Memorandum by the NHS Confederation (DS31)
NHS DENTAL AND ORTHODONTIC SERVICES
The NHS Confederation represents more than 95%
of the organisations that make up the NHS. We are the independent
membership body for the full range of organisations that make
up today's NHS across the UK. Our members include Primary Care
Trusts, NHS Trusts, NHS Foundation Trusts and independent providers
of NHS services.
The NHS Confederation welcomes the opportunity
to give evidence to the Health Select Committee on NHS dental
and orthodontic services. This evidence sets out our views, based
on feedback from a cross section of our members, particularly
those provided by members of our PCT Network. We are also providing
case studies from two of our members, which are included as appendices.
The NHS Confederation is of the view that the
contract for NHS dental services has the potential to deliver
PCTs have lacked the capacity to
realise the potential of the contractboth in management
resource and access to dental public health expertise. PCTs will
be aiming to address this shortfall as part of the World Class
Commissioning programme, currently underway.
There is an opportunity to consider
the future direction of dental services within the Primary and
Community Services Strategy, which is being produced as part of
the Department of Health's Next Steps Review Commissioning.
PCTs need to consider dental services
alongside all their other local priorities. We estimate that it
would cost £2.3 billion
to introduce full coverage of NHS dentistry across the country.
Clinical engagement is crucial; where
good relations are developed, good performance management arrangements
are usually in place.
This is especially important to improve the quality of services.
Incentives for prevention and health
promotion should be strengthened.
Funding needs to be reviewed due
to the shortfall created as a result of less income from patient
charges than expected and due to the consequences of allocations
based on historical activity.
This is particularly significant in the run up to 2009 when PCT
allocations for dentistry cease to be ring-fenced.
The origin of the problems in accessing NHS
dental services stems from the reforms in 1990 which changed the
way dentists were paid, lining payments to the numbers of registered
patients. Due to the large numbers of patients registered, (far
more than planned for) fees were cut in 1992 and significantly
reduced the earnings of dentists. The consequence of this was
that dentists drastically reduced their NHS work, and many turned
exclusively to private practice.
The Health and Social Care Act 2003 required
that, "each Primary Care Trust and Local Health Board must,
to the extent that it considers necessary to meet all reasonable
requirements, exercise its powers so as to provide primary dental
services within its area, or secure their provision within its
The protracted nature of the negotiations between
the Department of Health and the British Dental Association meant
that this only came into effect from April 2006.
However, these reforms probably represent the
most radical reform of NHS dentistry since 1948. The devolution
of funding to PCTs, alongside the statutory duty to commission
services provides opportunities to tailor services to meet local
health needs. This potentially enables PCTs to redress the uneven
distribution of dental services in some areas which has arisen
because previously dentists have been able to set up practice
in areas of their choice rather than in areas of greatest need.
The reforms are intended to address three key
1. Access to servicesby putting PCTs
in charge of commissioning.
3. Simplify patient charges.
Patients now pay standard changes (3 bands)
and dentists have a contract with the PCT to provide an agreed
number of units of dental activity (UDAs) per year. This replaces
the 400+ different patient charges in the previous contractual
The financial allocations for the contracts
were based on historic spend in 2003-04 and have been ring-fenced
for dental services until 2009. No additional resources were made
available to areas with higher needs. PCT budgets were also adjusted
(downwards) in line with anticipated income from patient charges.
This has caused additional financial pressure in some areas of
From 2009 the resources will be part of the
PCT general allocation.
1. The role of Primary Care Trust's in Commissioning
1.1 There is no consistent national picture
on the implementation of the reforms. This may be due to a range
of factors, not least that the changes coincided with the reconfiguration
of PCTs, but also the following:
1.1.1 A wide variation in the financial pressures
that have resulted from the implementation of the new contract
have been of major concern to some of our members and could potentially
affect their future commissioning plans. The principle reason
is the new arrangements for patient charges. PCTs had their resource
allocation reduced based on the anticipated income from patient
charges. This was predicted to be £634 million, however only
£475 million was actually payable during 2006-07. The lack
of revenue from patient charges appears to be due to dental practices
seeing more "exempt" patients (including children) than
predicted, who make no contribution to their treatment. This has
led to a significant financial shortfall for PCTs, who are faced
with uncertainty in relation to which patients will require NHS
treatment. This has affected many areas with high levels of deprivation
and, therefore, high levels of need. In a few cases PCTs are facing
the possibility that they may have to reduce the current level
1.1.2 The capacity of PCTs to use the new
contract has been raised by our members as a key concern. In the
light of the wide range of performance measures faced by PCTs
there is a danger that dental services commissioning is not necessarily
regarded as a mainstream issue.
1.1.3 Many PCTs have historically allocated
limited resources to manage dental services. Dental contracts
are often the responsibility of relatively junior managers, who
have a contract management role and little involvement in strategic
planning within their organisations. Their initial focus has been
to ensure that contracts were in place. Where dentists have left
NHS provision, new contracts have been let, but on the whole these
have just re-provided the previous services. In some areas only
two staff are responsible for managing 120 practices with 140
contracts. Should these staff leave, a lack of organisational
memory could compromise the commissioning and performance management
role of the PCT.
1.1.4 The limited access to dental public
health advice is also of concern to some members. The number of
Dental Public Health Consultants is decreasing at a time when
their input is of increasing value as PCTs are required to make
the shift from contracting to commissioning.
1.1.5 Some PCTs have extremely good relationships
between the PCT, Local Dental Committees and/or dental contractors.
Despite low levels of human resource, these areas have put good
performance management arrangements in place. Other areas have
extremely poor relationships and have limited arrangements.
1.2 Some members feel that the contract
itself offers sufficient opportunities for local commissioning
and that the utilisation of a balanced scorecard approach, which
measures whether the activities of an organisation are meeting
its objectives in terms of vision and strategy, alongside a clear
commissioning strategy, provides the potential to develop services
appropriate to local needs. However, other areas are not so positive,
and the key appears to be long standing good relationships with
1.3 The commissioning of dental services
must be considered as part of the Department of Health's World
Class Commissioning work programme or they will continue to be
regarded as a separate responsibility outside of mainstream commissioning.
2. Numbers of NHS dentists and the numbers
of patients registered with them
2.1 Our members report that they have few
concerns about the number of NHS dentists, but are concerned about
the lack of information about the availability of NHS dental services.
In areas where contractors have not signed contracts, or have
since left the NHS they have had no difficulty in re-tendering
the contracts. In many cases they have been able to commission
2.2 In London, where dentists did not take
up new contracts for 3% of services, PCTs have already been able
to replace all of these services by commissioning new or extended
services from other dentists.
2.3 National and SHA level information on
dental activity is provided by the Information Centre, who publish
statistics quarterly. It should be noted that the information
on the new contract is not directly comparable with the information
collected under the old contract.
2.4 We have used a simplistic calculation
to give an indication of the cost of covering the entire population
(100%). 55.7% (51.5% of adults and 70.7% of children) of the population
in England were seen by an NHS dentist in the two years to March
2007, which equates to 28.1 million people (20.3 million adults
and 7.8 million children). Treating these patients amounted to
a maximum total expenditure of £2,3978 million. Therefore,
it would cost £4,656 million if 100% of the population were
to be covered, which would require an increase of £2,258
million in funding. We readily acknowledge the simplicity of this
argument. A large number of patients, perhaps as high as 20%,
never access a dentist, although we would like to see this figure
fall. Some will choose to go privately and the way in which the
figures are reported is not necessarily indicative of need. However,
we thought it might be of interest to the Committee to have a
rough estimation of the cost of providing NHS dental treatment
to all. Clearly, PCTs would need to consider this call on their
resources alongside all their competing priorities.
4. The work of allied professions
4.1 Allied professions are an underused
resource and, as Western Cheshire PCT note in their case study
under Appendix B, it is necessary to have the benefits of a larger
scale operation in order to take full advantage of the benefits
of team working.
5. Patients' access to NHS dental care
5.1 Improved access to NHS dental services
is one of the key aims of the new contractual arrangements. Responsibility
for this has now been passed to PCTs from the dental profession.
It is important to recognise that not all PCTs have problems with
access. In fact, PCTs in London are addressing the issues raised
by a shortage of people coming forward to seek dental care rather
than a shortage of service provision.
5.2 An important part of the problem of
patient access is the lack of easy access to information about
the availability of NHS dental services, which is well documented
in the Citizen's Advice Bureau report "Gaps to Fill".
Many patients are unclear about how to find a dentist, despite
some PCTs managing central waiting lists and national campaigns
on NHS Direct and NHS Choices websites. Recent media reports with
examples of a patient resorting to superglue for dental treatment
actually occurred in an area where the PCT reports no difficulties
with access to NHS services.
5.3 PCTs are finding innovative ways of
addressing access problems. The benefits of operating a central
waiting list are documented in Appendix A, which is a case study
provided by Lincolnshire PCT, which has been able to offer 46,000
patients an NHS dentist. There are also many examples in London
where PCTs have implemented specific schemes aimed at improving
access. Tower Hamlets PCT has a dental access project which uses
mobile dental surgeries staffed by the salaried service. People
are dentally screened, and, if living in an area of low provision
of dentistry receive NHS treatment. This pilot has proved to be
very popular with the public.
5.4 In addition, all London PCTs directly
provide or commission a Salaried Primary Care Dental Service which
is able to deliver special care dentistry for vulnerable groups
and people with special dental needs. These services are variable
in their ability to respond to local needs, working to varying
5.5 Tackling inequalities to access to dental
care will require a range of initiatives to address the barriers
towards dental care and may require additional resources over
time to address uptake in areas of social deprivation and higher
unmet need and amongst vulnerable groups.
6. The quality of care provided to patients
6.1 Ensuring the quality of care provided
to patients is a key issue for PCTs. The first year of the contract
has naturally focused on agreeing contract values with practitioners,
and re-tendering contracts where dentists chose to leave the NHS.
In order to address quality issues many PCTs require additional
capacity. It is essential that PCTs engage with the profession
and their current capacity does not always support this. Further
improving the quality of care will be addressed as PCTs increase
their capacity to use the contract imaginatively.
7. The extent to which dentists are encouraged
to provide preventative care and advice
7.1 All PCTs have groups working on local
oral health strategy and will be working with key stakeholders
9. The recruitment and retention of NHS dental
9.1 PCTs have not encountered problems with
the recruitment of NHS practitioners. Members report healthy levels
of competition when re-commissioning services. They also report
that contractors have been able to recruit to posts when they
have become vacant.
64 See paragraph 2.4 for further detail. Back
See sub-paragraph 1.1.5 for further detail. Back
See paragraph 1.1 for further detail. Back
See paragraph 5.2 onwards for our views on this issue Back