Select Committee on Health Written Evidence


Memorandum by the Dental Practitioners Association (DS 28)

DENTAL SERVICES

INTRODUCTION AND NOTES

  1)  The Dental Practitioners' Association (DPA) welcomes this opportunity to submit evidence to the Health Committee's Inquiry into NHS dental and orthodontic services.

  2)  The DPA (formerly GDPA) was formed in 1954 and is the largest body that represents dentists in general practice. It consists of 1,000 practices containing 2,500 "high street" dentists. Uniquely its Constitution requires that the fifteen members of the principal executive committee and the Chief Executive must be dentists.

  3)  Within a document of this length we regret it is not possible to go into any detail regarding what might be learned from variations on the old system (as in Scotland except see para. 50)) or the variations on the new one (as in Wales and shortly in Northern Ireland).

  4)  For the sake of clarity this document will adopt the usual convention of referring to the arrangements in England prior to 1 April 2006 as GDS and the subsequent system as new GDS (nGDS). Similarly the piloting of various treatment provision systems in the period leading up to April 2006 as PDS and the fixed-term contract extensions awarded to early adopters of the pilot schemes as nPDS.

  5)  Where this document refers to Primary Care Trusts (PCTs) this includes Local Health Boards, insofar as their contracting and commissioning functions are identical.

  6)  The lack of any reference to patients' concerns should not be taken as a failure to acknowledge the distress caused by gradual collapse of NHS dentistry. We expect that the many organisations representing patients will make their case elsewhere with our full support.

EXECUTIVE SUMMARY

  7)  Dentistry is a unique combination of academic, manual and business skills. Very few other professions require a combination of all three.

  8)  Much of the current public dissatisfaction with the NHS dental services can be traced to a general decrease in NHS activity by each dentist due to the disparity in terms and conditions between the NHS and private sectors.

  9)  The dental contract imposed in April 2006 is characterised by inefficiency, inflexibility and unfairness and has introduced a number of perverse incentives.

  10)  Dentists do not leave the NHS for financial reasons. They invest the extra profit in improving their quality of life by giving patients more time and using better quality materials and laboratory work. On average a private dentist earns £800 more each year than an NHS dentist.

  11)  The DPA sees a rôle for dentists as the leaders of clinical teams with ultimate responsibility for the patient's overall care. It is more efficient for dentists to be confined to those procedures for which only they are qualified.

  12)  The key to prevention in dentistry is to give the practitioner a stake in the savings made. For example, a dentist who reduces his workload by (say) 20% due to prevention must not suffer a drop in income of 20% (as under the present and previous systems).

  13)  Once UDA targets were reached, it made good commercial sense to bid for more UDAs and this has led to a fall in the value of UDAs reflecting their lack of content. We consider that the value of a UDA will fall somewhat until it approaches the cost of production, at which time it will rise consistent with free market conditions of excess demand over supply.

  14)  The DPA would welcome the return of some form of registration of patients. Dentists do not like to see their patients on an ad-hoc basis and patients like to know who their dentist is and what rights they have. It is also consistent with the preventive cohort system (see para. 46)).

  15)  The question of whether the new arrangements represent adequate value for the taxpayer should be properly and expeditiously put in front of the National Audit Office.

  16)  The Health Select Committee has no constraints and, having given oral evidence in the past, the DPA respectfully asks that it is called to give oral evidence on this occasion as an organisation which is representative in the main area of this Inquiry.

EVIDENCE

  17)  Dentistry is a unique combination of academic, manual and business skills. Very few other professions require a combination of all three.

  18)  DPA members in primary care are self-employed subcontractors to the NHS. They own their own premises, employ their own staff and pay their own expenses. Subject to a three-month notice period they are free to do as much or as little NHS work as they wish. As a result, there are significant differences in their terms and conditions compared to salaried dentists and GPs.

  19)  In 1981, approximately half the current number of dentists on the General Dental Council register treated substantially the same population with no NHS access problems.

  20)  Much of the current public dissatisfaction with the NHS dental services can be traced to a general decrease in NHS activity by each dentist due to the disparity in terms and conditions between the NHS and private sectors.

THE ROLE OF PCTS IN COMMISSIONING DENTAL SERVICES

  21)  Prior to April 2006 Primary Care Trusts and Local Health Boards cared little about the dental services provided in their area. They played a minor part in the administration of the system which included processing applications to join or leave the area and had a rôle in inspection and testing.

  22)  From April 2006 PCTs have held the primary dental care budget and as a result they are now interested in dental provision. The handing-off of dental contracts to PCTs has coincided with the closure of the dental budget. As a result PCTs have a strong disincentive to expand dental provision to that part of the population which does not normally attend. (See also Perverse Incentives, para. 60))

  23)  During the piloting of schemes prior to April 2006, the DoH indemnified PCTs against any shortfall in patient charge revenue (PCR). This indemnity was withdrawn for the scheme proper. As a result PCTs have a strong disincentive to extend the service into areas of high need which may have low levels of PCR. (See also Perverse Incentives, para. 60))

NUMBERS OF NHS DENTISTS AND THE NUMBERS OF PATIENTS REGISTERED WITH THEM

  24)  The DoH has finally accepted after many years that the number of dentists with NHS contracts bears no relationship to the volume of dental services provided[59].

  25)  Since April 2006 there has been no registration of patients. Any cipher (such as the number of patients who visited a particular dentist in the last 24 months and have not seen another dentist since) is likely to be highly malleable and to have been arrived at because it gave the answer that was required.

  26)  Registration, measured using the new yardstick, confers no rights on patients.

NUMBERS OF PRIVATE SECTOR DENTISTS AND THE NUMBERS OF PATIENTS REGISTERED WITH THEM

  27)  All dentists in primary care (other than salaried dentists) are private sector dentists that sub-contract work from the NHS.

  28)  The proportion of turnover derived from private work is now greater than that from NHS work[60], but because private fee income per patient has stabilised at around three times that on the NHS, it is likely that NHS patients are still in the majority.

  29)  Dentists do not leave the NHS for financial reasons. They invest the extra profit in improving their quality of life by giving patients more time and using better quality materials and laboratory work. On average a private dentist earns £800 more each year than an NHS dentist[61].

THE WORK OF ALLIED PROFESSIONS

  30)  It is the DoH policy following from the Nuffield Report to hand off insofar as possible the routine care of patients to allied professions.

  31)  There has been an increase in the rôle of the allied professions in particular the hygienist/therapist which is the practitioner thought most likely to be able to assume the bulk of routine dental work currently carried out by highly trained and expensive dentists.

  32)  To this end registration and regulation of allied professions will be completed by July 2008.

  33)  The DPA sees a rôle for dentists as the leaders of clinical teams with ultimate responsibility for the patient's overall care. It is more efficient for dentists to be confined to those procedures for which only they are qualified.

PATIENTS' ACCESS TO NHS DENTAL CARE

  34)  The new contract was supposed to halt the drift of dentists away from the NHS. Every survey shows that it has failed to do so and that patients' access continues to deteriorate.

  35)  The abolition in April 2006 of charges for failed appointments was an ill-advised attempt to bring NHS dentistry in line with NHS practice. NHS dental patients accepted charges as reasonable and necessary for the proper operation of the appointment system and with very rare exception it worked reliably and well. It was a model for the rest of the NHS, not an aberration to be corrected.

  36)  The average dentist now loses time to the value of 600 UDAs (approximately £12,000 turnover) as a result. Failed appointments impede the access of other patients and result in underperformance. Fifty-two per cent of our practices report an increase in broken appointments averaging 35%.

THE QUALITY OF CARE PROVIDED TO PATIENTS

  37)  There is a common fallacy regarding dental work, which is that standards set by the General Dental Council ensure the uniform quality of dental work, whether provided on the NHS or privately.

  38)  The main differences between the quality of NHS and private work lie in the amount of time taken and the quality of materials and laboratory work. It is not true to say, therefore, that an NHS crown is the same as a private crown, only cheaper.

  39)  This misconception has led to many patients clamouring for NHS treatment on the grounds that it represents exceptional value for money. While that may be true, it is not for the reason generally assumed and once this is explained properly, far fewer patients choose NHS work.

  40)  It is incumbent upon any dentist to do the best possible job under the circumstances; however NHS constraints mean that the best possible job might not be the best job possible. In this, dentistry is no different from any other field of human endeavour.

THE EXTENT TO WHICH DENTISTS ARE ENCOURAGED TO PROVIDE PREVENTIVE CARE AND ADVICE

  41)  The mechanism of dental disease and the steps necessary to prevent it are well known. Prevention in dentistry works quickly, reliably and consistently.

  42)  Mechanisms exist in the private sector to deliver preventive care—in fact most third-party modified[62] capitation plans are built round such systems.

  43)  There is no reason so far as the DPA can see why NHS dentistry has not been modelled on an existing preventive system other than the DoH's aversion to implementing ideas that did not originate in-house.

  44)  A system of prevention in dentistry would produce oral health gains and financial savings much faster than could be expected in other medical specialities and would serve as a model for the NHS generally.

  45)  The key to prevention in dentistry is to give the practitioner a stake in the savings made. For example, a dentist who reduces his workload by (say) 20% due to prevention must not suffer a drop in income of 20% (as under the present and previous systems).

  46)  Prevention is consistent with registration, as a dentist must take responsibility for an improvement in the oral health of a cohort of patients and keeps a percentage of any savings made.

  47)  The so-called "5% reduction in workload" was more than swallowed up by increased administration and a greater than expected UDA target for children based on the false assumption that they all attend twice each year. In the current system no time is left for prevention.

  48)  To expect that a dentist will take time out of a target-driven system to carry out prevention is wishful thinking at best. Encouragement must come in the form of a system that rewards prevention, not exhortation.

DENTISTS' WORKLOADS AND INCOMES

  49)  The arrival of local commissioning calls into question the purpose of a Review Body when there is no agreed national pay rate, no universal scale of fees and 153 different commissioning bodies in England alone.

  50)  The Scottish may still find a need for an across the board pay increase but they have departed in many other ways from a DDRB-led pay system for NHS dentists. Twenty per cent of Scottish dentists' remuneration is now paid by way of grants from an open-ended budget.

THE RECRUITMENT AND RETENTION OF NHS DENTAL PRACTITIONERS

  51)  The DPA accepts that NHS recruitment and retention do not give cause for concern if using the number of dentists with an NHS contract as the yardstick. It is motivation to work wholly or mainly within the NHS that is the problem.

  52)  Measures such as an increase in dental student numbers, overseas recruitment and the returning workforce are not expected to have a significant impact on NHS availability.

NHS DENTAL REFORMS

  53)  The dental contract imposed in April 2006 is characterised by inefficiency, inflexibility and unfairness and has introduced a number of perverse incentives.

Inefficiency

  54)  The interpolation of a middle tier of management was an expensive, unnecessary and retrograde step. The desire to adopt a "command and control" attitude to the provision of public services owes much to a failed central Soviet style of management.

  55)  The question of whether the new arrangements represent adequate value for the taxpayer should be properly and expeditiously put in front of the National Audit Office.

  56)  Under the old system every dentist had a direct interest in cost saving. Under the new system an entirely different dynamic is operating, where expenditure is monitored at a level far removed from the activity.

Inflexibility

  57)  Under the old system a dentist could apply for permission to work in a PCT area and subject to a satisfactory application be in post within a very few weeks. Under the new system dentists may only apply where the budget exists and an application may have to be deferred until the next financial year. In the meantime the dentist may well apply elsewhere and a position may remain unfilled.

Unfairness

  58)  During the period for three years from April 2006 dentists will be paid a UDA value that is based on their historic earnings. Dentists that used to carry out many treatments per course will have high UDA values and dentists that used to carry out very few treatments will have low UDA values.

  59)  While the DoH maintains that historic treatment patterns will continue the DPA considers that this is most unlikely as dentists have in the past shown no hesitation to adapt to new ways of working. Dentists are having to meet identical targets for different contract values (even within the same practice).

Perverse Incentives

  60)  The number of complex treatments per course is dropping and this was flagged up as one of the intentions of the DoH in introducing the April 2006 contract. However the practitioner with a low UDA value and healthy patients will benefit much less from this effect than his neighbour.

  61)  Dentists with high UDA values benefit disproportionately by reducing their workloads. All dentists are discouraged from taking patients with high needs and chasing UDA targets conflicts with decisions based on clinical need. The disincentive to carry out complex treatments results in a de-skilling of the NHS workforce. These are a few examples of perverse incentives introduced by the new system.

  62)  Young dentists are now more likely to be delivering a core service of straightforward maintenance and not gaining a broad base of experience in their early years.

NHS DENTAL REFORMS—ONE YEAR ON

  63)  The notes below refer to a selection of assertions in this document which we believe are misleading or incorrect (figures in brackets refer to paragraph numbers in the document).

  64)  [1.1] Dentists were drifting away from the NHS but PCTs did not have the local funding to replace them.

  65)  It is true that dentists were drifting away from the NHS, however this was due to the increasing disparity in terms and conditions between the NHS and private sectors and not from lack of local funds.

  66)  [1.3] If a dentist ceases to provide NHS services, the local NHS is now able to bring in new services as a replacement.

  67)  Under GDS, funding followed the dentist, so when a new dentist moved into a PCT area the funding was automatically in place and the GDS budget was open-ended. Under the new system, funding is closed which prohibits any attempt at increasing access. Moreover if one dentist leaves, the PCT is left with the funding for one dentist, even if three are needed in the area. The new system is considerably worse than the old. PCTs would do well to concentrate on commissioning in areas of high need as that is all they are likely to be able to cover.

  68)  [1.4] PCTs have commissioned more services than were delivered in the last year of the old contract.

  69)  Services are now measured in Units of Dental Activity which are essentially empty courses of treatment. The commissioning of such units does not address the drop-off in treatment volume provided or the continuing access problems.

  70)  [1.5] There has generally been little shortage of dentists offering to expand their services . . . and an upward trend in the number of dentists providing NHS services.

  71)  The substitution of empty courses, for treatment items as a measure of productivity has (as intended) led to a temporary glut of UDAs. Initially dentists' appointment books were freed up as they found they could earn their points doing far fewer treatments. Rather than carrying out prevention they naturally used the extra time to create more UDAs towards their targets.

  72)  Once UDA targets were reached, it made good commercial sense to bid for more UDAs and this has led to a fall in the value of UDAs reflecting their lack of content. We consider that the value of a UDA will fall somewhat until it approaches the cost of production, at which time it will rise consistent with free market conditions of excess demand over supply.

  73)  [2.1] the location and volume of services were previously decided by dentists, not by the NHS.

  74)  Under the old system dentists took responsibility for establishing practices in areas that were dictated by the rules of the system in which they worked. These were mainly areas of high demand, since income depended on fees earned and we are still waiting for a satisfactory explanation of how to convert need into demand.

  75)  Dentists had a direct personal stake in the success of their practices and their large degree of autonomy meant that the relatively low business risk encouraged them to work within the NHS where they subsidised NHS practice in many cases from their private sector work.

  76)  It is not true to say that the "fee-per-item system created incentives for more invasive and complex treatment and increased costs—not consistent with reducing disease incidence[63]". Due to the surplus of demand over supply there was no incentive to create unnecessary treatment.

  77)  Under the new system, Primary Care Trusts dictate to dentists where they will work, which patients they will see and to whom they must sell their practice in case of ill-health or retirement.

  78)  The factors above have led to an increase in business risk which discourages most dentists from working wholly or mainly within the NHS.

POSSIBLE SOLUTIONS

VOUCHER SYSTEM

  79)  The Dental Practitioners Association (formerly the GDPA) has long been associated with a system of healthcare known variously as Grant in Aid or the Voucher System.

  80)  In this system the state makes a core contribution leaving dentists free to set their fees based on the service they wish to supply. As now, some dentists would work for core fees (for patients who are fully remitted or exempt or who want a basic NHS service) and other practices where patients would need to make a larger co-payment if (for example) they wanted a better quality material or prosthesis approaching private standards.

  81)  The patients' copayment would consist of their NHS charge plus any optional costs agreed with the dentist for better quality materials or laboratory work.

  82)  Before reading the following table it might be helpful to review para. 37 regarding the common fallacy about universal treatment standards.

Table 1

OBJECTIONS TO A VOUCHER SYSTEM WITH COUNTER ARGUMENTS

83)  It is divisive—the NHS is predicated on the idea of a universal standard of health care. If it is good enough for me it is good enough for you.      84)  This conspires against freedom of choice in health care and is a "levelling-down" argument.
85)  Thanks to GDC standards, NHS care is as good as private care only cheaper. 86)  See para. 37.
87)  The wealthy and intelligent must be forced to use the NHS as they are the only ones who will insist that standards are kept high. 88)  You cannot force anyone to use the NHS, and certainly not for the reason quoted.
89)  If the NHS caters for only part of the population then economies of scale will be lost for those which remain. 90)  As people leave the NHS more money is left to treat those who remain. The NHS is more than large enough to retain economies of scale.
91)  NHS money is being used to subsidise the private sector. 92)  All self-employed dentists work in the private sector and are subcontracted by the NHS.
93)  Dentists would use the variable copayment to confuse and overcharge vulnerable patients. 94)  This is a straightforward disciplinary issue.

REGISTRATION

  95)  The DPA would welcome the return of some form of registration of patients. Dentists do not like to see their patients on an ad-hoc basis and patients like to know who their dentist is and what rights they have. It is also consistent with the preventive cohort system (see para. 46)).

  96)  The contrived mechanism of recording the number of patients who attended within the last 24 months (and who have not seen another dentist) satisfies neither practices nor the patients.

CONSCRIPTION

  97)  The DPA strongly recommends against extending the already unpopular "command and control" approach further, by requiring every dentist to complete a stint in the NHS. An objective analysis of most dentists' lifetime NHS commitment will show that dentists already voluntarily work for the NHS far more than could reasonably be required of them under any scheme of conscription.

  98)  A conscription scheme would be disastrous for morale and have to overcome serious obstacles in relation to the symmetrical treatment of other groups trained at public expense but not currently forced to work in the public sector during periods of shortage.

ORAL EVIDENCE

  99)  To sum up the problems of the current system and possible solutions in such a short document has been a considerable challenge and inevitably there are many important areas which have suffered.

  100)  Regulation 19 of the National Health Service (General Dental Services) Regulations 1992 imposes a requirement on the Secretary of State to consult with an organisation that is most representative of dentists working within the GDS. Note the use of the word "an". This has been used by DoH to exclude organisations such as the DPA from supporting and representing our members on terms and conditions, to the detriment of all concerned including our NHS patients.

  101)  The Health Select Committee has no constraints and, having given oral evidence in the past, the DPA respectfully asks that it is called to give oral evidence on this occasion as an organisation which is representative in the main area of this Inquiry.

ACKNOWLEDGEMENTS

  102)  The Dental Practitioners' Association welcomes the opportunity to discuss this document with any interested party.

  103) The lead practitioner on this document is: Dr Derek Watson BDS LDS RCS DGDP, CEO, Dental Practitioners Association.

December 2007







59   "The numbers of dentists providing NHS services is a relatively weak indicator: it is the volume of services they provide for the NHS that is more important" DoH evidence to 37th Review Body, para. 6.11 Back

60   Source: National Association of Specialist Dental Accountants, figures for April 2005-March 2006. Back

61   Source: Information Centre for Health and Social Care. Back

62   Third-party capitation plans are called "modified" because the risk that patients might suffer a catastrophic dental accident is subcontracted to an insurer. Back

63   DoH evidence to 37th Report of DDRB Back


 
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