Select Committee on Health Written Evidence

Memorandum by Dr Paul Batchelor (DS 14)



  2.  This submission argues that while the previous arrangements for the delivery of National Health Service (NHS) dental care had shortcomings and many of the principles underlying the reforms were to be welcomed, both the content and the manner of the present arrangement's introduction were flawed. In particular, the assessments of the shortcomings of the previous arrangements were unsound and the risks associated with the new system inadequately identified. In consequence, the current arrangements have failed to address the issues that the Department of Health (DoH) wished to see dealt with.

  3.  Due to shortfalls in the monitoring arrangements of the present system, it is not possible to provide the data required to ensure probity to the previous level nor to answer many of the questions that the Health Committee wishes to investigate. The quality assurance mechanisms that previously existed have been disbanded and the replacement arrangements are feeble. What data do exist, particular those obtained from independent sources external to the NHS highlight growing inequities in access to care. The considerable sums spent on recruitment and education represent poor value for money as the workforce planning methods used are wholly inappropriate: unemployment within the dental profession is a real possibility, this despite the continued access problems. Furthermore, as external agencies have highlighted, considerable risks remain.

  4.  The policy decisions taken by the DoH to help ensure that the dental needs of the population are met are flawed. The DoH has failed to provide a coherent vision of how dental care can be provided to the population through cost-effective, efficient and sustainable arrangements. In consequence, the very issues that the Government wishes to see addressed, namely improving access and a reduction in the inequities in disease levels have not occurred and will not do so under the current arrangements.

  5.  To address this problem, a sound analysis of the actual extent and reasons for the identified issues must be undertaken. This includes a review of the workforce proposals and a modified remuneration system that adopts incentives to reduce inequalities, encourage effectiveness and promote quality.


  7.  The present submission is based on my areas of activity as an academic and consultant. I have had considerable experience of working and analysing dental care arrangements in the United Kingdom (UK) and abroad. This has included examining the usage of dental services by the population and factors associated with service usage, workforce planning, funding of care and developing quality assurance arrangements. I have acted as an advisor to a number of agencies that have been involved in examining dental care policy including the Office of Fair Trading, National Audit Office, Dental Workforce Review Team and Options for Change Working party within the UK, In addition I have acted for a number of agencies abroad including the Health Service Executive and the Competition Authority in Ireland, the World Health Organisation and as an advisor to a number of other foreign national health bodies.

  8.  The rationale given to support the introduction of the present NHS dental care arrangements is centred on a long history of reported failings. All have suggested problems with the previous delivery arrangements but from differing perspectives. The reports include: the Schanschieff Report (1986), examining the possibility of over prescription; the Bloomfield Review (1992), regarding payment mechanisms; the Audit Commission (2002) and the Office of Fair Trading (2003), exploring the manner in which the dental "market" operated, and; the National Audit Office (2004), dealing with the risks of the current arrangements.

  9.  Numerous consumer group reports have also been published. All reiterate a common theme surrounding the delivery arrangements, in particular, perceived difficulties in accessing dental care. The Government itself has also examined dentistry, perhaps the two most pertinent being a previous Health Committee (2001), dealing with access to NHS dentistry and the Public Accounts Committee (2004), examining the management of risks of the then proposed dental contract.

  10.  The success or otherwise of the present care arrangements need to be based within a framework to help identify the extent to which the reforms could provide benefits for patients and the public at large. The goals of the current system included the need to improve three elements: access to NHS dentistry, oral health and NHS dental services. The precise definition of NHS dentistry has not however even been made.

  11.  The main proposals to achieve the goals included a number of benefits for those working within the system including more time being spent with patients, not least to help improve quality, less bureaucracy and work pressure, the ability of the profession to plan and invest in their businesses, integration with the NHS National Programme for IT (NPfIT), and opportunities to modernise premises.

  12.  Using this framework the specific issues that the Health Committee wish to examine will be explored.


14.  The role of PCTs in commissioning dental services

  15.  To date, very little commissioning of dental care has occurred; PCTs have simply contracted with providers working under the previous arrangements. Some secondary and primary care is being commissioned where previous contractors have left the NHS system. While theoretically the idea of local commissioning of dental care may work, in practice the difficulties are enormous. Not least, PCTs require sound data both of dental need and reliable service data from all sectors of the dental delivery system. These include all primary care arrangements, including the non-NHS sector and the secondary care sector. These data then need to be analysed to provide a valid interpretation and subsequently, to develop an appropriate contract to commission care to best meet both the present needs and those likely into the near future. There is a lack of such expertise; in certain sectors the experience is non-existent. Data on non-NHS activity are absent as are those covering clinical disease and other relevant measures for the vast majority of the resident population.

  16.  PCTs also have a considerable number of activities in differing fields of healthcare to undertake. The priorities given to developing a cadre of informed and capable staff to deal with dental matters has historically been poor. There is a lack of transparency in most financial flows meaning that it is impossible to verify claims by either the DoH or the provider side on actual resource allocation. The methods being used to ascertain the patients' voice within the system are equally pathetic. As such, the PCTs role is currently very weak.

17.  Numbers of NHS dentists and the number of patients registered

  18.  The number of dentists contracted to provide NHS care has risen. In March 2006, the last data capture point of the old arrangements, there were 18930 dentists (principals, assistants and trainees with at least one open contract) working within the primary care NHS dental system. Currently, the number of NHS dentists, defined as "performers", is 21111. The latter figure is a cumulative figure: the precise number currently working will be smaller. Perhaps more importantly, this does not equate to whole time equivalents and in consequence data are largely meaningless. It is the overall capacity that is important. At present there are no such data. Indeed, NHS service data will not be available for some time to allow any meaningful comparisons between the previous and current arrangements, if ever.

  19.  The new arrangements mean that an individual no longer "registers" with an NHS dentist. Patient "usage" is based on the number of individuals who have been seen within the previous 24 months. Given that the new arrangements have only been in place for 20 months the data include individuals attending under the old arrangements. The limited data that do exist and which are supplied to PCTs suggest that, to date, there has been no major change in the number of patients seen.

20.  Numbers of private sector dentists and the number of patient registered with them

  21.  No data are held to provide the number of patients seen under non-NHS arrangements and as previously highlighted, the term "registration" is at best vague. The non-NHS sector consists of a wide variety of care arrangements ranging from individual agreements between a dentist and a patient through to more organised care plans, the largest of which is Denplan. The number of patients seen through the latter arrangement is probably in the region of 1.5 million: the data are commercially sensitive. Published work suggests that the total number of patients reported accessing for a non-NHS check over the last 12 month period for which data are available is in the region of 7.5 million individuals. This represents a doubling over a 10-year period to over 14% of the population. However, the Committee should also be aware that many individuals also receive care through non-NHS arrangements despite being an NHS patient. Furthermore, there is a considerable social gradient in non-NHS usage with nearly twice the percentage of the higher socio-economic groups attending for non-NHS care when compared to the lower socio-economic groups.

22.  The work of allied professions

  23.  The new arrangements have made little, if any differences to the possible contribution that allied professions could make. With the exception of dental nurses, the present numbers of such trained professionals are relatively small in comparison to the number of dentists. The clinical operators, namely dental hygienists and therapists, the former consisting of approximately 4,000 registered individuals, the latter approximately 400, form a small proportion of the total operator workforce. There are currently over 30,000 registered dentists with current projections adding over 1,000 new graduates each year. The number of projected new hygienists or therapists each year is 120. Due to their small numbers and the current structure of dental premises, many being single surgery 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.

  24.  Dental nurses are however crucial to the efficient and effective running of dental practices. However the Committee should be aware that, due to changes in registration requirements, there is a growing risk that many practices will be unable to comply fully with the necessary requirements and will have to cease delivering care in July 2008 if they wish to remain legal. Less than 8,000 of the notional total of approximately 40,000 dental nurses are registered and therefore compliant at the time of writing this submission.

25.  Patients' access to NHS dental care

  26.  Simply because an individual can access dental care under the NHS, this does not necessarily mean that any subsequent care is provided under NHS arrangements. The issue from a patient's perspective involves two distinct questions: can an NHS dentist be found, and, if yes, will any care required be carried out under NHS arrangements?

  27.  First, access itself to an NHS contractor remains variable. Numerous reports continue to highlight the problems. The registration arrangements for dentistry have always been different to those for medical care. Historically individuals who wish to ensure access to dental care have needed to attend irrespective of whether they have any clinical need with a continued reduction from, recently, 15 months to nothing under the current arrangements. The key question for policy makers is to what extent do those wishing to access care have a clinical need, not whether they feel they need to attend to ensure access. If the medical sector operated in the same way, there would be similar problems as found in dentistry.

  28.  The second issue centres on the availability of treatment through NHS arrangements. There is growing pool of data to show substantial changes in prescribing patterns within the NHS. This is almost certainly due to the changes in the incentive arrangements. The pattern of the changes would suggest that patients are getting inferior care, for example extractions as opposed to root canal treatments unless they are willing to have the care provided through non-NHS arrangements. Given the costs, this is almost certainly increasing the level of health inequalities.

29.  The quality of care provided to patients within the NHS

  30.  The changes introduced following the implementation of the current arrangements have completely reduced the levels of quality and risk assurance arrangements for NHS dental care. The changes have seen the dismantling of the most cost-effective and efficient quality assurance mechanism that existed anywhere in the world. The current arrangements, largely the counting of Units of Dental Activity (UDAs) against a predetermined annual target and a record check on a small number of dentist selected patients, are more or less useless for ensuring the quality of treatment.

31.  The extent to which dentist are encouraged to provide preventive care and advice

  32.  Although the new arrangements have included the possibility for the provision of a preventive care element there are no additional rewards to undertake such activities over the previous arrangements. The incentive system adopted has merged a number of elements together, for example the examination and the cleaning of teeth, with the preventive "package". In consequence, there are no financial benefits to the dental provider to actual provide the preventive element. Furthermore, the DoH have no knowledge of the extent to which it has been undertaken due to the poor data capture arrangements.

33.  Dentists' workload and incomes

  34.  Data on dentists' workload are sparse and, as highlighted previously, knowledge of the extent to which dentists commit to providing NHS care is absent. Data released following a request under the Freedom of Information Act show that nearly 50% of NHS dentists failed to reach the minimum output target for the first year of the new arrangements. Due to the lack of information on the actual content of activity, comparisons to previous working arrangements are impossible.

  35.  Recent data suggest that dental incomes are on average £100K but the methodology used to acquire the data, in particular the sampling arrangements, is highly questionable. In consequence, extrapolation from these data across the whole profession is likely to be very misleading. Data on the income of dentists working outside the NHS shows earnings to be remarkably similar but earned through treating fewer patients. This suggests that one determinant in retaining the NHS workforce lies not necessarily with financial incentives, but through reducing their workload.

36.  The recruitment and retention of NHS dental practitioners

  37.  Recruitment of contracts and hence indirectly, dentists to the NHS is now limited by national and local fixed budgets. In 2009 this restriction will be removed. However, if historical data can be relied upon, PCTs have found themselves with declining dental revenues in real terms that have coincided with increasing demands from all health sectors. The real issue is to what extent will a PCT wish to commission dental services given all the other health demands made upon it, and subsequently, what contractual agreements will it establish and with who.

  38.  What data are available suggest that NHS dentists find work professionally unrewarding. There is an emphasis on the simplest forms of treatment that cost the least to address the patient's needs. This is hardly conducive to entrants into the NHS to exercise their skills to the best advantage for the population. Opportunities for long-term professional development are severely limited within the NHS.


  40.  The reform of NHS dentistry should be based on dealing with the two main problems: access to and inequalities in oral health. The poor analysis of what data are available and the lack of insight by policy makers have lead to care arrangements that are failing the public. Access to NHS care should be improved and inequalities in health need to be reduced. The arguments to support the current emphasis on the development of local based contracting and a substantial increase in the workforce are highly contentious.

  41.  The increase in the workforce, with a projected requirement of over 5000 new dentists by 2011 has been derived using a workforce model that is inherently flawed. The model contains calculations based on numerous assumptions that are wrong. Furthermore, the overall policy is likely to be unsustainable given the projected costs and, more importantly, it fails to address the underlying causes of the access issue. Of equal importance is that the proposed increase in the number of dental personnel will increase the overall costs of the system substantially. While this may be acceptable if the benefits included improved levels of oral health and a reduction in oral health inequalities, neither of these is likely to be achieved.

  42.  The failings are as of a direct consequence of the deficiency in making an accurate diagnosis of the problems within the care system. The problem in access is as of consequence of: an increase in the numbers trying to access the system and at the same time dentists moving away from the NHS. Simply increasing the numbers of care providers will fail to alter the trend towards non-NHS provision and will prove extremely costly. Furthermore, the increase in numbers is likely to lead to over treatment, the provision of which is of questionable value.

  43.  Due to the fragmentation of the delivery system when combined with the totally inadequate monitoring arrangements, poorly constructed remuneration system and the shortage of dental public health expertise at a local level, accountability to Parliament is substantially weakened.

  44.  To address the growing problems a proper analysis of the dental care arrangements and the true reason for the perceived problems must be undertaken. The solution must centre on ensuring that practice is evidence based and that clinical governance is used to ensure that the care meets the quality standards. The delivery system needs to change to appropriate objectives to meet the needs of the population. The payment system should discourage inappropriate intervention and reorient efforts to improving effectiveness and quality. The most appropriate arrangement for achieving this should centre on capitation based payments with long-term registration arrangements.

Dr Paul Batchelor, BDS, DDPH, MCDH, PhD, FFGDP, FDS

December 2007


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Schanschieff S G, Shovelton D S and Toulmin J K, Report of the Committee of Enquiry into unnecessary dental treatment, HMSO, 1986.

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