Select Committee on Health Written Evidence

Memorandum by Which? (DS 33)


About Which? and our research on dentistry

  1.  Which? is an independent, not-for-profit consumer organisation with over 680,000 members. This makes us the largest consumer organisation in Europe. Entirely independent of government and industry, we actively campaign on behalf of consumers and are funded through our membership and the sale of our consumer magazines and books. 2007 marks our 50th anniversary.

  2.  Which? has undertaken extensive research into consumers' access to NHS dentistry and how the private market works for consumers, which has established us as the leading patient and consumer voice on dental services. We were members of the Department of Health Advisory Group on the reform of patient charges for NHS dentistry. In 2001, we submitted a supercomplaint to the Office of Fair Trading about the private dentistry market leading to a market investigation and a range of reforms including establishment of an independent complaints scheme for private dentistry.

  3.  Which?'s over-riding objective is that everyone should be able to get good quality oral healthcare when and where they need it, irrespective of their ability to pay. For many this will be access to NHS care, but for some it will be private care. If people choose private dental care, we believe they should have clear, transparent information about what treatment is proposed and its likely cost before any treatment commences.

  4.  This submission draws on our work over the past year to assess impact of the new NHS dental contract on consumers' access to care. This includes:

    —  "Mystery shopping" investigations into access to NHS care for routine and emergency care (repeating research undertaken in 2001 and 2005).

    —  Survey research on consumers' experiences of seeking dental care.

    —  Information from 130 of the 152 Primary Care Trusts (PCT) about what they have done to identify and meet the dental health needs in their local area[74].

    —  Letters and emails received from consumers in 2007 about their experiences of dental care.


  5.  Significant new investment in NHS dentistry and the introduction of a new NHS dental contract in 2006, together with PCT commissioning of services, have yielded slight improvements in consumers' access to NHS dental care. However, difficulties in access persist for many, particularly in certain areas of the country. These inequalities are exacerbated by a system for allocating funds to PCTs based on historic levels of NHS dental provision.

  6.  To address continuing access difficulties, Which? would like to see the allocation of PCT funds for dentistry based on community needs. Measures are also needed to ensure that anyone who cannot obtain NHS care is not left without any dental care because they cannot afford private treatment.

Consumers' experiences of current dental services

  7.  Which? research consistently shows that while most people try to get dental care every year, a significant proportion do not. Most recently, our 2007 research shows that almost two out of three people (64%) tried to get a dental appointment in the past 12 months,[75] consistent with our 2005 research. While most had gone for a routine check-up or non-emergency appointment, one in ten had sought an emergency appointment.

  8.  Reasons for not going to the dentist in the past year include difficulties in finding an NHS dentist in their area and the cost of treatment, as well as many feeling it was unnecessary because they had no problems with their teeth or they no longer had any natural teeth. The fact that not everyone wants to go regularly to the dentist highlights the need for a range of models of provision for dental care.

  9.  Over the past year, many consumers have told Which? of the difficulties they face difficulties getting dental care. For a few, this means difficulties accessing any sort of care, private or NHS. As one consumer told us:

    "Instead I found, after much difficulty, a private practice 60 miles away that would take me on. I have paid them four thousand pounds in just over two years, for very caring and painless treatment but I cannot afford this much longer. I have been on the waiting list for a local NHS dentist all this time." (Email from consumer, February 2007)

  10.  Surprisingly, a significant proportion of those who tried to get dental care (38%) did not even try to get NHS care. We do not know why some people do not automatically seek NHS dental care. It may be because their usual dentist no longer provides NHS care or they feel private treatment provides a better option. Or it may be they believe trying to find NHS dental care will be just too difficult.

Most can get NHS care easily

  11.  The good news from our 2007 research is that most people trying to get NHS dental care found it easy (68%) and the majority of people who sought NHS care (87%) did ultimately get an NHS appointment. However, there were marked regional variations, ranging from 95% in the North and 90% in London to just 75% in the South-West. Individual consumers have also told us about their positive experiences of finding NHS dental care, often to their surprise.

Difficulties with access to NHS care persist

  12.  However, difficulties getting NHS dental care still persist for many, particularly in certain parts of the country. Our 2007 research shows just over one in four people (26%) seeking NHS dental care said they found it difficult, with 16% saying they found it very difficult. Those seeking emergency treatment are more likely to say it was difficult: 38% compared with 25% for non-emergency treatment. Consumers have told us of their particular difficulties when moving to a new area or having to look for a new dentist when their current dentist retires or gives up NHS practice.

  13.  Results from our situation research in late 2006,[76] bear out this picture of difficulties finding NHS dental care. Just over one in three practices (36%) were taking on all NHS patients, with a further one in ten practices (11%) were taking only certain NHS patients, primarily children, those on benefits or exempt from charges.

  14.  Just over half (51%) of all dental practices contacted in England were not taking any new NHS patients. While this is a slight improvement on the 2005 level (58%), it is still not as good as the 2001 position when only 41% of practices were not accepting any NHS patients.

  15.  The main reasons given in our 2007 research for difficulty in finding NHS treatment were:

    —  Fully-booked/ not taking on new patients: 38%

    —  Gone/ are private: 25%

    —  None in the area: 24%

    —  Long waiting list: 6%.

  We continue to hear of dentists giving up NHS practice, leaving people feeling forced into private dental plans or schemes or faced with the choice of having to find a new dentist.

  16.  Getting NHS care can often mean long journeys, with mentions of trips as long as 60 miles or a round trip of 100 miles (although an improvement on the previous journey of 175 miles). Having to travel long distances for care can result in significant additional costs, particularly for families or those facing a long course of treatment, which are not reimbursable for those on low incomes under the HC11 scheme. It also acts as a disincentive to seek regular care.

Significant regional variations in the availability of NHS dental care

  17.  Underlying these results is a picture of significant regional variations in access to NHS dental care. People in London were least likely to have tried to find a dentist (48%), whereas those in Yorks and Humberside were more likely to have sought care (66%). With the exception of London, people were least likely to have sought NHS dental care in areas where access was difficult: only 57% in the South-East and 58% in South-West had tried to get NHS care compared with 71% in East Anglia. Access to NHS care was easiest in London and East Anglia, with 76% and 80% respectively saying it was easy compared with just 56% in South-West.

  18.  Results from our "mystery shopping" in 2006 support the picture of wide regional variations in access to routine and emergency NHS care, with the situation appearing best in London:

    —  The number of practices not taking on any NHS patients ranged from 80% in Yorks and Humberside and 75% North West to 28% in the West Midlands and London.

    —  The number of practices taking on all NHS patients ranged from 63% in the West Midlands and 59% London, to just 13% in the North-West, 15% in Yorks and Humberside and 16% in South Central, which was worse than average.

    —  Over one in five practices in the South-West (22%) and South Central (23%) said they were only taking certain NHS patients compared with 11% for England as a whole.

    —  88% of practices in London could offer an appointment within two weeks compared with 65% for England as a whole.

    —  For access to emergency care:

    —  Only 5% of practices in the South-West and North-West could offer an appointment within 24 hours compared with 27% in the North-East and 29% in London.

    —  Practices not offering any appointment at all ranged from 80% in the North-West to just 18% in London.

  19.  Difficulties in accessing NHS dental care also appear to be worse in rural/ "mixed" areas than in urban areas, resulting in consumers often having to travel significant distances to get NHS care. We found that:

    —  59% of practices in rural/ "mixed" areas were not taking all NHS patients compared with 49% in urban areas.

    —  16% of practices in rural/ "mixed" areas were taking all NHS patients compared with 39% in urban areas.

    —  23% of practices in rural/ "mixed" areas were only taking on certain patients compared with 9% in urban areas.

Consumers are unable to get certain treatment on the NHS

  20.  Consumers have told us that they have been refused certain treatments under the NHS or can only get NHS appointments at certain times of the day or week. Treatments refused include some of the more complex treatments such as crowns, dentures and bridges, and a refusal to undertake scale and polish under Band 1 treatments. People have also said that they have been asked to pay extra to get better "quality" materials than those available on the NHS.

  21.  Particular concerns exist about the availability of orthodontics care, with consumers confused by apparent inconsistencies in assessing whether individual children qualify for NHS care or not. But even if children are assessed as qualifying for NHS orthodontic care, they cannot always obtain it. In these cases, the high cost of private orthodontics care puts this treatment beyond the reach of many families.

Failure to get NHS care can mean having to go private or going without

  22.  Our 2007 research shows that if people cannot get NHS care, they are faced with either going private (7%) or going without (4%). Again there are marked regional variations with just 2% in the North going private compared with 13% in East Anglia. More people (9%) in the South-West said that they went without treatment.

  23.  For some, private treatment seems the only option, but this is often expensive and beyond the pocket of some consumers, particularly those on low or fixed incomes, or those exempt from charges for any NHS treatment. Signing up to a private dental scheme will incur monthly charges, which can be particularly high for people with poor dental health as premiums are usually related to dental health status. We have been told of consumers having to pay premiums such as £35 per month for a retired person and £50 per month for a retired couple. Alternatively, people may self-pay and face significant costs ranging from about £70 for a single filling to several hundred pounds for a crown or root canal treatment or even over a thousand pounds for a replacement bridge. Consumers who have to pay for private care often feel considerably aggrieved at what they see as having to pay twice (through taxes and private dental charges) for NHS care to which they feel entitled.

  24.  If people decide to put off having dental treatment because of difficulties getting care, their actions are likely to result in worsening dental health, which can mean relatively small problems become more serious. This often results in a reliance on emergency care to deal with problems when they can no longer be ignored, but even getting emergency NHS care can be difficult. Our research[77] shows that only 15% of practices could offer NHS treatment within 24 hours. A further 9% of practices could offer an NHS appointment but not within 24 hours, but 23% of practices could offer only a private appointment. We have received disturbing reports from consumers that deferring dental treatment because of difficulties in getting NHS care has resulted in having to have extractions, even in quite young adults.

The role of PCTs in commissioning dental services

  25.  Which? believes that PCT commissioning of NHS dental services provides the opportunity for a more systematic approach, allowing local NHS dental provision to be related to the local community's needs. However, the current system for allocating PCTs funds for dentistry is based primarily on historic levels of NHS provision in that area, and perpetuates existing inequalities of provision. In a patient-centred NHS funds for dental care should be related to community needs, both in terms of population size and the extent of dental health needs. Until there is a fairer allocation of funds between areas, major inequalities in provision will persist.

  26.  Our review of what PCTs have done to commission dentistry since introduction of the new contract has highlighted a very mixed bag of performance. Some PCTs have made major efforts to undertake dental health needs assessment, monitor complaints of unmet needs, calls to dental access centres and the PCT, and undertake patient satisfaction surveys. Some have used the resources released by dentists not taking up the new NHS dental contact to commission new services to meet unmet needs, or to focus on areas of particularly high dental health need or groups with special needs.

  27.  In terms of meeting needs of people without a regular dentist, some have established helplines, used significant resources to publicise services, or teamed up with the local Patient Advice and Liaison Service. Some have specifically commissioned open access slots at practices for people without a regular dentist, or have established dental access centres. Similarly, in order to meet urgent dental care needs, some have commissioned services to meet urgent unscheduled care needs as well as using dental access centres and out-of-hours triage systems. Many rely on NHS Direct to direct patients seeking dental care to appropriate local services both in-hours and out of normal surgery hours.

  28.  As the capacity of PCTs develops, so they should be better able to commission dental services to meet local needs. However, we are concerned that PCTs do not have sufficient expertise or capacity to take on a proactive role commissioning local NHS dental services, and are concerned about the impact of removing ring-fencing for dentistry in 2009. For many years dentistry has been afforded a low priority within the NHS, so we are concerned that when it is competing directly with other types of healthcare, it will not fare well.

Consumers need better information about dental services

  29.  Which?'s recommendation to anyone facing difficulty getting NHS dental care is to contact the PCT or NHS Direct. Our 2006 research shows that where people could not get an NHS appointment, two-thirds were given advice about how to find NHS treatment. Most commonly this was to contact NHS Direct (29%), but other suggestions included contacting another dental practice (19%) or the PCT (17%). Where people needed emergency care they were most often referred to a dental access centre or to NHS Direct. Accessible information about how to access NHS dental care will significantly benefit consumers, particularly those who feel there is no point in trying to get NHS care because it is just too difficult.

  30.  Consumers also need clear information about what dental care might cost. One benefit of the new system of NHS charges is to provide greater clarity about the cost of NHS treatment and current NHS charges should be displayed in every practice. But considerable confusion still exists about what dental treatment the NHS will cover and what it will cost.

  31.  A key part of our 2001 supercomplaint on private dentistry was the lack of transparent information, particularly about treatment costs. Despite requirements that practices should display indicative prices and provide written treatment plans and cost estimates prior to treatment beginning, this does not happen consistently. Enforcing this at a national level is impossible, but local Trading Standards may a role in ensuring that consumers receive clear information about dental treatments and its likely cost.

Key concerns about current dental policy

  32.  Our biggest concern about current dental provision is that access to NHS care is very much a postcode lottery, with many people not even trying to get NHS care. If dentistry is to remain an integral part of the NHS, this must be tackled urgently.

  33.  We are concerned that the current remuneration scheme for dentists clearly acts as a disincentive to provide more complex or extensive treatments under the different banding levels. This causes particular hardship to those who cannot afford private care or to supplement NHS care for these treatments.

  34.  We question whether greater focus should be placed on those with the greatest dental health needs. Poor dental health is closely related to socio-economic status and there is a danger of creating an underclass of people who cannot access any dental care because they cannot find or travel to get NHS care and cannot afford private care. As well as PCT commissioning, Which? suggests consideration should be given to spot-commissioning of services where the likelihood is that an individual will go without treatment.

  35.  Finally, we believe that much greater clarity is needed about what treatments are covered by the NHS and how to access them. An open and honest debate about the extent of NHS dental care is clearly needed.

December 2007

74   At the end of 2006 we wrote to all PCTs requesting information about what they had done to assess local dental needs; what they had done to commission services to meet those needs; what arrangements are in place to assist people obtaining NHS dental care in your area; and what arrangements exist to assist people to find urgent NHS dental attention. This was followed up by a Freedom of Information request in late November 2006. Back

75   Which? Omnibus research (2007): A representative sample of 2110 people were interviewed across the UK through the BMRB telephone omnibus survey in March 2007. Back

76   Between 6 and 10 November 2006, 466 calls were made to a random selection of dental practices from the 10 Strategic Health Authorities in England to find out whether they could be taken on at the practice as a new NHS patient. For each SHA, we randomly selected two to four PCTs aiming to achieve 40 calls in each area (80 within London). Back

77   Between 13 and 17 November 2006, 455 calls were made to a random selection of dental practices from the 10 Strategic Health Authorities in England to find out whether or not they would offer an emergency NHS appointment. For each SHA, we randomly selected two to four PCTs aiming to achieve 40 calls in each area (80 within London). Back

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