Memorandum by Dr Paul Batchelor (DS 14)
NHS DENTISTRY
1. SUMMARY
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.
6. INTRODUCTION
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.
13. FACTUAL INFORMATION
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.
39. RECOMMENDATIONS
FOR ACTION
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
REFERENCES
Audit Commission. Primary dental care services in
England and Wales Northampton: Belmont Press 2002.
Bloomfield K, Fundamental review of dental remuneration:
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Batchelor, PA. Changes in self-reported attendance
of British adults for dental check-ups between 1991 and 2000.
Prim. Dent Care. 2004 Oct;11(4):125-30.
Batchelor, PA. The historical and political background
to the proposals for local commissioning of primary dental care
by primary care trusts. Prim Dent Care. 2005 Jan;12(1):11-4.
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.
National Audit Office Reforming NHS Dentistry: ensuring
effective management of risks London: The Stationary Office, 2004.
Office of Fair Trading. The private dentistry market
in the UK. London: Stationary Office 2003.
Schanschieff S G, Shovelton D S and Toulmin J K,
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