Select Committee on Health Written Evidence


Memorandum submitted by Ray Thomas (CP 15)

INTRODUCTION

Why focus on dental implants?

  1.  Dental implants raise a number of questions of principle in relation to co-payments and NHS charges. These include:

    (a)  Ways in which co-payments and charges might take account of patient responsibility for their medical condition.

    (b)  How co-payments and charges might reflect both health benefits to the individual and benefits to the NHS in reducing medical needs.

    (c)  How co-payments might be used to encourage patients to take treatments outside the NHS in order to help raise standards of medical practice and encourage the exploitation of new technologies.

    (d)  How loans by the NHS to patients might be appropriate to support co-payments in cases where the benefits of treatment extend over many years.

SUMMARY

  2.  Implants are potentially a very large component of dental care for a nation that notoriously suffers from bad teeth. Implants replace the need for dental bridges and dentures. The potential demand for implants in the UK is measurable in terms of millions of patients, and (to make up for existing levels of tooth loss) 10s of millions of implants.

  3.  It is suggested that patients should generally be expected to pay a substantial proportion of of the cost of implants. But the use of implants and the development of implantology could be encouraged by introducing a system of co-payments. A specially designed system of co-payments could make implants affordable though loans and could support patients' use of implantologzy services outside the National Health Service and outside the UK.

THE IMPLANT TECHNOLOGY

  4.  Implants provide a lifetime solution to tooth loss. Bone ossifies around the implant and so implants preserve bone structure. A tooth based on an implant is more durable than a natural tooth. Thus implants save future dental costs as well as providing teeth for healthy living.

  5.  Implants promise a reduction of the costs of dentistry. Given favourable conditions a skilled implantologist can make three or four implants in an hour. The implantologist can generally deal with abutments and insert crowns etc even more speedily. Thus the costs of implants in terms of the time of skilled dentists is lower than that necessary for the existing dental technology.

  6.  An implant is a more simple solution than a bridge, for example, because the construction of a bridge requires the dental work on two adjacent teeth. It can be expected that the cost of an implant will generally be below that of bridge construction. Tooth loss itself leads to recession of the bone of the jaw. The cost of implants can be set against that of the prescription, impression, etc associated with fitting a denture, and the series of prescriptions and impressions etc that are typically necessary for the refitting of dentures in response to further tooth loss and bone resorption..

  7.  The effectiveness and falling cost of implants are attributable mainly to the development of technology in the design and production of titanium implants. The use of new information technology has supported further developments. Computer aided design, based on information from digital photographs, is already widely used to produce crowns that are an exact fit—thus reducing the need for adjustments at fitting stages.

  8.  Computer aided positioning systems based on information from X-ray photographs that will identify the optimum position for implants are at an advanced stage of development. Such computer aided positioning systems can be expected to supplement the skills of the implantologist. These advances in technology contribute to the productivity of dentists as well as higher quality dental care. It is expected that such developments will in the near future make fitting an implant and a crown a routine operation that can be accomplished within, say, an hour.

EQUITY ISSUES

  9.  Dental health is in part a personal responsibility. Good dental hygiene reduces the chances of problems that can lead to tooth problems. It is equitable therefore that patients should bear a proportion of the cost of dealing with tooth problems. This principle is already recognised by the practice of charging by the NHS for nearly all dental services for adults.

  10.  This principle applies to tooth loss as well as to other dental problems. In the case of implants it seems equitable that patients should pay a higher proportion of the cost of treatment than for other dental services because dental implants represent a high quality and permanent solution.

  11.  But implants can be expected to reduce NHS costs. The cost of making an implant and new crown may already below that of constructing a bridge. The use of implants can be expected to reduce future demand for dental services because the demand for services from patients with implants can be expected to be less than the demand for services by patients with dentures.

  12.  It appers appropriate therefore that the NHS should give material encouragement to patients to have implants. Sharing of the cost between the NHS and patient is appropriate. Perhaps a 50/50 sharing of cost would be just. The most equitable proportion could well depend upon more detailed examination of the issues than is appropriate in this submission. The case of implants demonstrates that where there are benefits in the way of a reduction of future demand for NHS services this could well be recognised by the co-payments system.

COSTS

  13.  One practical issue is that many patients cannot afford even 50% of the current cost of implants. But because implants are a long-term solution governmental loans to patients would be appropriate. Perhaps interest free loans over a period of say ten years could be instituted? The case of implants demonstrates that where benefits extend over a long period it would be reasonable to introduce the practice of government loans to support co-payment by individuals.

  14.  The major problem in encouraging the use of implants is the availability of appropriately skilled dentists. The dental profession in the UK appears to about a generation behind that of other European countries in this matter. The use of implants is already common in many European countries including those of the former Soviet Union. But in the UK there is a severe scarcity of dentists with expertise in implantology.

  15.  The scarcity of skills in the UK is associated with high prices. Cost quoted in the UK are typically £2,000 per implant upward compared with about £1,000 or less some other Eurpopean countries. Costs are widely expected to fall with the development of supporting technologies. But because of the scarcity of implantologists in the the UK falling costs can be expected to increase the difference between the high costs in the UK as compared with the low cost in other countries.

AVAILABILITY WITH THE NHS

  16.  The conditions under which implant services are available within the NHS are unclear. A search of the NHS website for tooth implants actually yielded information only on breast implants !

  17.  There are many things the NHS can do to raise knowledge and skills of implantology among its own staff. But there is no obvious way of bringing a whole generation of dentists in the UK up to standard that seems common in other European countries. Such developments go beyond the scope of this submission and the role of the Health Committee.

  18.  But it seems unavoidable that the best prospect for development of the quality of services available to the public in the UK requires encouragement of the use of dental servcies outside the NHS and outside the UK. In the short term it would be appropriate to encourage patients with a co-payment system to find service outside the NHS and in other countries.

  19.  The use of a co-payment system could also be used to obtain information from patients on the costs and qualtity of the services they use and so contribute to the development of implantology services in the UK. The availability of information on the experience of patients own experience of implants outside the NHS could provide a valuable means of furthering interest and knowledge among dentists in the UK. A system of co-payments to individuals seeking implants could contribute to that stock of knowledge and skills.

  20.  The case of implants provides a case where the existing system of charges and co-payments present barriers to the assimilation of advances in medical science and technology. It is hoped that this memorandum points to some ways in which these barriers might be overcome.

Ray Thomas

Open University

December 2005





 
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