Memorandum by the Dental Laboratories
Association (DS 26)
NHS DENTAL SERVICES
The primary driver of the NHS Dental Reforms
was to devolve the service to make it responsive to local need
and address problems of accessing NHS care. Also, as stressed
in the Department of Health's report on the reforms, One year
on, they were intended to "shift the service away from the
old system, which operated on a piecework basis (often described
as `drill and fill' treadmill) . . ."
In doing this we have seen a significant reduction,
around 46%, in Band 3 treatments, treatments that repair the consequences
of the "drill and fill treadmill". Moreover, the cohort
of the population that need these treatments, who benefited from
NHS dentistry, are going to make the greatest demand on dental
care during the next 20-30 years but are in danger of being abandoned
by the service.
1. THE PROBLEM
1.1 We begin our evidence by looking at
what has gone wrong following the most fundamental change to NHS
primary care dentistry in England and Wales since its inception,
with the introduction of personal dental services (PDS), before
considering the implications, if not addressed, and a possible
1.2 Our concerns are not only about the
significant fall in the provision of Band 3 treatments (treatments
requiring laboratory work like crowns, bridges and dentures) but
also the quality of what is provided. Of the 480 or so fees under
the old fee per item, general dental services (GDS), just over
40% involved laboratory work. Significantly, these accounted for
around 8% of courses of treatment (CoTs), Band 1 (checkups, scaling
and diagnostic procedures) 52% and Band 2 (fillings, root canal
treatment and extractions) 40%.
1.3 However, NHS Dental Statistics for 2006/07,
published by the NHS Information Centre (IC), show Band 3 treatments
during the first year of PDS 50% lower than under the GDS, at
4% of CoTs. These treatments have probably settled at around 56%
of what they were or 4.5% of CoTs. This was the level in quarters
three and four of 2006-07, following a recovery from 2.2% at the
beginning of the first quarter, rising to 3.7% by the end of it
and 4% in the second quarter.
1.4 The reason for very low Band 3 CoTs
during the early months of the PDS was that these courses of treatment
generally take longer than others to complete. Also, and more
significantly, there was a lot of activity, particularly in the
provision of what were to become Band 3 treatments, during the
final quarter of the GDS contract, as general dental practitioners
(GDPs) attempted to provide these under fee per item of service,
before the changeover to PDS.
1.5 The latter resulted in patients benefiting
from lower patient charges for single treatments before the significant
increases accompanying the PDS. The Department has exclusively
focussed on the reduction in the maximum patient charge from £378
under the GDS to £189.00 during the first year of the PDSthe
patient charge for Band 3 treatments. But for single treatments,
like a porcelain jacket crown, the patient charge increased by
168%; a full or jacket crown in non-precious metal by 139%; a
full upper or lower denture by 151%; and a full upper and lower
set of dentures by almost 50%. Increases in price of these magnitudes
will have significant effects on the demand for dental care.
1.6 This reduction in Band 3 treatments
was identified in our surveys of dental laboratories, conducted
at regular intervals following the introduction of the PDS and
during the pilot schemes. In the first year, this showed an overall
decline of 57% in units of Band 3 appliances supplied to GDPs
in England and Wales, compared to increases of 15% in Scotland
and 17% in Northern Ireland, both of which retained the GDS. For
individual items, the decline ranged from 41% for non-precious
metal crowns to 84% for chrome framed dentures. This was not matched
by an increase in private work, which increased by just 18%.
1.7 Band 2 items also experienced a fall
in demand, from around 40% of CoTs under the GDS to 30% under
the PDS, again reflecting increases in patient charges for individual
treatments. The patient charge for a Band 2 CoT was introduced
at £42.40, which compared, for example, to a price of £7.75
for a simple, amalgam filling under the GDS, an increase of over
580%, and even when combined with an examination, included under
Band 2, increased by 180%.
1.8 One of the consequences of a reduction
in demand for Band 3 and, to some extent, Band 2 CoTs has been
a significant shortfall in patient charge revenue, with knock-on
effects for primary care trusts (PCTs). In NHS Dental Reforms:
One Year On, the Department stated that patient charges were expected
to raise around £600 million, although warning that "a
number of PCTs, though not all, have been projecting lower than
expected income from patient charges during the first year . .
. the Department has increased funding allocations for 2007-08
to allow for slightly lower levels of patient charge income as
a proportion of gross expenditure."
1.9 As it turned out, patient charge revenue
was £475, a massive £125 million short of the £600
million assumed in the indicative gross allocations issued to
PCTs. The Department had plenty of warning that this might happen
from the PDS pilot schemeswe estimate that patient charge
revenue from these were some £80 million short of the £190
expected, out of a total spend of £764 million in England
1.10 As well as demand-side effects, there
were also supply-side effects influencing the provision of band
3 treatments. If a patient needed multiple crowns, for example,
and could afford the maximum charge, GDPs were quite willing to
provide these under the GDS as their fee was not constrainedsimply
the number of crowns times the fee. Although the PDS contract
value, target of units of dental activity (UDAs) and therefore
value of UDAs were determined by a GDP's previous activity under
the GDS, GDPs have been reluctant to provide multiple treatments
as they incur higher direct costs for the same fee (12 x £UDA).
This will be compounded after April 2009 when the dental budget
is no longer ring fenced and UDAs begin to float.
1.11 Partial dentures have bucked the trend,
with the Dental Treatment Band Analysis for England, published
by IC, showing that within Band 3, CoTs containing partial dentures
rose from 27.4% to 34.7%. Our surveys show that during the first
year of the PDS, there was a 76% increase in the most basic partial
denturethe single tooth denture.
2. DEMAND FOR
2.1 The Department's mantra accompanying
the introduction of the PDS and repeated to PCT commissioners
at every opportunity since, has been prevention, prevention, prevention.
The move away from intervention to prevention is appropriate for
childrenaccording to the World Health Organisation, UK
12 year-olds have the lowest levels of tooth decay in Europe.
It is also appropriate for adults brought up post 1960's, who
benefited from the introduction of fluoride toothpaste and a more
preventative approach to dental caries. However, it is totally
inappropriate for those born in the 1930's, 1940's and 1950's.
2.2 This cohort of the population was at
high risk of developing caries and increasingly enjoyed access
to dentistry through the NHS. Techniques universally favoured
cavity preparation based on the principle of "extension for
prevention". These patients had decayed teeth that entered
into the "restorative cycle"repeated placement
and replacement of restorations, with progressive loss of tooth
structure and weakening of the tooth. In short, those most likely
to need Band 3 treatments under the PDS.
2.3 It is these patients, with their huge
volume of restorations and expectations to maintain a natural
dentition, who will have the biggest impact on the demand for
dental care over the next 20-30 years but are in danger of being
abandoned by the PDS. The question has to be asked can one fee,
however it has been arrived at which, through time, will inevitably
degrade, ensure that this cohort of the population receives the
treatment it needs when it covers such a wide range of appliances
and therefore costs?
3. THE SOLUTION
3.1 We do not, however, see a return to
more fees for band 3 treatments as the way forward. Dentistry
is unlike medicine in that there are often a variety of ways of
restoring/repairing/replacing the dentition that differ in quality
and cost. The problem of having a different fee for a procedure
to reflect the laboratory component is no different to a specific
allowance built into the fee as under the GDSit inevitably
becomes the maximum and the GDP has no incentive to involve the
patient in decisions about what is used.
3.2 The patient is unaware of this cost
minimisation pressure, nor of its significance in limiting options,
even though there may be considerable choice availablechoice
about the aesthetic and durability of something that will be present
in their mouth for some considerable time. This complete lack
of transparency and consumer sovereignty is at variance with market
efficiency and is particularly difficult to accept in a health
care system where patient charges have been a feature since 1951,
introduced, ironically, for dentures.
3.3 However, if, as we propose, the patient
pays for the laboratory component and the NHS subsidises treatment,
we will see the emergence of an enfranchised patient, making real
and informed choices about the dental care they receive.