Select Committee on Health Written Evidence


Memorandum by the Department of Health (DS 01)

NHS DENTAL AND ORTHODONTIC SERVICES

EXECUTIVE SUMMARY

  1.  I am pleased to have this opportunity to set out where we are on NHS dental services—the achievements to date and the plans for further improvement.

  2. The first thing to note is that our record on dentistry is strong:

    —  England is a leader within Europe in improving oral health: according to the WHO database, our twelve year olds now have the best oral health in Europe, measured by decayed, missing and filled teeth.

    —  We are expanding the dental workforce by increasing the numbers of dentists in training by 25% (170 extra undergraduates). The new cohort will start to graduate from 2009. Two new dental schools opened in autumn 2007—in Plymouth and Preston. Dental Care Professionals (DCPs), who support dentists in their work have increased by 300%.

    —  This Government is committed to increasing access to NHS dental services and is continuing to provide both increasing financial investment and support for the NHS in growing and developing dental services.

Changes in dental needs since 1948

  3.  In looking at the challenges ahead and the rationale for the changes made to the dental system, it is important to remember the level of change there has been in dental need and demand since the NHS dental service began in 1948.

  4.  In the immediate post war years NHS dentistry served a nation with generally poor oral health, large amounts of untreated decay and therefore with extensive treatment requirements. A large proportion of the adult population were toothless (edentate). As recently as 1973, 40% of the population had no natural teeth. The NHS dental system set up in 1948 reflected a world where those with teeth typically needed complex treatment for extensive decay and those without required full dentures.

  5.  From the early 1970s onwards developments in dental care and particularly the spread in the use of fluoride toothpaste have meant that an ever-increasing proportion of adults retain their teeth into old age. By 1998, fewer than 13% of the adult population were edentate. If the trend has continued that figure is probably now just 6% (adult dental health surveys are carried out every 10 years or so). Decay rates had fallen in all groups (although there remains a marked gap between socio economic groups).

  6.  Over the last decade or so, 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. This presents new challenges about where the boundaries should lie between clinically needed treatment—available for all who want it from the NHS—and purely cosmetic treatment, which most would agree need not necessarily be offered on the NHS.

Our vision

  7.  Against the background of these changes in need and demand for dental care, our overarching goals for dentistry are now to:

    —  Improve oral health yet further and address inequalities, by bringing the health of those in poorest oral health closer to that of those in the best oral health.

    —  Ensure we steadily increase the number of patients who have access to accessible, safe, appropriate NHS dental services for all clinically needed care.

    —  Ensure that patients who continue to use private care—whether for clinical or purely cosmetic treatments—receive care that is regulated to the same high standards to which we already hold the NHS.

Rationale for Dental Reforms

  8.  The system set up in 1948 was provider and treatment driven. Dentists decided on the level and location of services, and under payment per item of service the more treatment delivered and the more complex that treatment was, the more the dentist earned. NHS dental charges were introduced in 1951 for charge paying adults (those under 18, or in receipt of income support or pregnant are exempt from all charges). Charges were based on individual items of service.

  9.  From the early 1990s, the inherent risks of a provider driven system that left dentists to decide where and what level of service should be available became apparent. As dentists drifted away from the NHS, service commissioners had no powers to seek alternative providers. The access difficulties that resulted, the legacy of which we are dealing with today, are well known.

  10.  The incentive to deliver complex restorative treatment was a good fit for a nation in poor oral health but an increasingly bad fit as decay rates declined. Dentists complained of being on a treadmill that allowed no time for preventive as well as restorative treatment.

  11.  The charging system became increasingly confusing for patients. By 2005-06 there were over 400 possible charges with a maximum possible charge of £389.00. Patients reported being often unable to tell from the charge whether they had had private or NHS treatment—and for very complex treatment—finding charges prohibitively expensive.

  12.  The system was as frustrating for dentists as it was for patients. The fee per item system left little time for preventative work. Dentists and patients welcomed the greater scope for a preventative approach the capitation system piloted through personal dental services pilots (PDS) offered.

  13.  However, as with any pure capitation system you have the opposite challenge from a fee per item system—how to ensure that as well as preventative advice patients also receive enough active treatment. The new system aimed to address the risks of both pure capitation and pure fee per item systems by offering dentists a pre agreed annual income but one which included pre agreed levels of activity.

  14. The reforms made three key changes.

    —  First and most fundamentally, they gave Primary Care Trusts (PCTs) power to commission services to meet local needs.

    —  They radically simplified the charging system into just three payment bands, leaving little room for confusion on what is private treatment and what is NHS, and slashing the maximum total charge in half.

    —  They removed the exclusive focus on active treatment—basic courses of treatment now include diagnosis and any preventative treatment clinically indicated ranging from simple scale and polishes to fluoride varnishes.

  15.  In the new system Units of Dental Activity (UDAs) provide a language for discussion of expected activity. It is important to be clear though that they are not the exclusive measure of performance or quality—specialist services including sedation, Out Of Hours services, domiciliary care and open access slot payments are all outside the UDA system.

  16.  For mainstream contracts, PCTs are free to agree local variations to payment as long as they are within the national legislation. For example some PCTs have chosen to pay a premium to practices setting up in areas where new patients are likely to need extensive remedial work. By agreement, these will tail off as the surgery restores the patients' oral health (and therefore treatment need and cost per patient reduces).

Conclusion

  17.  Many challenges remain but the first eighteen months have demonstrated beyond doubt that the new system is workable and working. Access has been broadly stable across the transitional period at national level. Access problems that developed over many years cannot be resolved overnight but already patients in particularly hard-pressed areas have felt the benefit. The transition from the old system has been particularly challenging for the profession and we do not underestimate the degree of culture change it has required.

  18.  The progress made—and particularly the fact that even in the inevitably hard first year dentists delivered 95% of the activity contracted for—is a tribute to those working on the front line. Many challenges remain, particularly to reassure dentists that while the new system has rightly moved control from providers to commissioners it is one in which those committed to NHS dentistry can flourish with a new certainty about their future. However the first 18 months have demonstrated that the new system is workable and provides a stable foundation for building robust services.

AREAS OF PARTICULAR INTEREST IDENTIFIED BY THE HEALTH SELECT COMMITTEE

  19.  The rest of this memorandum sets out in more detail the impact of the reforms on the areas the Committee have identified as of particular interest.

The role of PCTs in commissioning local dental services

  20.  The new system created for the first time in the history of the NHS a statutory duty on PCTs to ensure the provision of primary dental services to meet local need. Combined with the devolution of dental budgets to PCTs this revolutionised the system of dental services putting it for the first time on a similar footing to other mainstream NHS services.

  21.  PCTs are now empowered to assess need and develop services against those needs. Existing dentists were rightly given strong protections during the period of transition—not least a guarantee that their pattern of service or remuneration would not be changed (unless they agreed) for three years post reform. From April 2009 when the transitional period ends PCTs will have even greater ability, working in partnership with local dental providers to shape services to meet local needs.

  22.  PCTs have gone in eighteen months from, effectively glorified payment agents to full-scale commissioners of dental services. They have been supported in this transition by the national Primary Care Contracting team (PCC). PCC are a team of experienced NHS managers their programme ranges from hands on support to individual PCTs to a wide suite of guidance available to all dental commissioners. The full range of guidance is available at http://www.primarycarecontracting.nhs.uk/89.php

  23.  There is no doubt that taking on a full commissioning role during a time of wider organisational change presented PCTs with a significant level of challenge. Some PCTs are further ahead than others. Notable front runners include Tower Hamlets which has tailored services to meet the needs of a particularly deprived population through innovative use of outreach services delivered by local high street and salaried dentists.

  24.  Generally the first year saw a focus on getting the basics of the transition right and ensuring services delivered for patients through the critical first year. As commissioning matures and commissioners and providers get to grips with the system, PCTs are in the process of moving from contracting to true commissioning—designing services tailored for local needs rather than the original national inevitably somewhat rigid model.

  25.  It is notable that despite the national rhetoric, relationships between the profession and NHS are generally strong at local level. A Local Dental Committee (LDC) survey carried out at the height of dental concerns just after the new system had launched found that the majority of Committees reported good relationships with their local PCT even at that very early stage.

Patients' access to NHS services

  26.  The key gain of the new system is the ability to stop the previously relentless decline in access in a system where access was driven by business decisions made by individual dentists. The first 18 months have seen access stabilise—despite the need to re-commission services for around 900,000 people (those affected by the 4% of activity previously delivered by the one in 10 dentists who decided not to join the new system). The latest figures show numbers of patients seen at over 99% of service levels pre reform.

  27.  The main gains through this year have been at local level. Some previously very hard-pressed areas have seen nothing less than a transformation of access for local people. Milton Keynes, the Isle of Wight and Gloucestershire have seen particular successes in addressing long standing access issues.

  28.  At national level we expect services to grow as new services come fully on stream. The NHS is now commissioning more service than before the reforms and as services and performance mature, we should see a matching increase in services delivered. The Government is committed to growing access year on year.

  29.  But the NHS also needs to get much smarter at putting dentists with availability together with patients looking for a dentist. A dentist can take on new patients only when their current appointment book allows, whether or not they work in the NHS or only offer private care. This fact of high street dental life can lead to a feeling among the public that NHS dentists are scarce even in areas such as London where the reality is that supply actually outstrips uptake of services in many localities.

  30.  In these areas, the problem can be as much that patients cannot easily locate those practices that do have availability than one of overall local shortage. It is crucial that patients have a quick uncomplicated way of identifying local practices and, if they then have difficulty in finding one able to take them on, accessible help from the PCT.

  31.  This is why we have taken action to ensure that patients find the process of finding out whether there are local dentists taking on new patients increasingly simple. Many PCTs are already providing dedicated help lines. These have provided popular with patients and very effective in ensuring that when new capacity is made available those patients actively seeking care are made aware of the new service.

  32.  Nationally patients can find information on dentists via NHS Direct and NHS Choices. The information on NHS Choices has recently been strengthened by adding a telephone number for each PCT for people having difficulty finding a dentist to ring. This should drastically reduce the number of contacts individuals make before finding a suitable dentist.

  33.  We are currently consulting with the NHS on proposals to extend the NHS logo and identity to NHS dental practices. Historically dental practices have not had a high NHS profile. This, depending on the outcome of the consultation offers the opportunity for committed NHS dentists to badge their services more clearly as part of the wider NHS family.

The quality of care provided to patients

  34.  It is worth stating that patients are entitled to expect to receive, as of right, high quality dental care from dental professionals. We all take it as a given that an individual medical professional will deliver care to the highest professional standards and the dental profession and the NHS expects no less from dentists.

  35.  Concerns have been raised about the reduction in length and complexity of treatments seen since the reforms. However, we believe that this is broadly speaking an appropriate response to the greater clinical freedoms the new system has delivered—evidence that dentists are indeed off the drill and fill treadmill.

  36.  But it is essential that the NHS and practitioners can demonstrate that local patterns of care are appropriate to local treatment needs. In areas of poor oral health for example one would expect to see complex treatment forming a higher proportion of all treatments than in an area with better oral health and therefore less decay.

  37.  This is why we are introducing an enhanced clinical data set which will provide information which commissioners and providers can use to check care is appropriate to need. This core data set, which will be in place from 1 April 2008 has been broadly welcomed by patient groups, the profession and representatives of dental laboratories.

  38.  The new system is one of averages. It depends on dentists moving from the culture of a piece work system to one where the cost of treating one patient is offset by another needing little or no intervention. Some dentists have found this more challenging than others.

  39.  Outright malpractice, deliberately under treating patients for financial gain is rare. Dentists as ethical professionals have of course a duty to provide all care required—most would be shocked by suggestion they would under-treat to make an illegitimate profit at the expense of their patients, the NHS and taxpayers.

The extent to which dentists are encouraged to provide preventative advice and care

  40.  There was a consensus that the old general services contract was inappropriately focused on active treatment. The new contract has preventative advice included in Band 1 course of treatment. Dentists have expressed concerns that there is no explicit preventative "item of treatment". In our view, this is a hangover from the old way of thinking where every action had an individual price tag.

  41.  The calculation which set levels of UDAs required to deliver the same income as under the old system (for dentists moving from the old to new system) deliberately required 5% less active treatment to free up the time required for preventative care. In practice and as expected further time has been freed up by the marked reduction in length and complexity of courses of treatment.

  42.  The PDS pilots demonstrated that dentists are extremely keen to provide more preventative care. However, it also highlighted the lack of available evidence about what preventative treatment is actually effective. The Department has now produced a tool kit, "Delivering Better Oral Health" which provides for first time objective evidence on what preventative care works. The tool kit has been sent to all NHS dental practices and is also available on line at http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_078742

  43.  But, important as it is to ensure dental professionals have the time and materials to provide effective preventative treatment, we need to remember that all the evidence is that population level changes in oral health status are driven by factors outside the dental surgery.

  44.  The introduction of fluoride in toothpaste has been the key factor in delivering the markedly reduced decay in younger people. Fluoride toothpaste was introduced from the early 1970s onwards. It is sobering to remember that before this, dentists—despite their best efforts—were largely a disease service.

  45.  Fluoride toothpaste has not however reduced the variation in oral health between different socio economic groups. To date the only factor with a transformative impact on oral health across the social groups is the fluoridation of water. Data from oral health surveys which draw comparisons between areas with fluoridation schemes and those where no fluoride is added to the water supply, show that fluoridation is capable of countering the association between dental disease and social deprivation.

  46.  The government is committed to reducing inequalities in oral health. This is why the legislative framework governing fluoridation has been amended to give communities with high levels of dental decay a real choice of having their water fluoridated. If, after conducting consultations a Strategic Health Authority (SHA) finds that local people are in favour, it may require a water provider to fluoridate the water supply.

Numbers of NHS dentists and the numbers of patients registered with them

  47.  As at 31 March 21,041 dentists were listed on NHS contracts open at that date. This about the same as at 31 March 2006 although the new figures contain around 500 dentists employed directly by the NHS who were not included in the previous figures.

  48.  However, it is important to bear in mind that for dentistry pure headcount data, as this is, is a particularly weak indicator of levels of service. Most dentists combine private and NHS activity but there is no way of telling from the headcount whether an individual listed spends 10% or 100% of his or her time on NHS care.

  49.  A much stronger measure is whether PCTs can find providers to deliver commissioned activity and in turn, whether those providers can recruit dentists to deliver the clinical care.

  50.  One of the most striking features of the last year has been the improvement in the availability of providers looking to deliver NHS dental activity. In contrast with previous years, PCTs which have gone to tender have often had multiple bids to select a preferred provider from.

  51.  The new system has freed patients from the requirement to register with a particular dentist. Patients are therefore not nationally recorded as belonging to an individual practice or dentist as they were before (although most practices will continue to run practice "lists" just as they did before registration was introduced in 1990). Numbers of patients in regular contact with NHS dental services continue to be monitored through the count of the number of patients seeing an NHS dentist one or more times in any 24 month period.

Numbers of private sector dentists and the numbers of patients registered with them

  52.  Headcount information on dentists who currently work entirely outside the NHS has never been collected by the Department. Such dentists are not required or expected to make returns on patients they see privately. Similarly, dentists are not required to report details of patients receiving entirely private care to the centre. We can make some estimate of the level of private dental activity. This suggests around three quarters of all courses of treatment are delivered in NHS and a quarter privately.

  53.  Historically patients receiving private treatment have not had the same level of protection against clinical error as those receiving NHS treatment. This was particularly true where the dentist was operating outside the NHS system.

  54.  Action is in hand to provide stronger quality assurance for the NHS and for the first time to regulate the private sector.

The work of dental care professionals

  55.  Dental practices are now able to use dental care professionals—dental therapists, dental hygienists, orthodontic therapists and dental nurses—more flexibly and efficiently. This results from:

    —  legislative changes which have empowered the General Dental Council to introduce mandatory registration for Dental Care Professionals (DCPs) replacing restrictions on the range of their duties with a general principle that DCPS may practise within the competencies they have acquired through training and experience; and

    —  the replacement of the item for service system of remuneration with the local commissioning that allows dental practices to organise its workload to make full use of the skills of its staff.

  56.  These changes have brought challenges on the use of dental hygienists where the changes in recommended recall intervals recommended by National Institute for Clinical Excellence (NICE) and improvements in oral hygiene have reduced the clinical need for scaling and polishing. Most dental schools now provide a joint dental therapist/hygienist training course with opportunities for existing dental hygienists to undertake top-up courses in dental therapy.

Dentists' workload and incomes

  57.  The new contracts were aimed at freeing up dentists to deliver the care that was clinically indicated. The new arrangements have reduced the workload required of dentists while maintaining their income levels. The new system has, for contract holders, created stability of income alongside an increase in total income:

    —  The regular payments made to providers under the contracts give a guaranteed monthly income for pre-agreed levels of work across the whole year.

    —  The information published by the Information Centre in October on changes in patterns of treatment shows dentists are on average carrying out simpler and shorter courses of treatment—reducing workload and expenses.

    —  Existing general dental service (GDS) dentists had a 5% cut in the number of courses of treatment required (for same contract value) on transfer to the new contracts.

  58.  The new dental contracts also provide dentists with the long-term financial security they did not have under the old item of service system. GDS contracts are open-ended and allow dentists to agree their services and delivery pattern with PCTs along with any necessary variation to allow for staff changes etc. This provides a regular income stream every month, a month in arrears: a major improvement on the previous system where claims had to be submitted and agreed after the conclusion of the course of treatment with payment taking another four weeks on average. This improves cash flow and financial planning and significantly reduces the cost of working capital. It also allows agreed activity to be planned across the financial year to allow for holidays, training etc.

  59.  Dentists and the NHS have also asked us to provide a better indicator of clinical workload. We have taken account of these issues and have recently announced our intention to enhance the data provided by dentists to give a better indication of the clinical workload: although it will remain a relatively simple system to use and administer. This is intended to begin in April next year and should answer many of the criticisms from the profession that the current system does not allow for fair comparisons between practice workloads.

  60.  Although the transition period for the new contracts and the associated guarantees for dentists and ring fencing arrangements for PCT dental budgets were set at three years from April 2006, we do not expect any major changes to take place at the end of this period. PCTs and their dental providers should be building up long term, mutually beneficial working relationships. PCTs are highly unlikely to sever service contracts, provided there has been no serious breach of contract requirements or service standards.

  61.  The main significance of the three-year period is that, during this period, money from contracts that lapse through retirement, dissolution of practices, etc has to be used by the PCT to re-provide more dentistry. This gives real stability; neither before nor after the transitional period can a PCT unilaterally reduce the remuneration given to a provider.

The recruitment and retention of NHS dental practitioners

  62.  One of the main concerns about the new system as it was set up was whether enough dentists would join to ensure a viable service. In the event nine out of 10 existing dentists decided to sign the new contract. One of the earliest and most striking gains of the new system was that contrary to expectations in the dental world the new system had a galvanising effect on would be providers of NHS services.

  63.  The one in 10 dentists who left represented around 4% of all activity. (This reflected the fact that those who left were on average those with least commitment to the NHS). This 4% was fully re- commissioned at national level within six months of the launch of the reforms. PCTs, initially to their considerable surprise, have continued generally to find no shortage of takers when they are in a position to offer additional NHS activity.

  64.  The experience of the first 18 months suggests there is a strong appetite among many dentists to expand their NHS practice—the new commissioner led system means that for the first time expansion is not the random by product of a business decision but can be managed and targeted on areas of shortage.

  65.  For hard pressed NHS commissioners it was startling to find, after years of having to seek dentists from overseas that they were in a buyers' rather than sellers' market. This was equally salutary for dentists.

  66.  There is no room for complacency on the recruitment and retention of NHS dentists which is why we have expanded the training so significantly. Nor do we underestimate the residual concerns many providing NHS services still have about their place in the new system. But by no stretch of the imagination can we say there is a current crisis of recruitment or retention in terms of supply of dentists wanting to provide NHS services. This is the first time in many years this could be said and is no small first achievement for the new system.

Department of Health

6 December 2007





 
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