Memorandum by the Department of Health
NHS DENTAL AND ORTHODONTIC SERVICES
1. I am pleased to have this opportunity
to set out where we are on NHS dental servicesthe 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 2007in 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
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 treatmentavailable
for all who want it from the NHSand purely cosmetic treatment,
which most would agree need not necessarily be offered on the
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 carewhether for clinical or purely cosmetic
treatmentsreceive 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 treatmentand for very complex treatmentfinding
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 systemhow
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 treatmentbasic 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 qualityspecialist 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).
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 madeand particularly
the fact that even in the inevitably hard first year dentists
delivered 95% of the activity contracted foris 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.
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
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 transitionnot
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
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 commissioningdesigning services tailored for local
needs rather than the original national inevitably somewhat rigid
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 stabilisedespite
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
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 deliveredevidence 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 requiredmost
would be shocked by suggestion they would under-treat to make
an illegitimate profit at the expense of their patients, the NHS
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,
dentistsdespite their best effortswere largely a
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
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
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 professionalsdental therapists, dental hygienists,
orthodontic therapists and dental nursesmore 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 treatmentreducing 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
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
64. The experience of the first 18 months
suggests there is a strong appetite among many dentists to expand
their NHS practicethe 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
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