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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