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.
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,
consistent with our 2005 research. While most had gone for a routine
check-up or non-emergency appointment, one in ten had sought an
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,
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:
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
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
16% of practices in rural/ "mixed"
areas were taking all NHS patients compared with 39% in urban
23% of practices in rural/ "mixed"
areas were only taking on certain patients compared with 9% in
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
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
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
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
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
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
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
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.
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
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
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
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