Memorandum by Denplan (DS 24)
1.1 Denplan welcomes the House of Commons
Health Select Committee inquiry into dental services and the chance
to contribute to it.
1.2 The Committee's terms of reference focus
on the impact of the dental reforms made in April 2006. In this
written submission to the Committee, Denplan aim to consider these
terms of reference in the wider context of the future of the entire
dental care sector. We aim to address how the under-lying aim
of dental care provision should be framed in order to achieve
a high quality of preventive, comprehensive and inclusive dental
care in the long term, and the implications of this on a sustainable
model of dentistry which can be created going forward.
1.3 We believe that private dentistry is
an important part of dental provision in the UK. It can serve
to complement, rather than compete with, NHS dentistry by providing
additional options for patients and by helping to reduce the costs
of running a modern dental surgery. The capitation approach of
Denplan also incentivises both patients and dentists to achieve
and maintain dental health, and discourages "episodic"
dentistry. Any further reform to the dental system must take the
complementary role of the private sector into account.
1.4 We have set out how we feel that the
current system puts the wrong emphasis on short term care provision
whereas a long term vision based around preventive care and oral
health could improve efficiency, and reduce the need for surgery.
Firstly, the system must allow the outcome of dental care to be
measured in such a way as to ensure that oral health is demonstrably
maintained and improved. Secondly, the system does not align the
best interests of the dentist and the patient. It may incentivise
patients to "save up" their problems, whilst dentists
see themselves as financially discouraged from caring for those
with the greatest dental needs. It encourages "episodic"
dentistry. Thirdly, the current system does not encourage the
dentist or the patient to focus on preventive care which would
give the patient a much better chance of avoiding major disease
and treatment and would save considerable resources, making dental
provision more sustainable in the long term.
1.5 Finally, we believe that the current
system is not sustainable in the long term and we feel that the
failure of successive reforms have demonstrated this. Therefore
we have set out both short term and long term proposals for a
more sustainable model of dental provision in the UK.
1.6 We feel that we have significant experience
to contribute to the on-going debate around dental provision in
the UK and would be pleased to give oral evidence during the inquiry
should you wish us to do so.
2. COMPANY PROFILE
2.1 Denplan was founded by two dentists,
Dr Stephen Noar and Dr Marilyn Orcharton in 1986 around the principle
of a capitation payment system, rather than dental insurance.
The dentists aimed to create an alternative approach where the
best interests of patients and dentists were synonymous: prevention-based
capitation. In this approach, patients would know in advance the
reasonable sum they would pay for their dental care needs, whilst
dentists would have a sound and regular income allowing them to
invest in their teams, their practice and their development. Over
20 years on, our main product is the capitation based plan, Denplan
Care; although we also provide other financing products as well
as support services including professional development and training,
quality assurance and risk management, complaints handling, marketing
and business advice.
2.2 In 2007, Denplan works with over 6,500
dentists and has 1.9 million patients registered, of whom 90%
are contracted individually to their own dentist, the remainder
being served under employer-arranged plans. Over the past 20 years,
most Denplan member dentists have retained a balance of private
(fee-paying) and NHS patients. Our internal research shows that
the "average" spread of patients in a Denplan practice
is as follows: 39% capitation, 40% private fee-paying and 21%
3. POLICY SPHERE
3.1 As a pioneer of dental provision and
the largest private sector provider in their field, Denplan endeavour
to remain engaged with policy makers and we feel that we have
much to add to the on-going debate about the future of dentistry.
Denplan's objective is the support of ethical, high quality, preventive-based
private dental care through appropriate funding mechanisms, where
the dentist remains in control of his/her practising circumstances.
We believe that, whilst the issue of NHS dental reform does not
affect Denplan specifically, a healthy NHS dental system is important
for dentistry in the UK and encourages patients to take responsibility
for managing their own oral health.
3.2 We gave oral evidence to the Health
Select Committee in 1993, in the aftermath of a previous NHS contract
reform, and written evidence to the inquiry in 2001 when we were
positively commended and acknowledged in the subsequent report.
In 2002, we participated in the "Options for Change"
work published by the Department of Health and which was widely
cited as the principal forerunner of the current reforms.
We have also commissioned research over the years into the provision
of dentistry, notably from Demos (1996 and 2000), York Health
Economics Consortium (2003), and Office for Public Management
4. HOW PUBLIC
4.1 The Health Minister, Ann Keen MP, recently
estimated that around nine million people seek private dental
However, industry commentators believe that the private dental
market is worth up to £3 billion overall in the UK
and Information Centre (NHS) figures note that more than half
of the income of the practice-owning dentists, for whom they have
information, is derived from private treatment (51% in 2004-05;
58% in 2005-06).
Overall, we estimate that the NHS contributes between 50% and
60% by volume and 40%50% by value of the total dental market.
4.2 The majority of dentistsas evidenced
by the NHS information statistics cited abovework in a
"mixed NHS and private" model. The option that a dentist
has to devote a proportion of their time to providing private
dentistry is often a vital factor in enabling them to continue
to provide NHS treatment to those patients who need it. The statistics
suggest that this position is now becoming polarised, with more
dentists working almost wholly in one sector or the other.
4.3 Our internal experience is that the
cost of running a contemporary dental surgery, which complies
with the plethora of modern regulation and legislation, averages
out at around £160 per hour. This is similar to the figure
recently confirmed by the British Dental Association (derived
from Scottish government estimates).
4.4 Private dentistry is sometimes characterised
as being "in competition" with the NHS, however many
dentists see mixed practice as a logical solution to these business
needs in the provision of good quality care for all their patient
4.5 We strongly believe that a comprehensive
(all necessary treatment) and inclusive (for all the population)
system of primary dental care delivery cannot be provided by the
public sector alone. The spread of available public finance simply
cannot stretch to cover identified dental demand. Unidentified
dental need is yet another issue.
4.6 The polarisation of practice which the
current reforms are engendering will not best serve the interests
of the public, the Government or the profession. We therefore
believe that it is very important that a more holistic approach
is taken when considering further and future reform and that the
likely impact of any change on the entire dental profession and
industry, and the ability of a dentist to provide mixed NHS and
private care must be considered.
5. HOW CAN
5.1 We feel that there are some fundamental
elements the 2006 dental reforms did not address, which would
bring about significant improvements in the way in which care
is given and managed, and which would significantly strengthen
the long-term viability of the dental system. Firstly, the system
must allow the outcome of dental care to be measured in such a
way as to ensure that oral health is demonstrably maintained and
improved. Secondly, the system does not align the best interests
of the dentist and the patient. It may incentivise patients to
"save up" their problems, whilst dentists see themselves
as financially discouraged from caring for those with the greatest
dental needs. It encourages "episodic" dentistry. Finally,
the current system does not encourage the dentist or the patient
to focus on preventive care which would give the patient a much
better chance of avoiding major disease and treatment and would
save considerable resources, making dental provision more sustainable
in the long term.
i. Lack of health measurement within system
distorts the focus of care
5.2 We believe that a major flaw in the
current UDA system is that it intrinsically encourages the dentist
to focus on the short term outcome of the course of treatment,
whereas the long term health of the patient is in fact the only
real indicator of how successful the care provided has been. Although
details of specific treatment provided under NHS care will once
again be identified by dentists on claim forms from April 2008,
there is no measurement of the effectiveness of dental care delivered.
There therefore needs to be a better measurement as to how dental
health can be achieved and the dental system needs to be able
to accommodate this. Health gain seems to us to be the most obvious
choice when measuring the effectiveness of dental care.
5.3 Other than the decennial Adult Dental
Health survey, no good measure exists of the oral health of the
population at large, nor in individual areas or contracts, although
widespread inequities in the prevalence of common dental diseases
Measurement of the oral health of 12 year olds, whilst a good
international measure, is a narrow one.
5.4 Within Denplan's capitation approach,
both patients and dentists are incentivised to achieve and maintain
dental health. Under Denplan's Excel programme, oral health is
measured and monitored by both dentist and patient. This measurement
system has been externally reviewed and is based on the academic
model originally intended for the (then) Dental Practice Board.
The Public Accounts Select Committee and the National Audit Office
both drew on essentially the same index for their reports.
A similar measurement system would enable the long term oral health
of patients to be tracked and would therefore encourage care geared
towards the improvement of long term health.
ii. The patient's relationship with their
5.5 It is widely believed amongst industry
commentators that the current attention to access and the effects
of the UDA target system, along with recent guidance from NICE
that patients who do not need treatment should only be seen by
a dentist once every two years, may be encouraging episodic dentistry,
and discouraging relationship dentistry.
5.6 Statistics (such as those quoted by
the NHS and in Parliamentary answers) on "access" consistently
fail to distinguish between these types of dental demand, as distinguished
from dental "need". It is of course desirable to have
need translate into demand, but consistently, some 20%-30% of
the population do not believe that they have cause to visit regularly,
whilst others visit only infrequently.
This of course affects the type of care that they receive and
they miss out on the regular check ups which can catch any problems
before the need for treatment arises.
5.7 Many patients do seek ongoing, preventive
care and increasingly this proportion of the populationwho
value dental health and not merely the absence of current dental
diseaseis growing. This is despite their identification
as the "worried well". These patients require and seek
an ongoing relationship with their dentistusually their
dentist of choice and whom they have grown to trust.
5.8 Patient who choose episodic dentistry
should have their needs met: both NHS and private systems can
address these needs and, importantly, provide an opportunity to
convince patients of the advantage of on-going regular and preventive
care, should they wish to avail themselves of this. Those who
do wish to do so should be encouraged to take individual responsibility
for this, with state-aided funding for those who require it.
iii. The value of preventative dentistry
5.9 Unlike medicine, dentistry is principally
about the management of two, almost entirely preventable, conditions:
dental caries and periodontal disease. An opportunity therefore
exists for a preventive approach to these conditions. Public health
measures (including fluoridation and education) are important
components, but on-going management and reinforcement at the individual
patient level is also key.
5.10 For dental caries, the "tooth
death spiral" suggests strongly that the avoidance of the
first "surgical invasion" of a tooth (by the dentist's
drill) is the most significant objective of preventive care. Minimal
invasive techniques are the most likely to prolong tooth life.
Periodontal disease requires, for the most part, intensive personal
monitoring and meticulous care (by both patient and the dental
team), although it probably presents a serious risk to only a
proportion of the population. Identification of the at-risk is
an important task, since links with diabetes, heart disease and
the damaging effects of smoking have been shown.
5.11 Good evidence-based dentistry is expensive
to provide, both in terms of facilities, equipment, materials,
and whole-team professional development and training. Dentists
have, in the past, invested significant amounts to secure this
environment. Future funding cannot solely depend on state provision
unless, again, major changes are made in budget allocations.
6. THE FUTURE
6.1 In the long term, we believe that a
complementary approach to the provision of primary dental care,
where both the public and private sectors work together, is essential
for meaningful progress, the efficient use of public funds and
the exercise of patient autonomy.
6.2 We believe that in order for the public
provision of dentistry to be sustainable in the long term future,
public health and the provision of urgent and "episodic"
care would sit best with the public sector. Ongoing routine maintenance
and preventive care would be best served by a responsible and
ethical private sector, with assistance for those who are genuinely
unable to afford it. Elective and cosmetic dentistry should rightly
remain in the domain of the individual's choice and funding.
45 House of Commons Health Select Committee (2001)
Access to NHS Dentistry Summary of Recommendations (a) Back
Department of Health (August 2002) Options for Change Back
Rt Hon Ann Keen MP, Parliamentary Under Secretary of State for
Health (12 September 2007) speech to Primary Care Trusts Back
Market & Business Development Dentistry Market Research Report
(June 2007); Laing and Buisson Dental Market Report (2003) Back
NHS Information Centre: Dentists Earnings survey, (September 2007) Back
British Dental Association (November 2007) Better Health, Better
Care, response from the British Dental Association Back
See for example: London Health Observatory Oral Health Overview
Burke FJ and Wilson NH (1995): Measuring Oral Health: an historical
view and details of a contemporary oral health index (OHX). Int
Dental J 45(6): 35-70 Back
House of Commons Committee on Public Accounts (July 2005) Dept
of Health-Reforming NHS Dentistry HC167: Recommendation 12. Back
Bradnock G, White DA, Nuttall NM et al (2001). Dental Attitudes
and Behaviours in 1998 and implications for the future Br Dent
J.190 (60-68) Back
Elderton RJ (2003). Preventive (evidence-based) approach to quality
general dental care. Med Princ Prac Suppl 1: 12-21 Back