Memorandum by the NHS Workforce Review
Team (DS 23)
The reforms to the dental contract
have created opportunities that should have positive benefits
for the service, patients and dentists alike, through improved
access to NHS dentistry, reduction of health inequalities and
promotion of a more evidence based, preventative approach to dental
The success of these reforms relies
on meeting the oral health needs of the local population alongside
partnerships with dental service providers including dentists
and other dental professionals.
The Workforce Review Team (WRT) believes
that it is too early to comment on many aspects of the impact
of these reforms.
Primary Care Trusts (PCTs), who may
be focused on other priorities, need to be able to access appropriate
independent expert advice to support and drive these improvements
as they move away from contracting and focus on commissioning.
WRT recommends that greater use should
be made of a "basket of indicators" that monitor dental
services and capture oral health, access patient experience, alongside
weighted measures of activity.
More thought needs to be given to
ways of dealing with those dentists who reach their targets early.
2.1 The Workforce Review Team (WRT) is a
national body working on behalf of the NHS in England, primarily
to support workforce decision making within the 10 strategic health
authorities. WRT's core role is to review in detail the supply
of and demand for the healthcare workforce across all specialties
and professions, and to advise on the most practical and effective
use of resources. It employs expert professional advisors from
the healthcare professions, including dentistry. This intelligence
and WRT's relationships with key dental stakeholders enable it
to have a strategic overview of the dental workforce and its challenges.
2.2 It currently works through a service
level agreement with the Department of Health (DH) and provides
valuable workforce information to key stakeholders including DH,
strategic health authorities (SHAs), employers and commissioners.
Profiles of healthcare workforce groups are published on the www.healthcareworkforce.nhs.uk
3. THE IMPACT
3.1 Initially, in their new roles, PCTs
have focused on continuation of existing services ("contracting"),
but increasingly are commissioning new and additional dental services
informed by local oral health needs assessments.
3.2 PCT dental budgets are based on a test
period that took account of patients' charges. In the event of
a shortfall in forecast patient charge revenue, there is a risk
that PCTs' commissioning budgets are effectively reduced as they
underwrite these shortfalls.
3.3 These new obligations place increasing
pressure on PCTs to have appropriate dental public health advice
and a competent, knowledgeable commissioning team.
3.4 Paradoxically, concurrent changes to
PCT and SHA configurations have led to a loss of dental expertise
at many levels, which risks undermining the dental services commissioning
3.5 WRT believes that PCTs will need to
retain a focus on improving the working lives of dentists and
their teams in order to secure services and maintain access for
4. THE IMPACT
NHS DENTISTS AND
4.1 WRT has commissioned a report
which comments on the lack of descriptive literature on successful
workforce planning in relation to healthcare (WRT 2007). Consideration
should be given to a range of measures that demonstrate a dental
service that is clinically effective and promotes best practice.
4.2 There is a challenge in analysing information
on numbers of dentists and patients because data collected before
and after 1 April 2006 cannot be directly compared.
4.3 When comparing the numbers of NHS dentists
on 31 March 2006 (21,111) and 31 March 2007 (21,041), it would
appear that there has been little change in numbers. There are
a number of other significant factors that should be considered
when making assumptions about the impact of reforms on dentist
4.4 The number of dentists on the General
Dental Council (GDC) register with addresses in England on 31
March 2006 was 24,935 and on 31 March 2007 was 26,105. A factor
in this increase is international recruits from both within and
outside the European Union. These extra dentists provide predominantly
NHS dental care.
4.5 Analysis of available data from the
Information Centre (IC) suggests that the number of patient visits
to dentists measured over a two year period has remained relatively
stable since the introduction of the new contract.
4.6 The number of dentists is not an indication
of activity, which may be monitored through a range of indicators
including weighted measure of courses of treatment using units
of dental activity (UDAs) and units of orthodontic activity (UOAs).
4.7 WRT suggests that any assessment of
primary care dentistry should take account of primary dental care
provided by dental care professionals.
5. THE IMPACT
5.1 Data on private sector dentistry is
5.2 Based on early feedback from some PCTs,
the number of dentists providing purely private dental care is
likely to have increased since the introduction of the new dental
contract. However, this will have had very low impact on local
access because those extra dentists are mostly ones who had small
NHS commitment, and because PCTs were able to replace these lost
5.3 As with mixed and NHS dental practices,
private dental practices do not normally have registration lists.
5.4 In the light of reported experience,
WRT believes that patients are most likely to migrate to private
care because of a wish to stay with the dentist of their choice
or because they are unable to access NHS dental care, rather than
because they have a specific wish to have private dental care.
6. THE IMPACT
6.1 Data on dental care professionals (DCPs)
remains very poor, but is expected to improve with the arrival
of mandatory registration in July 2008.
6.2 PCTs may commission dental services
from registered DCPs acting as providers.
6.3 Effective deployment of DCP skills creates
the potential to free up dentists' time.
7. THE IMPACT
TO NHS DENTAL
7.1 WRT believes it is important to ensure
that we measure:
opportunities for access;
subsequent real activity increases;
improvements in oral health including
addressing oral health inequalities.
7.2 WRT believes it is too early to say
whether there has been increased access to NHS dental care.
7.3 The reforms have created significant
opportunities to improve access (including equality) to NHS dental
care because PCTs can retain funding and reinvest in dental services
whenever a contract is relinquished.
8. THE IMPACT
8.1 WRT believes that it is too early to
assess the impact of these reforms on the quality of care provided
to patients. A robust primary care dentistry clinical governance
framework is already in place.
9. THE EXTENT
9.1 Changes to recommended recall intervals
should free up time and enable dentists to spend more time on
prevention and health promotion. It is the view of WRT that there
is a risk that this may not happen without appropriate monitoring,
incentives and realistic and achievable targets.
10. THE IMPACT
10.1 Because of the changes in measuring
activity and reporting, it is not possible to meaningfully assess
the impact on workloads.
10.2 Data from the IC suggests that the
number of interventions by dentists has decreased. This is in
line with aims of the reforms, which aspired to fewer interventions,
freeing up more time for a preventative approach.
10.3 Dentists who have not achieved their
agreed targets may be subject to recovery of payments which will
affect their salaries. WRT suggests that PCTs and dentists need
to work together to monitor and manage activity effectively.
11. THE IMPACT
OF NHS DENTAL
11.1 Dental performers list regulations
mean that older dentists and overseas graduates who have not undertaken
dental vocational training (VT) nor can demonstrate equivalent
experience, must undertake a period of training before joining
the list. As practices become more familiar with these new regulations,
more opportunities should become available for these dentists.
Most deaneries provide "Introduction to the NHS" courses
to support new (non-VT) entrants to the NHS, which includes EU
11.2 WRT considers it too early to assess
the full impact of these reforms on the recruitment and retention
of NHS dental practitioners.
11.3 Because dental services are now commissioned
to meet local needs, recruitment and retention initiatives for
NHS dental practitioners will be driven by local demand.
11.4 Nonetheless this must be considered
in the context of the national picture. The combination of significant
expansion of dental undergraduate places, increased numbers of
dental therapists and continued migration of overseas qualified
dentists into the UK, poses a risk of over-supply of the primary
care dental workforce.
NHS Workforce Review Team
44 "Who does workforce planning well?: a Rapid
Review for the Workforce Review Team"; Warwick Institute
for Employment Research; D L Bosworth, R A Wilson and B Baldauf;
November 2007 Back