Memorandum by Citizens Advice (DS25)
Access to NHS dentistry has been
an issue of longstanding concern to the CAB Service. Citizens
Advice has therefore welcomed the fact that, under the April 2006
reforms, Primary Care Trusts (PCTs) now have a statutory duty
to provide dental services to meet "all reasonable requirements".
However we regret that, although
the key aim of the reforms was to improve access, no attempt was
made to reduce the postcode lottery by targeting additional funding
on those PCTs where access had traditionally been poor. We believe
this is a key explanation for the failure of the reforms to deliver
any growth in NHS dentistry since April 2006.
CAB evidence from around the country
continues to demonstrate serious access problems at the local
level. Many people have gone without regular treatment, instead
relying on emergency services when they are in pain. Others have
felt they have no option but to seek private treatment even when
this is not what they want or can afford.
NHS charges can also be a barrier
to access. There is a need for better promotion of the help available
through the NHS low income scheme.
In a recent CAB online survey, around
a third of respondents who had received NHS treatment since the
reforms, said they were not satisfied with their treatment. Some
reasons given reflected a service under pressure. Others said
that they had been incorrectly told by their dentist that necessary
treatment such as scale and polish and root canal treatment were
not available under the NHS.
We are concerned that some PCTs with
significant access problems may be adopting a narrow interpretation
of their new duties, focusing on spending at the level of their
ring-fenced budgets based on historic spend in the area, rather
than on undertaking a comprehensive assessment of local need and
commissioning to meet all reasonable requirements.
1. Citizens Advice welcomes the opportunity
to submit evidence to this inquiry. In 2006-07 bureaux in England
and Wales dealt with 6,260 enquiries regarding dentistry, the
main concern being the availability of NHS dentistry (34%).
2. Ever since the early 90's, bureaux have
been reporting this problem and the concern of local people when
they are unable to find a dentist. There can be no doubt that
people see access to NHS dentistry as a prioritywhenever
a local dentist withdraws from the NHS or a new practice opens,
the story usually finds it way to the front page of the local
3. Citizens Advice has therefore welcomed
the dentistry reforms introduced in April 2006, which had improvement
in patient access as a key objective. We have particularly welcomed
the fact that PCTs now have a statutory duty to provide dental
services to meet "all reasonable requirements". This,
together with clear statements from Ministers that the Government
is "committed to providing NHS dental services for all those
who wish to use them"
has rightly raised public expectations.
4. It is therefore very disappointing that
Government statistics from the first 12 months of the reform showed
no increase in the number of patients receiving NHS dental treatment
but rather a slight fall. Moreover this fall appears to have accelerated
in the first quarter of 2007-08. We believe that the key explanation
for the failure of the reforms to improve access is that the ring
fenced funding allocated to PCTs to deliver their new duty was
not based on any assessment of local need, but rather on the historic
spend on NHS dentistry in each area. This therefore perpetuated
existing inequalities in access and has made it extremely difficult
for those PCTs in the historically most under funded parts of
the country to fulfill their new duty.
5. This submission is informed by case evidence
submitted by bureaux since April 2006 and by two on line surveys.
The first of these, to which 4,705 people responded, was carried
out between May and October 2006 and focussed on people who had
been unable to find an NHS dentist (access survey). The results
were included in our 2007 report Gaps to fill.
The second survey carried out between August and November 2007,
to which 341 people responded, provides some information on the
experience of people who have had NHS treatment since the reforms
came into effect (patient experience survey).
6. In our response we have focussed on those
aspects of the inquiry on which we have evidence.
TO NHS DENTAL
7. A key objective of the April 2006 reforms
was to improve access to NHS dentistry. It is therefore very disappointing
that the statistics for the first year of the reform showed a
reduction of 50,000 in the number of patients receiving treatment
in the previous 24 months. This means there was no progress in
meeting the needs of the two million patients who the Government
estimates are unable to find a dentist. Moreover the most recent
figures covering the first quarter of 2007-08 show a fall of over
200,000 in the number of patients receiving treatment, compared
with the previous quarter. This suggests that even the more modest
aim of ensuring through recommissioning that access does not deteriorate,
is not being met.
8. Nor has there been much progress in reducing
the postcode lottery at the local level. For example in South
East Central Strategic Health Authority (SHA) where access was
already relatively poor, the percentage of patients seen fell
from 51.4% to 49.8% over the 15 month perioda reduction
of almost 56,000 patients. And within the SHA, falls were even
greater amongst those PCTs with poorest accessin Surrey
PCT numbers of patients seen fell from 47.1% to 44.2% and in West
Kent PCT from 48.7% to 43.9% over the period.
9. Another way to assess the postcode lottery
is to look at the number of dentists taking on new patients. In
our CAB evidence report Gaps to fill, we analysed the data
on the nhs.uk website, and this revealed huge differences between
PCTs. Whilst in 22% of PCTs at least four in 10 dentists were
accepting new charge paying adult patients, in another 26% of
PCTs, no dentists were shown accepting this group of patients.
10. It has not been possible to update this
analysis because the information is now presented differently
on the website. Nor is information about the number of dentists
with open lists publicly available either nationally or at PCT
level. However bureau evidence from around the country continues
to demonstrate serious access problems at the local level. People
on low incomes living in rural areas appear to be particularly
affected, often facing long and expensive journeys to reach the
nearest available dentist. It is important to note that, unlike
travel to hospital, there is no help available from the NHS low
income scheme with travel costs to primary care services such
as dentists, presumably on the assumption that these services
will be available in the local community.
A CAB in Northumberland reported a young mother
on a low income, who needed emergency dental treatment. She had
to travel 10 miles to the nearest available treatment centre,
which was not easy with three children. She would have to take
half a day's leave and therefore lose wages.
A CAB in Hampshire reported an 87 year old woman
who was enquiring about the possibility of finding a local dentist.
She currently has to travel from her rural town to Southamptona
journey which she cannot manage on her own and therefore has to
rely on her daughter. There used to be two NHS practices in the
town but both have now gone private and the bureau has been calling
on the PCT, to no avail, to replace the lost NHS service.
A CAB in Kent reported a 77 year old client who
had a broken tooth. She had been into bureau previously for debt
problems and cannot afford a private dentist. To get to the nearest
NHS dentist involved an 8 mile bus journey, followed by a train
and then a walk.
11. From our access survey it was clear
that patients faced limited options. The majority of respondents
(64%) said they simply went without regular check ups or treatment.
9% said that, instead of adopting a preventative approach to their
case, they relied on emergency dental services for treatment,
including A&E, when a crisis arose. This was not always satisfactory
as the treatment provided would often not deal with the underlying
A CAB in Surrey reported a woman in low paid
work who had problems with wisdom teeth. There are no NHS dentists
available but she couldn't afford to see a private dentist. She
therefore waited until the problem was sufficiently severe that
she could go to the emergency dentist at the local hospital. She
ended up with an infected wisdom tooth and was given treatment
and very strong painkillers which made her feel so unwell that
she was off work for five days. She still has an ongoing problem
needing further dental work.
"I cannot register with a NHS dentist, so
I had to go to an emergency one when I had an abscess. He told
me my teeth were in a poor state, but seeing as he was only an
emergency dentist, all he was allowed to do was treat the abscess.
The dentist staff was fabulous; it's just that their hands were
tied." (survey respondent)
12. 18% said they had felt forced to accept
private treatment even when this was not what they wanted or indeed
A CAB in Suffolk reported a client who had severe
toothache at the weekend. There was no NHS dental care available
in the area and he was referred to Great Yarmouth for treatment.
He could not get up there and therefore went to a private dentist
in a nearby town and had an extractioncosting £110.00.
He wanted to know if there is any way he can get any help with
A CAB in Hampshire reported a 79 year old client
who had been unable to find an NHS dentist when her previous one
ceased taking NHS patients. She finds travelling difficult and
so feels she has no choice but to use a private dentist.
13. 27% of dentistry enquiries to bureaux
in 2006-07 related to NHS charges and it is clear from CAB evidence
that these can also be a barrier to access. The structure of the
charges was radically changed from April 2006 and Citizens Advice
was represented on the Department of Health's Patient Charges
Working Party which proposed the current structure. The advantages
of the changes are that the structure is much simpler so that
it is less easy for patients to be confused as to whether they
are paying for NHS or private care. It is also welcome that the
maximum charge has been reduced from nearly £400 to £194,
and that the flat rate structure goes some way to breaking the
link between poorer oral health and higher charges. It is crucial
that charges do not fall disproportionately on those with greatest
health needs, thus deterring them from accessing the NHS services
14. However the fundamental problem remains
that NHS dental charges are significant. The review of charges
was undertaken on a nil cost basis, with the requirement that
the same proportion of revenue should be recouped through patient
charges as under the previous scheme. This was despite the fact
that there had long been criticism of the affordability of NHS
dental charges, as discussed in our 2001 report Unhealthy Charges.
This found that the main reason why patients who had an NHS dentist
had not had a check up the previous year was because they could
not afford the cost.
15. Between August and November 2007, we
included a questionnaire on the Citizens Advice website for people
who had had NHS dental treatment since the April 2006 reforms.
77% of the 329 people who responded had paid for their NHS treatment
(the rest were exempt). Of these, 42% said they found it difficult
to meet the cost of this charge. This percentage reduced to 27%
amongst those paying the Band 1 charge (currently £15. 90),
but increased to 54% amongst both those paying Band 2 (£43.60)
and Band 3 (£194) charges.
16. Help with charges is available for people
on low incomes through the NHS Low Income Scheme. However the
dental contract does not require dentists to provide any information
about this scheme or to hold the relevant leaflets and claim form.
As a result, bureaux often report that clients fail to claim for
the help to which they are entitled. Recent MORI research undertaken
for the Department of Health as part of their review of Help with
Hospital Travel Costs, found that, of a sample of respondents
all in social grade D and E (and therefore likely to be entitled
to help) only 11% had heard of the NHS Low Income Scheme.
A CAB in Norfolk reported a client who was on
long term incapacity benefit with a weekly income of £81.35.
He therefore assumed that he was entitled to free NHS treatment.
He did not have his reading glasses with him and wrongly signed
forms to get free treatment by ticking the box that he was receiving
income support (IS). As a result he was charged a £79.50
penalty fee with an additional charge of £39.75 if the money
was not paid within 28 days.
The bureau found that the client should have
been entitled to a small IS top up, which would have given him
automatic entitlement to free dental care.
17. Only 6% of CAB enquiries in 2006-07
were related to issues around the quality of care, suggesting
that this is not such an issue of concern for patients as access
and charges. We therefore specifically included a question in
our 2007 patient experience survey about how satisfied they were
with the treatment provided. 32% said they were very satisfied
and a further 36% said they were fairly satisfied. However 32%
said they were not satisfied with the treatment they received.
Patients who had had Band 2 treatment were more likely to say
they were dissatisfied (41%) than those who had received Band
1 (26%) or Band 3 (11%) treatment.
18. Many of the reasons given reflect a
service under pressure, with patients saying they felt rushed,
found themselves repeatedly seeing a different dentist or had
to wait months for appointments.
"I was told that I would have three fillings
in the appointment I made but when I turned up on time my dentist
was running late. When I finally went in he said he only had time
to do one filling."
" . . . The only practice that would take
me on employs all locums."
19. Some respondents and CAB clients have
also complained that they received incorrect information and were
not given all the treatment needed on the NHS, as they are entitled.
A CAB in Devon reported a client in her 70s and
exempt from charges on grounds of low income. She had a tooth
removed by an NHS dentist who then recommended that her teeth
needed cleaning. However he wouldn't do this on the NHS and referred
her for private treatment at a cost of £26.
"A few days ago my husband was in a lot
of pain. He went to our dentist who we have been with for many
years (NHS). He was told he had an abscess and needed root canal
treatment (band 2). He was told by our dentist that he couldn't
afford to do the treatment on the NHS."
20. It is not easy for patients to check
whether what they are told by their dentist is correct, or indeed
to know how to challenge such practices when they do occur. And
as long as access problems continue, patients are in a vulnerable
position. Few will want to risk taking up the issue with the practice
itself, for fear of jeopardising the dentist/ patient relationship
or even being removed from the list altogether.
A CAB in Surrey reported a client who made a
complaint about her experience of poor treatment from her dentist.
The dentist then told her she was not wanted as a patient. She
is currently in pain but has been unable to find an alternative
21. Undoubtedly from the PCT perspective,
April 2006 was not an auspicious time to take on new duties in
relation to the delivery of NHS dentistry as many were still coping
with the consequences of reconfiguration which took place in Autumn
2005. In addition many faced the need to manage significant budgetary
problems over 2006-07. Then the initial challenge was to cope
with recommissioning the dental activity from those dentists who
decided not to sign the new contract.
22. During the winter of 2006-07 Citizens
Advice contacted 40 PCTs which appeared from the nhs.uk website
to have the poorest access. The responses from these PCTs highlighted
two issues of concern.
23. Firstly PCTs appeared to be adopting
a narrow view of their new duties. Rather than commissioning services
to meet the reasonable requirements of their area, they were only
recommissioning lost activity where a dentist withdrew services
and so spending only up to their ring fenced budget, regardless
of its adequacy. Thus one commented that "action that the
PCT has taken will ensure that the ring fenced dental allocation
is fully spent on providing an equitable access for local residents".
24. This is also reflected in the more recent
experience of local bureaux, several of whom have undertaken their
own surveys of local demand in order to demonstrate to the PCT
the need for additional dentistry in the local area. Interestingly,
despite the fact that many dentists have been critical of the
new contract, PCTs have not said that they have a problem in finding
dentists prepared to take on NHS work. Rather the barrier to improving
access appears to be inadequate PCT budgets.
25. The second issue was that some PCTs
appeared to be basing their estimates of need for services on
the number of enquiries to their dental helpline or the numbers
on their waiting list. But this assumes everyone in need of a
dentist is aware of these resources and has used them in their
search for a dentist. Responses to our access survey suggested
very differently, with only 19% replying that they had contacted
their PCT or their PALS as part of their search, although this
is usually the way to access the waiting list and helpline. Only
one PCT said they were considering undertaking a local patient
survey in order to accurately assess local demand for NHS dentistry.
26. We also believe that PCTs need to do
more to increase public awareness of their new responsibilities
with regard to NHS dentistry and make sure people know the best
way to find a dentist. Recent changes to the NHS Choices website
have increased the visibility of the local PCT dental helpline
number. However even amongst respondents to our on-line access
survey, who by definition were web users, only 52% used the website
in their search for a dentist, so it is clearly important that
other publicity strategies are used. Some PCTs have displayed
posters in key areas such as GP surgeries and libraries, informing
people about how they can get help with finding a dentist, but
this practice is not universal. This becomes particularly important
in circumstances where a dentist is withdrawing from providing
NHS services, and so large numbers of patients in a local area
will be looking for an alternative provider.
27. It is also important that mechanisms
are put in place so that patient satisfaction with their treatment
is fed into the PCT contract monitoring process.
28. It is extremely disappointing that,
15 months after the dentistry reforms were introduced; Government
statistics are still showing a decline in overall access to NHS
dentistry. We believe that a key reason for this failure is that
those PCTs which had poorest access before April 2006 were not
given any additional funding to help them fulfil their new duties
to meet all reasonable requirements. As a result, at PCT level,
inequalities in access have only been entrenched by the reforms.
29. Given the serious financial budget constraints
which many PCTs faced in 2006-07 it is perhaps not surprising
that many appear to have focussed only on spending their ring
fenced budget. We believe that the priority now must be to address
access inequalities through targeted additional funding before
the three year ring fenced period ends in 2009. Otherwise it is
very unlikely that the reforms will achieve their objective of
providing NHS dental services for all those who wish use them.
56 Ministerial conference speech, Commissioning of
NHS dentistry: the future, 17 September 2007 Back
Gaps to fill: CAB evidence on the first year of the dentistry
reforms, Citizens Advice, 2007 Back
Unhealthy charges: CAB evidence on the impact of health charges,
Citizens Advice, 2001 Back