Memorandum by the Oxfordshire PCT Patient
& Public Involvement Forum (DS 15)
NHS DENTAL AND ORTHODONTIC SERVICES
IMPACT OF THE REFORMS ON DENTISTS AND MEMBERS
OF THE PUBLIC: EVIDENCE FROM SURVEYS IN OXFORDSHIRE
1.1 Members of the southern group of the
Oxfordshire PCT Patient & Public Involvement Forum undertook
two independent surveys in October 2007 in order to assess the
situation for patients, public and dentists in Oxfordshire.
1.2 The evidence provided for the Select
Committee in this report supplements that contained in the National
Dentistry Watch Survey Report from the Commission for Patient
and Public Involvement in Health but reflects locally expressed
1.3 The report highlights the serious concerns
articulated by Dentists and the public in Oxfordshire on the adverse
effects of the reforms on the dental health of many people. Dentists
are particularly angry about the Units of Dental Activity (UDA)
banding system that acts as a disincentive to patient needs-based
treatment in some cases, and frequently fails to cover real costs.
Members of the public are primarily concerned
about restricted patient access to NHS dental services and the
inability of some people to find an NHS dentist at all. People
are angry about the high cost of both NHS and private dentistry,
particularly people in lower income groups.
On behalf of patients and public, members of
Oxfordshire PCT Patient & Public involvement Forum are particularly
concerned about the discriminatory effect the reforms have had
on access to dental treatment for persons with low incomes and
those with high dental needs.
1.4 The report also notes the high number
of dental practices providing NHS care, albeit frequently combined
with private practice, and the high levels of satisfaction expressed
by NHS patients about the treatment they receive.
2. IMPACT OF
The Forum found that 94% of responding dental
practices offer both NHS and Private treatment.
However, 59% of responding dentists believe
that the quality of NHS dental care has been compromised by the
reforms, and 73% believe that it is inferior to dental care provided
in private practices.
2.1 Impact of the reforms on NHS dental service
provision in Oxfordshire
73% of responding dentists indicated they have
serious concerns related to the Contract, and none feel satisfied
Issues raised include difficulty in maintaining
standards of treatment, the loss of clinical freedom to address
individual needs, the unhelpful nature of restrictions placed
on the numbers of patients that can be accepted and the shortfall
in remuneration received for the use of high quality materials
as indicated by patient need, all of which are seen as disadvantageous
for patients. Patient need is seen as secondary to meeting targets
imposed by the system.
For some dentists, full NHS provision has become
financially unviable, with financial survival forcing a change
either to part time or full private provision. Only a very few
dentists take an altruistic approach, indicating that they view
discriminatory treatment provision as unacceptable, and therefore
choose to provide equal quality of care for both NHS and private
patients through supplementing the shortfall through their private
A number of dentists see private practice as
the only way to enable them to update equipment and materials
2.2 Impact on NHS service provision of the
Units of Dental Activity (UDA) banding system
Dentists made many adverse observations about
the UDA system. Pressure is placed on dentists to reach their
UDA target; this is likely in many cases to result in the quality
of treatment being offered to be reduced.
The UDA system is seen to encourage a "treadmill"
target-driven service. The treatment bands penalise dentists prepared
to take on patients with high dental needs. Dentists are effectively
penalised for taking on patients with a history of poor oral health
on the NHS as these patients cause dentists to miss their UDA
targets.Some practices are restricting treatment based on UDA
values such as crowns and bridges.
Complex treatment on the NHS attracts the same
UDA value as some quick simple treatments. One example given of
this financial disincentive is the situation where remuneration
for providing twenty fillings to an individual within a single
course of treatment is the same as if providing one filling only.
Thus, in some practices, treatment is now being staged, ie necessary
treatment delayed, to make it financially viable for the dentist.
A further point raised concerns the lack of
continuity in the contract arrangements after 2009 which compromises
the ability of dental practices to plan future services.
2.3 Impact of the reforms on the ability to
provide quality care to patients
Dentists expressed a number of concerns relating
to the quality of care they are able to provide under the current
Some dentists are finding it more difficult
to provide adequate NHS dental care. It appears that high quality
treatment is not valued as the Reforms make it more difficult
for dentists to give adequate care through imposed financial disincentives.
Dentists cannot afford to provide high quality
materials and laboratory work where needed for NHS patients, unless
they subsidise their NHS work with private work.
Some dentists no longer accept new child patients
due to impossibility of maintaining standards of prevention, conservation
and laboratory work. These issues potentially pose more adverse
outcomes for patients.
The ability to upgrade equipment and materials
is also compromised by the reforms. Equipment and material upgrades
are commonly entirely dependent on the ability to subsidise from
private practice incomes.
Concerns are also being expressed about the
potential adverse impact of the reforms on some people's general
health through reduction in ability to access dental treatment
and preventative initiatives.
2.4 Negative incentives for dentists arising
from the Reforms
The reforms are seen to provide an incentive
for dentists to provide the cheapest, shortest treatment rather
than the most appropriate, with a potentially negative impact
on patient care. For example, the current system encourages tooth
extraction rather than restoration/root canal treatment and provision
of spoon dentures rather than bridges.
The system also makes dentists unwilling to
register patients with poor oral history as limits on UDAs available
to the dentist, and the UDA banding structure does not encourage
the care of patients at high caries risk and/or with multiple
treatment needs. In some cases, fillings are being postponed for
6 months in order to gain remuneration that better covers the
Dentists believe that the system may discourage
some patients from seeking a regular check-up.
The impact of the reforms on children's dental
health is a major concern. Inevitably, children who require a
lot of treatment are less likely to be accepted by dentists, who
will effectively be out of pocket if they treat them properly.
This is especially true of children with high decay rates and
children requiring root canal therapy as the 3 UDAs allowed for
either 1 restoration or 15 means these patients pose a disproportionate
drain on limited resources.
2.5 Impact of the reforms on Patients' access
to NHS dental care
All responding practices tried to offer appointments
at times which were convenient to patients (including early, late,
or Saturday morning). 83% provide a practice leaflet to keep patients
Dentists are aware of patients complaining that
there are very few NHS dentists who accept new patients. Dentists
are also concerned that patients with high treatment needs may
have difficult finding a dentist willing to do multiple items
Concerns were expressed that some practices
have been given much larger contracts than they can treat well
but many continue registering patients and not providing regular
care. But some practices are severely restricted in the number
of patients they are able to treat under the contract; in some
cases their contract is too small to deal with the demand for
It was also suggested that waiting lists are
growing due to increase in demand/need but there is no commensurate
growth in NHS provision.
2.6 Impact of the reforms on provision of
preventative care and advice
Some dentists said they no longer accept new
child patients due to impossibility of maintaining standards of
prevention. The reforms give little time or incentive for preventive
work or dental health education for children. One dentist who
would ideally like to spend more time with children to educate
them in regard to their oral health said that they do not have
any extra time to set aside to achieve this.
Whilst hygienist services are recognised by
the profession to be an important preventative measure, under
the reforms these are being denied to people on low incomes who
cannot afford to access them now.
2.7 Impact of the reforms on specialist service
The reforms disallow growth potential in delivery
of NHS specialist services.
Orthodontics is an area of real concern in terms
of reduced access and long waiting times. The reforms are seen
to effectively operate a rationing system.
2.8 Impact of the reforms on Dentists' workloads
While over two thirds of dentists surveyed say
they have a reasonable workload, others consider their workload
to be excessive in terms of "endless waiting lists and huge
pressures", "a paperwork mountains that fills every
lunch break and some evenings", "pressure to achieve
UDA targets" and "having no tea break, no lunch break,
starting at 8 in the morning and not getting home until after
6. Paperwork requires working on at weekends".
One dentist points out that they "are a
dental surgeon and this is what they do best".
2.9 Impact of the reforms on private dental
service provision in Oxfordshire
The majority (94%) of responding dentists provide
combined NHS and private services and many have been forced to
take up private work to maintain the viability of their practices.
It is clear that only a minority of dental practitioners
are able to make the current system work to their advantage but
it is questionable whether all patients receive an adequate deal
in these circumstances. Securing an acceptable level of income
(over and above practice overheads) requires an unacceptably swift
throughput of patients. This inevitably compromises the dentist's
ability to accept those who have complicated dental needs. Current
policy is likely to favour shorter rather than longer treatments
and is potentially open to abuse. Those on very low incomes who
do not qualify for exemption are doubly disadvantaged by the introduction
of the new contract. Even when they secure access to an NHS dentist,
the costs of some treatments are prohibitive for those not exempt
and at the least anomalous for others. Private care is not an
option for many, and some people are either going without dental
care altogether, or declining elements of treatment needed because
of cost. The dental health of children may now be satisfactory,
but will not remain so unless a better service at a more attainable
cost can be introduced.
3. EVIDENCE FROM
3.1 Patient access to NHS dental care
31% of the 384 people surveyed by the Forum
were current NHS patients, 54% were private patients and 14% not
registered with any dentist. 3% of NHS patients have to travel
over 100 miles to see a NHS dentist.
Amongst the private patients, almost half have
been unable to register with an NHS dentist although they wish
to do so, and many of these people find the cost of private dentistry
excessive in relation to their means.
Some private dentists continue to treat the
children of private patients on the NHS, and with the lack of
NHS places available, this locks parents into the private system
in order that their children can receive dental care.
Finding an NHS dentist in Oxfordshire is a major
issue for many people. The procedure for finding an NHS dentist
is complex and fraught with misinformation. Many people follow
this tortuous path only to fail.
People with high treatment needs are uniquely
disadvantaged; even if they can afford to use an NHS dentist they
are not welcome as their treatment uses too many units of dental
activity which both disadvantages other patients and leaves dentists
out of pocket. This also applies to same-day access to emergency
treatment where units of dental activity are confined to a daily
quota that cannot be exceeded.
Some patients entitled to free treatment during
pregnancy are having to pay for dental treatment due to lack of
7% of respondents have had to resort to self-treatment
at some point.
3.2 Quality of care provided to patients in
Although a few members of the public did identify
some quality issues relating to NHS dental treatment they had
received, 90% of patients receiving NHS dental care in Oxfordshire
say they are happy with the treatment they receive. The shortage
of NHS places remains a key issue in Oxfordshire.
This Forum believes that the Reforms were
introduced with insufficient consultation with patients"
groups, insufficient regard to the principles of good dental practice,
insufficient consideration of ethical principles and public health
interests. Insufficient consideration is also evident of the impact
of the Reforms on children, people on low incomes and other disadvantaged
groups. The inadequacies and anomalies of the UDA system have
resulted in sub-standard dental health provision for many people
in Oxfordshire. A more effective contracting system is required
that addresses some of the adverse impacts of the current Contract
on patients and public in terms of preventive measures and quality
and availability of treatment including rationalisation of payments
to dentists. The aim should be to promote high levels of both
dental and general health in the whole population.
There is a huge swell of public anger reacting
to this lack of availability of NHS dental services, and indeed
a concern that the current NHS contract discriminates against
the dental needs of those who are on low incomes and those with
high dental needs. Many dental practitioners are also angry and
disillusioned with the reforms.
The procedure to find an NHS dentist who will
agree to take patients is seen to be so complex and so dependent
of the state of a potential patient's mouth and teeth, that the
system discriminates against older and less advantaged people
who may not have the means, the energy or the determination to
find out how to proceed.
Within such a utilitarian system where individual
patient need is secondary to the needs of all patients on a dentist's
caseload, inevitably the reforms in their current configuration
place many individuals at higher risk of both oral and general
health problems. Also, with the associated reduction in dental
health promotion activity and reduced access to preventative treatments,
Forum members are concerned for the future dental health of those
least able to access dental services if further reform of the
current system is not enacted.
Members of the Oxfordshire PCT Patient &
Public Involvement Forum recommend that the Committee agrees the
following areas for action:
To revise and update the present dental contractual
arrangements to allow:
A more patient-focused, rather than
cost focussed philosophy within existing funding constraints.
A system where extra funding can
be accessed in cases of high dental need.
Better and easier access to NHS dentistry
for all who wish to use it.
More flexibility within contracts
to enable dentists to use their clinical judgement in cases where
individual needs may vary.
Better and swifter access to orthodontic
treatment for children.
A higher level of dental health promotion
activity, both individually and in the wider public arena.
A root and branch review of the current
UDA system that takes realistic account of practice overheads
and allows more flexibility in choice of treatments and materials.
A more flexible charging system for
patients that more closely reflects the value of dental treatments
Copies of the Oxfordshire PCT Patient &
Public Involvement Forum's full reports on their Dentist and Public
Surveys are available on request from the Forum.
Marion Judd (member)
Oxfordshire PCT Patient & Public Involvement