Select Committee on Health Written Evidence

Memorandum by Sarah Elworthy (DS 18)



  In my opinion the new dental contract is unable to provide patient centred effective dental care for children because:

    1.1  The UDA does not measure effective patient centred care;

    1.2  The "banding" system for payments does not reward dental practices for effective patient centred care; and

    1.3  The PCT does not have the ability and structure to work with dental practices to set appropriate financial and clinical targets to achieve patient centred effective dental care.


  I am a general dental practitioner of 20 years experience. I own a small three surgery practice in the market town of Cranbrook in Kent. The practice was established 12 years ago. We treat adults as private patients. Children under 18 years of age are offered NHS care. We achieved IiP status in 2000 and the BDA good practice scheme in 2001

  The practice mission statement of "integrity, choice and value" underpins our objective of providing effective patient centred, evidence based dental care. We feel we have achieved this under the new dental contract. However we have been unable to achieve our UDA target and are under threat of significant financial penalties. This will means we will have to compromise our standards of care or opt out of providing NHS care for children. I would like the committee to understand why the new contract is failing our practice and therefore our patients. I hope this may be of some use in sorting out the current debacle.


  To provide the appropriate care and advice to minimise and treat dental disease, and to provide the skills and knowledge to remain dentally fit for life.


    —    Effective prevention advice to our patients and their parents from pregnancy onwards.

    —    Provision of effective preventative treatments ie fluoride varnish, fissure sealants.

    —    Early detection of dental disease with appropriate but minimally invasive treatment.

    —    Patient friendly appointments to encourage regular attendance and efficient treatment.

    —    Fast access to emergency care to minimise distress and maximise treatment success.

    —    Education in dental health to the wider community.


  Careful consideration of the DoH reports NHS Dentistry: Delivering Change by the CDO (England) July 2004 and the Framework Proposals for primary dental services in England from 2005 gave us encouragement that the above strategy would be valued by the NHS.

  Training of current staff and engagement of therapist to provide effective team to support the dentist

  We engaged with the PCT well in advance of the new contract to ensure the PCT supported our aims

  We utilised our IT systems for information on patient numbers, treatment needs and surgery hours

  We utilised our IT system for efficiently and effectively providing flexible appointments, quality control and audit

  Support from the PCT in funding via the new contract, and other direct grants from Government initiatives for training and investment in dental surgeries and Oral Health Educators.


  6.1  An adequate regular monthly income has given us the financial security to continue successful and effective strategy for child dental health in Cranbrook.

  6.2  The removal of fee per item has given us the flexibility to prioritise surgery time and care to those with greatest need.


7.1  The wrong measuring stick (UDA)

  The UDA measures treatments provided. It does not measure effective or patient centred care. We have increased the number of children that we care for before the new contract. We continue to conform to the principles of best practice as laid down by NICE and The Royal College of Surgeons We have provided a better level of service and equivalent surgery hours as we did before the new contract. We provide treatment that prevents dental disease, reduces repeat procedures and reduces referrals to (costly) secondary care. Unfortunately this is not valued and does not equate to the required levels of UDA's. If the government wants the PCT's to be responsible for the provision of dental care that is sensitive to patients needs a more appropriate measuring stick is required.

7.2  Banding; a disaster for patient centred care

  The system of banding discourages dentists from taking on new patients with high dental needs, as greater surgery time for multiple treatments is not rewarded financially. The UDA's can be maximised by forcing patients to book appointments spaced two months apart. We prefer to see children promptly if they need treatment thus limiting disease progression. We want to encourage attendance and so offer convenient appointments after school and increase availability in the school holidays. Most children are dependant on their often busy, working parents to ensure they attend for dental care.

7.3.  Poor management

  The PCT's need to have a good understanding of dental practice in order to work effectively with dental clinicians. The PCT's need to have clear objectives and strategies. These need to be effectively communicated to the dental clinicians. I have had a number of meetings with various PCT managers. Their level of knowledge on dental practice appears to be limited to their own (limited) dental experiences. Factual knowledge on the dental needs for the area appears negligible, and they have no obvious strategies or objectives other than in terms of the UDA and rewarded by the "banding" system. Although I can appreciate the desire to promote competition between dental practices in tendering for contracts, it is the patient care that will suffer if the measured `units' are not appropriate for the patients needs.


  Our successful dental care has resulted in increased demand from parents for NHS children's dentistry at our practice.

  Increased demand has not been met with increased funding. We have spare capacity and would be very happy to provide more NHS care for children. We would be able to work our surgeries more efficiently if we could expand our NHS care for children. The framework proposals 2005 encourages PCT's to support larger more efficient practices that utilise therapists,hygienists and oral health educators. We are saddened that the dental health of the children on our waiting list is being further compromised by these restrictions. Is this because we are in a reasonably affluent area and the PCT do not consider it necessary?

7.5  Removal of patient register

  No registration results in lack of continuity of care. Building up a good long term relationship with the patient (and for children, with their parents too) is a major part of effective preventative dental care.

7.6  Conflict of interest

  The PCT appears to have two conflicting roles. To manage the provision of dental care, and to award the contracts for the provision of dental care for all the NHS providers in the area. I cannot imagine a business situation where a manager is working for multiple business that are in competition with each other for contracts issued by the managerial staff. Combined with targets that are not sensitive to patients needs

7.7  Private/NHS partnerships

  There appears to be reluctance for mixed practices. However with limited funding and regional socio-economic variations this would be something to be harnessed rather than ignored.

  From my experience most dentists do not opt for private dentistry for purely financial gain but to enhance patient care and regain professional satisfaction.

7.8  Clarity

  Can the government (or rather the tax payers) afford to provide dental care for the whole population? Should the politicians decide the priority groups, and the funding available? The managers and clinicians can then set realistic and achievable objectives for the provision of adequately funded dental care for those groups.


  I sincerely hope this brief over view is helpful to the committee. We have provided the dental care that the DoH proposed in their reports and implemented the new contract in the same spirit. We have succeeded in providing effective patient centred care. We have not achieved our UDA target and have been threatened with significant reductions in funding.

Sarah Elworthy BDS

December 2007

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