Memorandum by the British Dental Association
NHS DENTAL SERVICES
1.1 The new dental contract has failed to
meet the Government's own success criteria for the future of NHS
dentistry, as set out in the Department of Health (DH) report
NHS Dentistry: Options for Change and which was widely
supported by the profession.
1.2 Despite its stated aims, the new contract
has both failed to free dentists from the workload "treadmill"
and to allow time to provide the preventive care that is essential
to reduce the oral health inequalities which still exist across
1.3 A prevention-based system could be delivered
if the NHS contract used a range of quality-based performance
indicators rather than sole reliance on a single flawed output
measure. Instead, dentists are facing financial penalties derived
from untested targets.
1.4 Patient groups, dentists and the Government's
own figures reveal patients still face problems finding NHS dental
care. Confusion also exists over the "registration"
of dental patients, which was abolished by the reforms. Clarity
is required over what is meant by "access" to dental
care and the impact on the nation's oral health of a new system
which seems to work against continuity of care for individual
1.5 Primary care trusts (PCTs), now responsible
for the local commissioning of dental services, must be given
the resource required, in both funding and expertise, to fulfil
their new role effectively and meet the oral health needs of their
communities. Strong working relationships should be developed
between primary care trusts and dentists to enable them to plan
how to meet these needs.
1.6 The majority of dentists work in a mixed
economy, providing both NHS and private care. The relation between
the two is complex with many practices effectively using private
income to subsidise NHS work. The private market is now growing
and set to expand further. Dentists who move towards private practice
are prompted by the opportunity to spend more time with individual
patients and focus more on prevention, and do not experience significant
increases in income.
1.7 To date, dentists have propped up NHS
dentistry by virtue of their professional relationships with patients.
However, the target-driven nature of the new contract, which fails
to encourage prevention, threatens the continuity of care. The
financial penalties and uncertainty faced by many dentists puts
the future of NHS dentistry at risk.
2.1 The British Dental Association (BDA)
is the professional association and trade union for dentists practising
in the UK. Its 23,000-strong membership is engaged in all aspects
of dentistry including general practice, salaried services, the
armed forces, hospitals, academia and research, and includes students.
2.2 The new dental contract impacts on dentists
in all areas of the profession. The focus of this evidence is
principally on general practice, but also has consequences for
salaried primary dental care services. This evidence applies equally
to general dental services and personal dental services contracts
which, in contrast to their equivalents in primary medical services,
are almost identical.
2.3 The House of Commons Health Committee
last reported on NHS dentistry in 2001. The committee called for
a new, long term strategy for NHS dentistry, reporting that the
system of remuneration in the general dental service at that time
was the main factor for dissatisfaction among both professionals
Following that report, the DH and BDA worked together on NHS
Dentistry: Options for Change,
a report which considered radical options
for modernising NHS dentistry. The DH and BDA's key aims for reform
move towards locally commissioned
and funded services, responsive to local health needs;
experiment with different ways
for paying dentists; and
place prevention at the centre
of dental care.
2.4 Consensus exists among the dental profession
and patient groups that these aims are not being met. The Government's
own data demonstrates that its reforms are failing to meet important
aspects of its own success criteria.
2.5 The fundamental cause of the failure
of these reforms remains that which was identified by the committee
in 2001: a system of remuneration which is directly and indirectly
causing dissatisfaction among both professionals and patients
and hindering the provision of prevention-focused dentistry.
2.6 The BDA welcomes the Secretary of State's
commitment to make public health the priority of the DH, but is
concerned that these reforms will stall positive progress to promote
good oral health and tackle health inequalities, which continue
to blight the health chances of the most disadvantaged groups.
3. THE ROLE
3.1 The BDA supports the development of
dental services to meet the needs of local patients. Providing
services based on assessment of local communities' needs, allows
longstanding health inequalities and "dentistry deserts"
to be addressed.
3.2 To commission dental services successfully,
PCTs must have the right resources, in terms of both funding and
expertise, and engage with local dentists and patients. However,
the varying success with which PCTs have been either willing or
able to do this has resulted in a new postcode lottery of NHS
dental provision. The difficulty faced by some PCTs when commissioning
dental services results from their commissioning budgets being
based on previous spending levels. Therefore, areas which were
historically under-funded before the new contract continue to
3.3 The BDA has called for the Government
to allocate full dental budgets for PCTs so that they are no longer
reliant on patient charge revenue. In the first year of the new
contract, PCTs were required to collect approximately 25% of their
dental commissioning budget via payments from patients who must
pay for NHS dentistry. However, in 2005-06 patient charge revenue
was £159 million (26%) lower than expected by the DH.
PCTs were forced to cover this deficit by a combination of commissioning
less dentistry than they otherwise should have and by implementing
inflexible performance targets for dentists. Reliance on patient
charge revenue ensures that PCTs' dental commissioning budgets
remain unpredictable for future years.
3.4 The funding predicament faced by PCTs
comes in the wider context of the chronic under-funding of NHS
dentistry. The proportion of the NHS budget spent on dentistry
in England is now lower than it was in 2002-03, at only 2.8%.
Unless the Government invests additional funding into NHS dentistry
the only source of further growth to meet demand is through the
3.5 The National Audit Office warned in
2004 that PCTs would need "to develop new expertise in dentistry"
given that they had "little experience of high street dentistry".
The development of effective working relationships with local
dental committees and local dentists is a crucial part of addressing
this requirement. The BDA is playing a proactive role in providing
advice to support this process, a contribution recognised by the
3.6 The expertise of consultants in dental
public health is also vital for effective strategic commissioning.
The recent loss of a number of consultant posts is therefore of
great concern. This loss of dental public health capacity also
undermines the Secretary of State's elevation of public health
to the top of the national agenda, and his recognition that this
is "pivotal" to reducing health inequalities.
3.7 It is vital that PCTs, having drawn
on these resources, publish plans on how they intend to reduce
health inequalities and improve the oral health standards of their
3.8 To commission effectively, PCTs also
need information about the oral health of their patient cohort.
The Adult Dental Health Survey, carried out every ten years by
the Department of Health, is an invaluable tool to monitor populations'
oral healthand indeed will be essential to evaluate the
impact of the current reform programme. The BDA is calling for
the funding of the survey, which has been delayed a year, to be
4. NUMBERS OF
NHS DENTISTS AND
4.1 When considering the relationship between
NHS and private care, it must be recognised that the vast majority
of dentists work in a mixed economy. It should also be noted that
since 1 April 2006 a patient can no longer be registered within
4.2 The vast majority of general dental
practitioners make available to patients a combination of NHS
and private care. The Options for Change report acknowledged that
this model of mixed provision should be welcomed: "private
dentistry contributes to patient choice, provides dentists with
options and independence and delivers those treatments that the
Government does not wish to finance".
4.3 Analysis of DH data suggests that the
value of the private dentistry market is now at least equal to
that of NHS provision and that it is continuing to expand.
The 2005-06 report of the review body on doctors' and dentists'
remuneration showed that in most practices there was cross subsidy
of costs between private and NHS work. General dental practices
are independently managed businesses that contract to provide
services for the NHS. Unlike general medical practitioners, dentists
have to buy their own premises, buy their own equipment and employ
their own staff. This report demonstrates that, in effect, the
income from private treatment is keeping NHS practices in business.
4.4 According to the DH, there are now 570
fewer dentists holding NHS contracts in England than there were
prior to the introduction of the new dental contract. However,
the BDA believes the real loss to the NHS since April 2006 is
approximately 1,000 dentists.
4.5 A further indicator of change in the
current dental market is the rise in the number of patients who
have joined private capitation schemes to pay for their dental
care. To take just one example, Denplan, one of the UK's largest
providers, has seen a 30% increase in patient registration since
4.6 Patient registration was first introduced
to NHS dentistry as part of the contract reforms in 1990. It was
abolished as part of the 2006 reforms. BDA members are told by
their patients that they greatly value a long term relationship
with their dentist. The BDA is concerned that the loss of registration
may have an adverse effect upon the continuity of care received
by patients. The 2006 contract has created a system that favours
episodic, pain-relief oriented treatment rather than promoting
disease prevention. We discuss the number of patients accessing
dental services in section 6.
5. THE WORK
5.1 Major changes are underway in relation
to Dental Care Professionals (DCPs) with the advent of regulation
bringing additional responsibilities and accountability. The BDA
has strong links with the DCP associations, and welcomes and is
committed to the development of the wider dental team and the
professional growth of individual team members.
5.2 Dental nurses have always played an
essential role in the dental team. A wider group of professionals,
including therapists and hygienists, also have positive contributions
to make. However, their potential is not being fully realised
because of the cost pressures within NHS general dental practice
(discussed at section 8, below). In addition, DCPs and dentists
share many of the same concerns about the viability and stability
of NHS dental practices.
NHS DENTAL CARE
6.1 The BDA urges the Department of Health
to define what "access" to NHS dental care should mean.
The BDA argues that the new system favours sporadic and discrete
treatment episodes rather than long term continuing care for those
patients seeking a regular treatment pattern.
6.2 Even taking the DH's reductive interpretation
of access, the April 2006 reforms have failed to improve access
for patients to NHS dentistry. The latest figures from the DH
show that over a 24 month periodthe maximum recommended
period between dental examinations27.8
million patients accessed NHS dental services.
This is a reduction of 266,000 patients since the 2006 reforms.
6.3 In March 2007 the BDA published the
results of a survey of dentists' experience of the new general
dental services contract. Eighty-five per cent of respondents
said that the new contract had not improved access to NHS dental
services for patients, 88% said that access to orthodontic services
had not improved and only 10% were able to take on new patients.
6.4 Research conducted by patients' organisations
reinforces these concerns. Citizens Advice states that patients
still face significant problems finding a dentist.
Market research published by Which? also shows significant regional
variation in the availability of NHS dental care, with an average
of just a third of practices across England taking on new NHS
The most recent Wanless review on healthcare spending shows public
satisfaction with NHS dentistry to be lower than for all other
NHS services, with a decline of 20 percentage points between 1998
6.5 The pressures in general dental practice
have also led to increased demand on the salaried primary dental
care services and on dental hospitals. A BDA survey of clinical
directors showed that 87% of services were experiencing increased
waiting times for specialist care due to these additional referrals.
These services are often designed specifically to treat patients
with special or complex treatment needs; any disruption therefore
risks creating difficulties for patients in the greatest need
6.6 It has been at least seven years since
the Government conducted even a rudimentary assessment of the
unmet need for dental care. It found then that two million patients
who wished to receive NHS dentistry, were unable to do so.
The BDA believes this underestimates the size of the current problem.
The Healthcare Commission's national patient survey in 2005 found
that 69% of patients not registered with an NHS dentist would
like to have been.
This equated to approximately 15 million people.
7. THE QUALITY
7.1 Dentists want to provide high quality
care for patients within a prevention-based system, as proposed
in Options for Change. Yet patients' quality of experience is
now threatened by the time pressures on dentists generated by
the new target-driven system.
7.2 These contract reforms have introduced
a new system for measuring the performance of NHS dentists. A
target for the number of units of dental activity (UDAs) a dentist
or practice must perform annually is written into each contract.
For simple procedures, such as a check-up, dentists are awarded
one UDA; work that also involves intervention, such as fillings
and root canal treatment is worth three UDAs; and dentists are
awarded 12 UDAs for work that also necessitates laboratory involvement
such as bridge-work or dentures.
7.3 There are significant anomalies within
this system, which result in it being more complex and unfair
than the above description would suggest. Dentists earn the same
number of UDAs regardless of the number of items of treatment
provided within a course of treatment. For example: a patient
requiring one filling would fall into the Band 2 course of treatment,
earning for the dentist three UDAs. A patient requiring four fillings
and root canal therapy would fall into the same band, also generating
for the dentist just three UDAs.
7.4 As well as appearing arbitrary, this
system of performance measurement fails to promote a more preventive
approach to care because of the pressures on time it creates.
A recent report from the London Assembly called on the DH to "consider
how it could revise the current NHS dental contract so that preventive
care is built into the way PCTs manage and monitor dental contracts
and should consider whether dentists should be financially rewarded
for providing preventive advice".
7.5 One of the Government's stated aims of the
reforms was to get dentists off the workload "treadmill"
to allow additional time for preventive care. The last official
study into general dental practitioners' workload showed that
a fully committed NHS dentist worked 43 hours per week, in that
time seeing 140 NHS patients.
In a survey of dentists' attitudes to the 2006 reforms, 82% strongly
disagreed with the statement that "the new NHS contract has
removed the treadmill effect". For fully committed NHS dentists
this figure was 88%.
7.6 The UDA is more than a performance indicator:
it is the principal unit of currency of the new contract. Anything
less than 96% of UDA performance may lead to serious repercussions
for NHS dentists. Data supplied by the NHS following a freedom
of information request showed that in 2006-07 almost half of dental
contractors actually failed to provide the required number of
The proportion of dentists who met their UDA target was only 20%,
if those who performed additional unfunded NHS servicesie
at their own expenseare also included.
7.7 BDA research found some areas where PCTs
have taken a constructive and sensitive approach to dentists missing
their UDA targets; but others did not. The variability of PCTs'
approach is illustrated by the research, which found that of practices
that had not achieved 96% of their target in the first year of
the new contract, almost 40 per cent faced clawback of money already
paid by their PCT. Just over 35% said that their PCT had insisted
that the uncompleted UDAs be performed in the 2007-08 contract
7.8 The BDA is aware of clawback where dentists'
work rate has remained unchanged from previous patterns; some
of these cases involve clawback of tens of thousands of pounds.
To take just one example: a fully-committed NHS dentist in the
Wirral felt forced to close his practice having been required
by his PCT to pay back £20,000.
7.9 The BDA supports the DH's oral health
plan, Choosing Better Oral Health,
and the "prevention toolkit" that derives from it. But
the reality is that when dentists spend additional time with patients
to explain about oral hygiene, nutrition and disease prevention
they do so at the risk of missing their UDA requirement or by
disproportionately increasing their clinical working time.
7.10 The BDA has consistently argued that
the UDA is a flawed measure, which was untried and untested before
implementation, and has called on the Government to scrap it as
the sole indicator of performance. It supports the Department
of Health's advice to PCTs to include factors such as oral health,
access, quality and patient experience in dentists' contracts.
This approach would enable PCTs to develop and agree contracts
with dentists and practices that reflect the needs of patients
in their area.
7.11 It appears from two reports that the
contract reforms have resulted in a change to the complexity of
NHS courses of treatment.
According to the DH "the new contractual arrangements were
designed to encourage simpler courses of treatment, where clinically
appropriate, with less complex and invasive procedures".
These preliminary changes to treatment complexities should be
seen in the context of the majority of dental contractors missing
their UDA targets, as discussed above.
NHS DENTAL PRACTITIONERS
8.1 The implementation of the new contract
has prompted many dentists to question their future in NHS dentistry.
BDA research shows that, a year into the reforms, dentists were
more concerned than ever about their long term future in the NHS.
Dentists' concerns relate to the target-driven nature of the new
contract and how this influences their clinical practice and the
financial security of practices.
8.2 The BDA argues that issues around recruitment
and retention can only be addressed by tackling the faults in
the new contract and safeguarding future funding levels for NHS
8.3 Dentists have been moving away from
the NHS since the early 1990s, a trend which the 2006 reforms
have exacerbated. This movement is manifest in individual dentists
leaving the NHS entirely and others changing the balance of their
practice to carry out a greater amount of private care. Information
from the NHS highlights the extent of the shift towards private
Using NHS earnings as an indicator of commitment, the percentage
of total NHS work fell from an average of 47.6% of earnings in
2004-05 to 41.9% in 2005-06, a fall of 5.7%. The largest reduction
was for dentists aged under 35, whose NHS earnings as a percentage
of total earnings fell by 20.7%. Analysis of the attitudes of
senior dental school students suggests that the future dental
workforce expects to spend a smaller proportion of its time delivering
NHS dentistry. The supply of NHS dental hours could be further
reduced by these students' intention to take longer career breaks
to raise children and earlier retirement than the current workforce.
8.4 The reason for this shift towards private
practice is not to earn more money. Data from the DH suggests
private dentists are more able than NHS dentists to invest in
their practices, in terms of the ability to pay for modern equipment
The same DH data demonstrates only a small difference in earnings
between predominantly NHS and predominantly private dentists,
of approximately 6%. Instead, the BDA's research identifies that
dentists move away from the NHS in order to spend greater time
providing prevention-based care to their patients.
8.5 In terms of recruiting new NHS dentists,
a survey of last year's vocational dental practitionersnewly
qualified dentistsfound that by the summer, more than one
in five had still not managed to secure employment for the coming
year; this is three percentage points up on the same time 12 months
Among those that had yet to secure a job, many reported that their
lack of experience was a key factor hampering their search for
employment. This is symptomatic once again of the new target-driven
UDA system which strongly favours productivity over a focus on
9. ORAL EVIDENCE
The BDA would be pleased to give oral evidence
to the committee if it would be helpful to the inquiry.
British Dental Association
5 Access to NHS Dentistry, report of the House
of Commons Health Committee, 2001, paragraph 22 Back
NHS Dentistry: Options for Change. Department of Health,
According to a survey of five year olds conducted by the British
Association for the Study of Community Dentistry, there is a seven-fold
difference between PCTs in England with the best dental health
and those with the worst. By the age of five, more than a third
of British children have suffered tooth decay, missing teeth or
fillings; in some parts of the country as many as three-quarters
of children are affected. Back
Gaps to Fill: CAB Evidence on the First Year of the NHS Dentistry
Reforms. Citizens' Advice, 2007 Back
According to figures published by the Department of Health, 23
August 2007, patient charge revenue only generated £475 million
instead of the expected £634 million, resulting in a shortfall
of £159 million in the dental budget. The NHS Dental Statistics
for England 2006-07 are available from the Information Centre
for NHS and Social Care. Back
NHS Primary Dental Care expenditure data for 2006-07 provided
in a parliamentary answer. NHS data from the NHS Operating Framework
for 2007-08 Back
Reforming NHS Dentistry: Ensuring Effective Management of Risks;
National Audit Office, 2004, page 8 and Part 2 Back
Barry Cockcroft, Chief Dental Officer for England, Speech to BDA
Conference, May 2007 Back
"The Healthy Society", Speech in the House of Commons,
Rt Hon Alan Johnson MP, Secretary of State for Health, 12 September
NHS Dentistry: Options for Change, Department of Health,
The UK Dentistry Market Development. Market and Business
Development, 2007. The health intelligence company Laing and Buisson
reached similar conclusions in 2003. Back
DDRB supplementary evidence, analysed and published in the BDA
"Policy Bulletin", August 2005 Back
According to the DH, at 31 March 2007 there were 21,041 dentists
performing NHS dental services in England. The BDA argues that
the comparable figure for pre-April 2006 would be approximately
22,073. This is derived by taking the old England and Wales general
dental services figure of 21,254, a number supplied by the Dental
Practice Board. Welsh GDPs are then subtracted, which is approx
1,031 (source: BDA Wales). But we then incorporate the BDA estimate
of 1,200 salaried dentists in England and 650 VDPs. This calculation
suggests a net loss of 1,032 NHS dentists. Back
Denplan currently has 1.8 million registered patients, compared
with 1.3 million patients three years ago, an increase of approximately
30%. Information from the Denplan Media Centre. Back
Dental recall: recall interval between routine dental examinations,
National Institute for Health and Clinical Excellence, 2004. Back
NHS Dental Statistics for Quarter 1, 2007, Information
Centre for Health and Social Care Back
BDA survey of members, March 2007 Back
Gaps to Fill: CAB evidence on the first year of the NHS dentistry
reforms. Citizens' Advice, 2007 Back
Check-up on NHS Dentistry: dental contracts one year on,
Which?, March 2007 Back
Wanless, D. Our Future Health Secured? A review of NHS funding
and performance. King's Fund, 2007, page 223. Back
BDA survey of clinical directors, September 2006 Back
Modernising NHS Dentistry: Implementing the NHS Plan, Department
of Health, 2000, par 2.17 Back
Survey of patients: primary care trust, Healthcare Commission,
2005, page 17.ONS data shows the population of England to be 50.8
million. The Healthcare Commission found that 43% of patients
were not registered with an NHS dentist; of those, 69% wanted
to be. This equates to approximately 15 million people. Back
Teething Problems: A Review of NHS Dental Care in London,
London Assembly Health and Public Services Committee, November
2007. page 21. Back
Review Body on Doctors' and Dentists' Remuneration; Supplement
to the 31st Report. Office of Manpower Economics, 2002, pages
69 and 100. Back
BDA survey of members, March 2007 Back
BDA analysis of information supplied by the NHS Business Services
Authority showed that 47% of dental contractors failed to provide
at least 96% of the contracted number of units of dental activity. Back
BDA survey of local dental committees and PCTs, August 2007 Back
The case referred to was that of Dr Clive Morgan, of Greasby in
Wirral PCT. Back
Choosing Better Oral Health: An Oral Health Plan for England,
Department of Health, 2005. Back
NHS Work Stabilised at All Time Low, the Dental Laboratories
Association, 2007.Dental Treatment Band analyses: England
2007, Information Centre from Health and Social Care Back
NHS Dental Reforms: One year on, paragraph 4.6. Department
of Health, 2007. Back
BDA survey of members, March 2007. This showed that 57% of dentists
were less confident about the future of their practice than they
were two years previously. This compared to only 27% when asked
that same question in 2002. Back
Dentists' Earnings and Expenses Report 2005-06, The Information
Centre for Health and Social Care: Back
Stewart F, Drummond J, Carson L, Theaker E: Senior Dental Students'
Career Intentions, Work-life Balance and Retirement Plans,
British Dental Journal, 2007, 203 (5) 257-264 Back
Dentists' Earnings and Expenses Report 2005-06, The Information
Centre for Health and Social Care Back
BDA Private Practice survey, 2002 Back
BDA survey of vocational dental practitioners, June-August