Memorandum by CHALLENGE (DS 06)
1. This submission, produced by CHALLENGE
argues that while many of the principles underlying the reform
of NHS dental services were to be welcomed, the manner of their
introduction has been seriously flawed. In particular, key areas
of the reforms have been introduced without the necessary preparatory
work and forward planning.
In consequence, the new arrangements have failed
to provide many of the important benefits that the DoH wished
to achieve: there are growing inequities in access to care; the
quality assurance mechanisms are woeful, and there are few, if
any data to answer the specific questions that the Health Committee
wishes to investigate. Furthermore, as numerous external agencies
have highlighted, considerable risks remain.
The PCTs are, in the majority, ill equipped
to handle local commissioning of NHS dentistry largely due to
the lack of data on which to base any commissioning decisions,
growing inequalities in care arrangements, a lack of quality assurance
arrangements, and a growing likelihood of unemployment for expensively
trained dental personnel.
We conclude our submission by offering our ideas
on a positive way forward to try to resolve the many difficult
issues facing the parties involved. In order to help those with
limited time to spare our conclusions are outlined in the next
part of this paper.
2. CHALLENGE would argue that reforms to
the previous NHS dental service were required and, providing sensible
proposals with an open dialogue are introduced, a new arrangement
could work with the support and good will of all sides.
3. The attitude of all parties needs to
be moderated. The increasingly personal fighting that has been
raging for the last 20 months must cease and a semblance of peace
must be restored if progress is to be made. The Health Committee
might wish to promote a new working relationship between the Department
of Health and the dental profession. That relationship is, according
to many commentators, irretrievably damaged. For the good of the
population's oral health that situation cannot be accepted, efforts
must be made to rebuild it.
4. The present arrangements have led to
a polarisation of the parties. The factions should meet in public
and discuss their problems afresh but based on a clear understanding
of what is to be achieved. If the dental profession can be convinced
that real improvement is the goal this move could herald real
5. The NHS must once again be seen as a
"a good employer" or "a trustworthy contracting
partner" if the downward spiral of NHS dentistry is to be
reversed. This may require some acknowledgement of past errors
and a new policy direction.
6. PCTs need staff who will be capable of
commissioning dental services in an appropriate manner. The current
programme of training and education is weak and the low priority
given to dentistry by PCTs means that few staff have remained
in position for sufficient time in order to develop a working
relationship with the dental providers.
7. The payment system needs to be completely
overhauled. The work undertaken in Personal Dental Services (PDS)
pilot sites from 1998-2005 needs to be revisited and the perceived
failures ironed out. The PDS contracting model came from an earlier
report "Options for Change" that was widely supported
by the profession. Going back to that model and that report would
be seen as a very positive step.
8. The new contracts were introduced with
many legal features that favoured the PCT to the detriment of
dentists working under NHS regulations, those issues need to be
addressed sensibly and modifications agreed.
9. The issue of patients' charges need to
be re-examined. Cost remains the biggest single barrier to accessing
care. Alternative mechanisms for raising revenue to fund dental
care should be explored.
10. New funding arrangements that make best
use of allied professionals easier in general practice, especially
where dentists are difficult to recruit, should be created.
An introduction to CHALLENGE
11. CHALLENGE is a dental political pressure
group (formed in October 2006) seeking to persuade the Department
of Health to alter the way that NHS dentistry works. Our members
do not believe that NHS dentistry is working for patients and
it is certainly not supporting the many thousands of dentists
who would still like to work for the NHS.
The three founder members of CHALLENGE are:
Eddie Crouch, Secretary of Birmingham Local Dental
Committee, Chairman of the Annual Conference of Local Dental Committees
2008 and an orthodontic practitioner in Birmingham.
John Renshaw, former Chairman of the British
Dental Association (2000-06) and general dental practitioner in
Ian Gordon, Chairman of Tees Local Dental Committee
and a general dental practitioner in Teesside.
We have sought help in the writing of this response
paper from Paul Batchelor, Consultant in Dental Public Health
and University Lecturer.
Background to this enquiry
12. The current contracting arrangement
for the provision of NHS dentistry has been in place for 20 months
but it is still causing severe problems. In many places patients
are unable to gain access to NHS care and dentists are still leaving
the NHS for the private sector. The situation has been investigated
many times recently by several important bodies.
13. The Prime Minister (Tony Blair) in 1999
stated in a Party Conference speech that he would make sure anyone
who wanted to could see an NHS dentist. The Health Committee itself,
under then Chairman, David Hinchliffe, looked into access to NHS
dentistry in 2001, the Audit Commission looked at NHS dentistry
in 2002, the Office of Fair Trading looked at private dentistry
in 2003 and the National Audit Office looked at NHS dentistry
in 2004. Following the external assessments, new contracts were
introduced supposedly to support dentists providing NHS dentistry.
However, the problems have not been solved; there have been patient
focused reports on NHS dentistry from the Citizen's Advice Bureau,
the Consumers' Association and the Patients' Association.
14. CHALLENGE welcomes the opportunity to
submit evidence to the Health Committee and to comment on the
principles underlying the reforms of dental services that were
introduced in April 2006 and in particular the extent to which
the changes have been consistent with the principles.
15. The benefits for patients outlined by
the Chief Dental Officer at the time were:
to improve access to NHS dentistry;
to improve oral health; and
to reform and improve NHS dental
16. To achieve this, the Department of Health
proposed to introduce new working arrangements and ensure a fair
deal for dentists and their teams. The benefits for the dental
more time to be spent with patients;
more time to allow improved quality;
less bureaucracy; less work pressure;
the ability to plan and invest in
integration with the NHS National
Programme for IT; and
a chance to modernise premises with
the help of the NHS.
17. Using these objectives, our submission
will address the nine key points in turn that the Committee wishes
to explore. In addition, CHALLENGE will also comment on the future
issues that will need to be addressed if the overall objective
of a fair and equitable NHS dental care system is to operate within
The role of Primary Care Trusts in commissioning
18. Low staff numbers, inexperience and
high rates of turnover amongst PCT personnel have to date produced
widely variable success in managing NHS dental services. There
is clear evidence to show that relinquished contracts are not
being rapidly re-commissioned and important commissioning decisions
have been influenced by internal PCT budget considerations. There
is a lack of transparency within PCTs to allow an assessment of
dental expenditure, or indeed on commissioning arrangements. Bureaucratic
processes vary widely, even in similar localities, with a postcode
lottery affecting policy and service delivery. There is suspicion
of favouritism and a lack of openness in commissioning procedures,
"preferred providers" receiving favourable treatment,
with the winning factor often declared to be "value for money"
but the criteria used being obscure and, in particular, the patients'
voice is absent.
Numbers of NHS dentists and the number of patients
19. While the number of NHS contracted dentists
has risen, as has been highlighted in other reports, this does
not necessarily equate to overall increased capacity. There is
a lack of accurate and sophisticated data on the whole time equivalent
(wte) workforce. In reality, the NHS has no idea how many dentists
actually work in the service.
Patients no longer "register" with
an NHS dentist. The new contracts abolished registration. Many
patients find this a real mystery. They still value and regard
"registration" as a most important feature of NHS dentistry.
The new measure of patient activity is the number
of patients who have been seen in the last 24 months. Given that
the new arrangements have only been in place for 20 months that
data are invalid. What data do exist highlight a considerable
growth in the non-NHS sector suggesting increased inequalities.
Numbers of private sector dentists and the number
of patient registered with them
20. Estimates vary and no data are held
centrally but survey work undertaken by CHALLENGE suggests that
there may be as many as 2,000 wholly private practitioners in
England and they, along with the many thousands of practitioners
who provide a mixture of NHS and private treatment, may be providing
privately funded care for as many as 7.5 million patients.
The work of allied professions
21. Allied professionals may be able to
make a contribution under the new arrangements but currently the
numbers of such trained professionals are relatively small. We
would wish to split the allied professions into two categories:
clinical operators and non-clinical operators. For the clinical
operators, namely dental hygienists (4,000) and therapists (400
qualified in 2006), due to their small numbers and the current
structure of dental premises, the opportunities for benefits through
their increased adoption are limited. Furthermore, the only major
review of the cost-effectiveness of their employment showed few
if any financial benefits. The other allied professionals, especially
dental nurses, are crucial to the efficient and effective running
of dental practices. However we would wish to draw to the attention
of the Committee that, due to the General Dental Council's new
registration requirements for dental nurses, there is a growing
risk that many practices will be unable to comply fully with the
necessary requirements and may even have to cease delivering care
in July 2008. Currently less than 8,000 of the notional total
of 40,000 dental nurses are registered and therefore compliant.
Patients' access to NHS dental care
22. We wish to break this issue into two
separate questions. First, can a patient find an NHS dentist willing
to take them on when he or she wants one and, second, if an NHS
dentist can be found, will that dentist be willing or able to
provide the kind of treatment the patient needs?
The answer to the first question is that NHS
access remains patchy. If you live in Bradford or Teesside you
will probably find access fairly easy. If you live in Epsom or
Winchester you will not be so fortunate. This is yet another NHS
postcode lottery. In some areas, like Birmingham, where access
was never a problem under the old system, there have been signs
of an access problem for the first time.
The second, new and additional access problemthe
availability of appropriate forms of treatment through NHS arrangementsis
a direct result of the introduction of the new contracts in April
2006. There is growing evidence of a substantial alteration in
prescribing patterns within the NHS. The pattern of the changes
would suggest that patients are getting inferior care with less
and less advanced work being carried out.
The quality of care provided to patients within
23. The present arrangements have completely
removed the most cost-effective quality assurance mechanism that
existed anywhere in the world. NHS dental contracts are now monitored
solely by counting Units of Dental Activity (UDAs) with no capacity
for the quality of the treatment to be assessed or rewarded. The
Department of Health wanted simpler courses of treatment, but
there is no evidence to suggest that simpler treatment is the
kind of service patients need or want. No part of the new contract
allows additional rewards for dentists who provide quality care
with quality treatment planning appropriate to patient needs.
The extent to which dentist are encouraged to
provide preventive care and advice
24. The new dental contract includes preventive
care within band 1 of the UDA linked payment system. This band
encompasses examination, basic scaling and any appropriate diagnostic
tests such as radiographs, so there is no additional reward for
preventive care. The contract was introduced with an alleged 5%
reduction in treatment targets (UDAs) to allow dentists more time
with patients and to provide more preventive care. In reality,
inflated output targets and inaccurate conversion of previous
treatment patterns into UDAs have not reduced dentists' workloads
at all and prevention is not being supported. Many practitioners
are finding that their output targets are not being reached, some
47% having fallen short in the 1st year.
Dentists' workload and incomes
25. The evidence on dentists' workload has
been badly damaged by the new contracts. We no longer know how
much work is being done by NHS dentists although the numbers of
patients accessing care remains roughly the same. Anecdotally,
dentists claim they are doing more NHS work than ever to meet
their imposed UDA targets but it is impossible to find a way to
verify these claims. Evidence recently brought to light from DoH
data shows that 47% of NHS dentists failed to reach even their
96% minimum output target for the year 2006-07. This would indicateas
has often been allegedthat UDA targets were deliberately
calculated higher than was sensible prior to the new contracts
coming into force.
Dentists' incomes are equally difficult to establish.
Data published recently shows good income figures but the sample
is narrow and badly skewed, reflecting the earnings of single-handed
practice owners whose incomes may be derived from a variety of
sources. This is a very strange sample to use and it has been
criticised previously. Extrapolation from this data across the
whole profession is very dangerous in statistical terms.
The closing down of the old system and the introduction
of a new system has created a bubble of practice turnover but
this will not be repeated as contract values and UDA values come
under pressure and expenses rise.
The recruitment and retention of NHS dental practitioners
26. Recruitment of dentists to the NHS is
now limited by national and local fixed budgets. PCTs find themselves
with too little cash and too many demands on it. New recruits
to the service have to go cap in hand and bid for a share of a
limited pot. Once dentists do enter the NHS they find the work
unrewarding in professional terms with the emphasis on the simplest
form of treatment that will cost the least to put the patient's
immediate problems right. This is bad news for someone coming
into the profession to exercise their newly acquired skills to
the best advantage for the population. Opportunities for long
term professional development are severely limited within the
27. The new arrangements for NHS dentistry
have failed to improve the service to patients. The reasons for
that are simple for all to see. Contract managers working within
PCTs do not have the time, the ability or the capacity to make
the most of the opportunities that the new contracts offer.
Dentists have been forced into new contractual
arrangements they would never have agreed to if they had been
given any real choice, they have been forced to reduce the quality
of the service they offer, to work harder than ever and to accept
poorer working conditions. Many of them find the lure of the private
sector to be very powerful. They can find there the freedom of
professional expression and the ability to provide a wide range
of modern treatments simply denied to them and their patients
within the NHS.
This combination of weak NHS management, disillusioned
and disheartened professional staff and inflexible working arrangements
is a massive disincentive for all the parties involved. As always
in situations like this, it is the patients who are caught in
the cross fire and they find themselves on the receiving end of
a poorer service that is patchy at best and comes to them at greater
cost than before.
The only party that seems to see nothing but
good in the current situation is the Department of Health and
their judgment is highly questionable.
John Renshaw BChD MFGDP
NHS Dentistry: Options for Change, Department of
Health, August 2002, London
NHS Dentistry: Delivering Change, Report by the Chief
Dental Officer (England) July 2004. DoH: London