Select Committee on Health Fifth Report


2  General Dental Services 1948-2006

The pre-2006 system

13.  NHS dentistry was founded in 1948 with the establishment of the General Dental Service (GDS). The GDS provided patients with "dental care via general dental practitioners (GDPs) who mainly worked as independent contractors from high street and local surgeries".[13]

14.  In 1993 our predecessors described the history of the management of the GDS since 1948 as one of "supervised neglect".[14] In effect the way that services were delivered through the GDS had remained largely unaltered for nearly sixty years.[15] Until 2006 those dentists and orthodontists who chose to work within the GDS did so as independent practitioners and were able to choose where they established their practice and which services they provided to patients.[16] Many dentists operated in what the British Dental Association (BDA) described as "a mixed economy" providing both NHS dentistry and private treatment according to the level of demand in their locality. Secondary dental care, usually for particularly complex cases, was provided in hospitals by dental specialists.

15.  Another important element of NHS dentistry was the Community Dental Service (CDS). The CDS comprised approximately 1,000 dentists who were employed by local health authorities and received an annual salary. CDS dentists provided a service for particular categories of patient: for example, those with an extreme phobia of dentists and those with special needs.[17]

16.  The Dental Practice Board (DPB) provided probity and quality assurance to the system.[18] One of its roles was to detect poor or unnecessary treatment given to patients. Dentists recorded the treatment given to patients and the DPB examined a sample of patients to ensure that the work claimed for by dentists had in fact been carried out.[19]

17.  In 2005-06 the NHS spent £1.78 billion on NHS dental services.[20] In 2005-06, a dental practice owner on average received an annual income, net of costs, of £114,000.[21] Dentists who used the facilities within another dentist's practice received an average annual income of £61,000.[22] According to the BDA, in 2005-06 an "average dentist" earned 41.9% of their income from the GDS with the remainder from private practice.[23]

Changes to the system, 1948-2006

18.  Since the establishment of an NHS dental service in 1948 there have been three major developments:

19.  NHS dental charges were introduced in 1951 for adult patients, with exemptions for those in receipt of income support or who were pregnant or nursing mothers. Charges were made according to an itemised list of treatments which, by 2006, had mushroomed to over 400 items ranging from a simple check-up to more complex root canal treatment and crown work.[24]

20.  The next significant change occurred in 1990 when the Department introduced registration for adult patients. Capitation payments for treating children up to the age of 16 were also introduced. The declared intention of the new arrangements was to place greater emphasis on continuing dental care. However, following the changes, in 1991-92 the Department had overspent its dental budget by £190 million. [25]

21.  In 1992-93, in an attempt to bring the expenditure on dental services under control, the Department reduced the amount paid for each item of treatment by 7%.[26] This action resulted in great discontent amongst the dental profession and in 2001 our predecessors concluded that since the 1992-93 dispute there had been "a defined haemorrhage of dentists away from the NHS".[27]

Oral health of the nation

22.  During our inquiry it was universally accepted by our witnesses that there had been a radical improvement in the overall state of the nation's dental health since 1948. In the immediate post-war period large numbers of the adult population were literally toothless (edentate), as a result of a wide range of factors. In 1968 37% of the adult population of England and Wales had no natural teeth.[28] By 1998 the figure had fallen further to 13%.[29] The Department estimates that today 6% of the population are edentate.[30] The improvements in oral heath are due to a combination of developments, including fluoridation (of toothpaste and, in some areas, the water supply).

23.  Within this overall positive picture, there are generational differences in oral health. Dental practitioners sometimes refer to 'the heavy metal generation', that is people aged over 45 who did not benefit from fluoridated toothpaste or water supplies when they were children. This cohort has, unlike previous generations, maintained their teeth but frequently has had large fillings (which from time to time require replacements involving more complex treatment). In comparison, people aged under 45 generally have better dental health. The implication for dental services of this generational difference is discussed in more detail in chapter 3 of this report.

24.  For children, the figures for oral health have shown similar improvement since 1948. During our inquiry, citing statistics on comparative oral disease collated by the World Health Organisation (WHO), Dr Barry Cockcroft, Chief Dental Officer (CDO), told us that the oral health of English children was comparable with the best in the world.[31] Although this was disputed, there has undoubtedly been a significant improvement.[32] Decay rates have fallen in all social groups albeit significant disparities remain between socio-economic groups and between regions of the country (between for example, Birmingham which has relatively good oral health and Manchester where oral health is worse).[33]

25.  While oral health has generally improved, demand for dental services has not diminished. The Department explained that there had been a change in demand as "patients' focus has moved from simply ensuring their teeth are healthy and pain-free to an ever-stronger desire that they should also be cosmetically pleasing".[34]

26.  Moreover, problems of gaining access to GDS dentistry grew during the 1990s in some parts of the country and discontent increased about how dentists were remunerated for the treatment they provided under the GDS. Faced with these problems the Department began to consider how best to improve the system.

The case for change

27.  During the 1990s the Department argued that the GDS no longer met the oral health needs of the population and required substantial reform. A series of publications beginning with Modernising NHS Dentistry in September 2000 made the case that the most pressing concerns facing the GDS were to improve:

28.  In 2001the Health Committee examined the Department's analysis of the problems facing dentistry and its proposals for addressing them. In Access to NHS dentistry, published March of that year, our predecessors described patient access to NHS dental services as inequitable and noted that the situation was deteriorating further as dentists left the NHS and developed their business in the private sector. Our predecessors also argued that the Department's proposals contained in Modernising NHS Dentistry lacked sufficient weight to deal with the changed situation facing dental services.[36]

29.  In 2002, a further report by the Department, NHS Dentistry: Options for Change, provided more analysis of the problems faced by NHS dentistry.[37] The key problems it identified were:

  • As before, access to services: significant problems of patient access to NHS dentistry existed in areas of England as a result of "dentists drifting away from the NHS".
  • Remuneration for dentists: dentists were paid on a fee per item basis. The Department argued that this payment system created incentives for invasive and complex treatments and little scope for preventive work. In addition it contributed to a "drill and fill" treadmill which was dispiriting for dentists. This resulted in a situation where, according to the Department, "the more treatment delivered and the more complex that treatment was, the more the dentist earned".[38]
  • Patient charges: there were over 400 patient charges for different treatments and this caused confusion for patients. The Department also argued that some patients were uncertain about whether certain types of cosmetic treatment were available through the GDS.

30.  In addition, the CDO told us that the payment system provided incentives for some dentists to "over treat" patients, in other words to provide unnecessary treatment. Although he accepted that the vast majority of dentists only treated patients according to clinical need, he argued that,

Anything that incentivises intervention where it may not be necessary, where you can treat these things with a fluoride varnish or something like that, is a better way to go. The old system did create an incentive.[39]

31.  Many of our witnesses, including the British Dental Association (BDA) and the Dental Practitioners' Association (DPA), and others who were highly critical of the new contract, accepted that the dental system had needed reform. Mr John Renshaw of Challenge told us, "I do not think anybody would ever claim that the old system was perfect".[40] Ms Susie Sanderson, Chair of the Executive Board, BDA, told us

The BDA worked with the Department of Health and signed up very enthusiastically to the aims of Options for Change which looked at the local needs for dental care, explored different ways of remunerating dentists to deliver the provision of care and also made sure that the quality of care was robust…We thought they were very fine aims.[41]

Conclusions

32.  Since the establishment of the General Dental Service in 1948, there have been many improvements. The nation's oral health has improved significantly: in the 1940s a large proportion of the population were edentate; by 1968, 37% of the population had no natural teeth; the estimated figure in 2007 was only 6%. Increasingly the focus of dentistry has switched from pain relief to the provision of preventive care and cosmetic treatment.

33.  Nevertheless, by the 1990s there was a powerful case for reform of the General Dental Service contract. It was widely agreed that, while in some areas of the country provision of NHS dentistry was good, overall it was patchy. Moreover, the payment system lacked sufficient incentives for the provision of preventive care and advice. In addition, the Department argued that there were too many incentives to provide complex treatment.


13   Department of Health, Departmental Report 2007, Cm 7093, May 2007 Back

14   HC (1992-93) 264 Back

15   Ev 2 Back

16   Orthodontics is the branch of dentistry concerned with growth of the face, development of the teeth and bite, also of the prevention and correction of problems with the teeth and bite. Back

17   DS 45 Back

18   In 2006 the DPB was dissolved and its functions merged into the Business Services Authority. Back

19   DS 37 Back

20   NHS Information Centre for Health and Social Care, NHS Expenditure for General Dental Services and Personal Dental Services England, 1997/98 to 2005/06. The figure given is net of patient charges.  Back

21   Most dentists worked in both the GDS and private sectors. Therefore the proportion of income earned through the GDS differed in each case. Back

22   Review Body on Doctors' and Dentists' Remuneration, Cm 7327, April 2008 Back

23   Ev 55 Back

24   Ev 2 Back

25   Our predecessors concluded in their 2001 report that "Dentists feared the net effect of the reforms would be to depress their incomes. To protect their incomes they worked harder (by a factor of 8.5%) increasing the payments due to them and leading to an overspend in 1991-92 of £190 million". HC (2000-01) 247-I Back

26   HC (2000-01) 247-I  Back

27   Ibid. Back

28   http://www.statistics.gov.uk/downloads/theme_health/AdltDentlHlth98_v3.pdf Back

29   Ev 1 Back

30   Ev 1 Back

31   Q 137 Back

32   Q 61 Back

33   Ev 33 Back

34   Ev 1 Back

35   Department of Health, Modernising NHS Dentistry, September 2000 Back

36   HC (2000-01) 247-I Back

37   Department of Health, NHS Dentistry: Options for Change, August 2002 Back

38   Ev 1 Back

39   Q 230 Back

40   Q 3 Back

41   Q 367 Back


 
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