental services.
20. Although the proposed new NHS dental
patient charging system has greater transparency in the sense
that a patient knows that he/she will be paying one of three possible
charging bands, there remains an asymmetry of information[3]
between the patient and the dentist. The patient will only know
the exact amount of the patient charge for their NHS dental care
on the advice of the dentist after an examination, which has a
charge of £15.50.
21. The BDA is opposed in principle to NHS
dental charging, the fact is that consequent Government's have
positioned charges as a fundamental component of the NHS dental
budget. However, given that NHS dental charges have been commonplace
for over 50 years, the BDA strongly supports the notion of transparency
and equity where NHS dental charges are levied. Unfortunately,
the Government continues to send out mixed and confusing messages
to the public. For example, during the debate on the Health and
Social Care (Community Health and Standards) Bill on 19 November
2003, Dr John Reid, then Secretary of State for Health, stated:
"The Bill represents the next important stage in improving
and revitalising our National Health Service. Let me make it plain
right from the start that, to Labour Members, that means a National
Health Service built on the founding principle that everyone in
this country should have equal access to healthcare free at the
point of delivery—a principle that will be defended and
protected as long as this Government are in power". This
sentiment was further echoed by Prime Minister Tony Blair in his
keynote speech to the Labour Party's 2005 conference when he stated:
"I will never allow the NHS to charge for treatment."
The BDA believes that the Government's failure to send out clear
messages about the reality of charges for NHS dentistry will mean
that the benefits in terms of transparency of the new patient
charges system will continue to be compromised.
What criteria should determine who should pay
and who should be exempt?
22. The core principles of the NHS imply
that there should be no NHS dental patient charges and as such
the issue as to who should receive exemptions is a moot point.
However, the Government has not taken the opportunity, as would
be in line with the NHS core principles, to abolish NHS dental
charges as part of the current reforms to NHS dentistry.
23. The BDA is not in a position to offer
criteria on who should pay and who should be exempt from NHS charges
as the BDA is opposed in principle to charging for NHS dentistry.
However, given the reality that the Government continues to levy
charges for NHS dental treatment, the BDA does have concerns about
access and provision of oral healthcare for older people.
24. In the BDA's 2003 report Oral Healthcare
for Older People: 2020 Vision, the BDA emphasised that the
reform of the NHS dental charging system needed to take account
of the anticipated growth in the number of older people in England;
the fact that older people are more likely to require more complex
treatment in the future; and that they also tend to be among those
least able to pay. The BDA advocates a free oral health risk assessment
for patients aged 60 and above, with referral to a dentist for
a strategic long-term oral healthcare plan, for those older people
identified as likely to need complex restorative care. Combining
this with free NHS examinations for patients aged 65 and over
is likely to improve the oral health of the nation's older person's
population greatly. However, given that the BDA would support
"in principle" the ending of NHS dental charges, the
action points above, were charges to be abolished, should be encouraged
as "good practice" in the provision and delivery of
oral healthcare for older people.
How should relevant patients be made more aware
of their eligibility for exemption from charges?
25. It is clear that patients are currently
not always sure as to whether or not they are exempt from NHS
dental charges. There needs to be a more coordinated approach,
firstly, between Government departments and, secondly, with patient
and professional organisations (such as the BDA) on the most appropriate
way for making people aware of their eligibility for exemption
from charges.
26. The current HC11 Help with health
costs published by the Department of Health (DoH) is a complicated
document and attempts to cover all aspects of charging in the
NHS in one document. The BDA would like to see a stand alone DoH
document that focuses solely on dental charges and exemptions
within NHS dentistry. The document should obtain the Crystal Mark
from the Plain English Campaign, be available in Braille, on audio
cassette tape, on disk, in large print and in a range of foreign
languages.
27. The BDA would also look to the Government
to send a clear message to the public that for those who do not
qualify for exemptions, the NHS patient charge they pay does not
contribute towards practitioners' earnings and that it is Government
policy to levy charges for NHS dentistry.
Whether charges should be abolished?
28. In a statement to BDA members, in 2005,
the BDA's General Dental Practice Committee (GDPC) reiterated
that "GDPC continues to reject the principle of charging
patients for NHS dental treatment."
29. Currently, 30% of the total expenditure
on NHS dentistry comes from patient charges. The BDA believes
that should charges be abolished, this 30% currently paid by dental
patients should be made up from central Government funding to
ensure that the overall total expenditure on NHS dentistry remains
unchanged.
30. Missed or late cancellations are an
avoidable waste of valuable NHS resources and under the current
system NHS dentists often make a small charge for this waste.
Should NHS charges be abolished the BDA would support a capped
charge to act as a deterrent for patients missing appointments
or for late cancellations.
31. The abolition of NHS patient charges
for dental treatment will remove a key barrier for access to dental
care for parts of the population, many of which have far greater
dental care needs than those who currently access the system.
In the longer term, removal of charges will also contribute in
reducing the prevalence of oral health inequalities across England.
32. It is worth remembering that oral health
means more than good teeth: it is integral to general health and
essential for wellbeing, enabling an individual to eat, speak,
and socialise without active disease, discomfort or embarrassment.
James Clark
British Dental Association
6 December 2005
1 These social classes are assigned on the basis of
the occupation of the head of household using the Registrar General's
Standard Occupational Classification. Occupations are assigned
to six social class categories: professional occupations (I);
managerial and technical occupations (II); skilled occupations
(III) with IIINM as non-manual and IIIM as manual occupations;
partly skilled occupations (IV); and unskilled occupations (V). Back
2
This is where a healthcare professional chooses which types of
patients that they treat; as a general rule of thumb these patients
will be lower risk patients that generally require less (and in
many cases less costly) healthcare intervention. Back
3
Asymmetry of information describes a situation where two economic
agents in a market transaction have different amounts of relevant
information. So for example a dental patient may go for a check
up (believing that the charge would be £15.50) but in fact
needs a filling which would have a charge of £42.40. Back
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