Memorandum by British Dental Health Foundation
1. The new dental contract introduced in
April 2006 was the most fundamental change to the system of delivery
of NHS Dentistry since the inception of the NHS. It followed a
long term review and far sighted reports such as "Options
for Change" which had promised a radical move away from the
perceived treadmill of NHS dentistry and a "drill and bill"
model towards an approach which was patient centred with an emphasis
on prevention. Personal Dental Service pilots were supposed to
trial the proposed changes but in the event much of the funds
allocated for these trials were hijacked to the provision of Dental
Access Centres to try (with no possible chance of success) to
fulfil the Prime Minister's pledge of NHS Dentistry availability
2. The new contract when it was finalised
failed to implement many of the proposals contained in "Options
for change" and has implemented a new simplified "drill
and bill" structure.
3. Following such a major change it would
have been expected that some parts of the new contract would work
well and others would need further development and adjustment.
The unwillingness of the Department of Health to consider any
significant and meaningful changes to the system imposed in April
2006, assuming that they got it all right first time round is
to be deplored.
4. In practice whilst lip service is given
to greater emphasis on prevention this has not been recognised
within the payment system and an opportunity has been lost.
5. The charging system for patients has
been simplified but in the process when combined with the UDA
system the effect is that patients are in general paying more
for similar treatment than they were doing prior to institution
of the new contract.
6. The simple three band UDA system has
introduced perverse drivers into the system with radical reductions
in the levels of complex treatment provided under band 3, little
or no molar endodontics and an increased incidence of extractions
and provision of partial dentures.
7. Local commissioning whilst admirable
in principle has in many cases led to insecurity for practitioners,
uncertain career pathways for the newly qualified dentist and
has failed to address differences in the cost base of practice
across the country.
8. The removal of ring fencing for dental
funding to PCTs in 2009 combined with a perceived downward pressure
on UDA values is perceived as presenting a real threat to those
dentists continuing to work within the health service and to the
availability in the future of a quality NHS Dental Service for
9. Lack of provision of NHS orthodontics
remains a major concern and the new contract has made an already
appalling situation of undersupply far worse. The problem here
is, however, a chronic one and can only be solved in the long
term by the provision of more training places for orthodontists.
1. The British Dental Health Foundation
is the UK's leading charity dedicated to the promotion of good
oral health by the population. It was formed in 1971. The charity
receives no government funding. It runs a national dental helpline
answering over 40,000 patient enquiries a year, distributes over
a million patient education leaflets a year and runs two major
annual awareness campaigns, National Smile Month, established
31 years ago and Mouth Cancer Awareness Week. The author of this
evidence, the Chief Executive Dr Nigel Carter was a practising
dentist for over 20 years and is a member of the New Dental Contract
Implementation Group by invitation of the then Minister of State
Rosie Winterton MP (now Key Stakeholder Group).
2. The Role of PCTs in Commissioning Dental
2.1 In principle devolution of commissioning
of dental services to a local level is to be welcomed, but in
practice the effectiveness of this measure has been very mixed
across the country. Some PCTs have embraced their new role and
appear to be using the funds available effectively to provide
high quality services within their area whilst others do not appear
to have adapted so well to their now role and are showing little
in the way of innovation and good practice.
2.2 A real opportunity was missed in development
of the new contract to redistribute funds or allocate new funds
to ensure equality of provision across the country. If a PCT had
low levels of provision of NHS Dental Services prior to the Institution
of the new contract the funding they received did not allow them
to address this imbalance.
2.3 Where contract values come up for re-allocation
the ability of the PCT to determine where they wish to provision
new services is to be welcomed since this can address areas of
previous lack of provision within the community and to shape the
service to meet need. This is being implemented with various degrees
2.4 Some PCTs are concerned about their
levels of patient charge revenue (PCR) and as a result have not
been reallocating units of dental activity to provide improved
access but instead have kept the funding to mitigate any PCR shortfall.
This is to be deplored since it prevents extension of provision
to those wishing to find an NHS dentist.
2.5 It is a matter of concern that where
units of dental activity (UDAs) are returned to the PCT there
seems in many cases to be a wish to retender for this provision
on a lowest cost base. Whilst this may appear to potentially allow
for additional provision, in practice if pursued this course will
lead to provision of a poorer level of service by the contractors
and a tendency to exclude those patients not currently accessing
the service who may have the greatest need for treatment and be
uneconomical for the practitioner at low UDA levels.
2.6 The reorganisation of PCTs which took
place in the first few months of the contract was counterproductive
to efficient delivery since staffing changes in many cases meant
that developing knowledge and skills in the dental arena were
2.7 The number of Consultants in Dental
Public Health has been severely reduced since the introduction
of PCTs. Many consultants are split over several PCTs on a part
time basis and with a lack of consistency of direction are hampered
in delivering effective advice.
2.8 Some Strategic Dental Health Authorities
do not even have an identified dental priority or lead which is
an appalling state of affairs.
2.9 The ability of PCTs to adequately monitor
dental practices is of some concern especially when it comes to
items such as infection control procedures.
2.10 PCTs have responsibility for provision
of out of hours service. In some cases this is difficult to access
and inadequate. More robust systems need to be in place.
3. Numbers of NHS Dentists and the number
of patients registered with them
3.1 Following the initial fall out of dentists
who did not accept the new contracts offered to them the numbers
of dentists appear to having remained substantially stable. It
is discouraging, however, to now see an increasing number of dentists
either leaving or planning to leave NHS Dentistry. This trend
appears to be greatest amongst the most experienced practitioners
who see the potential for selling their practices within the NHS
(traditionally part of their retirement planning) to be diminished
by PCT control over whether a contract would be offered to their
successor and at what level.
3.2 2009 when the dental budget for PCTs
loses its ring fencing is seen by many as a great threat. At this
stage the PCTs will be able to renegotiate contract values with
the practitioner and many feel that this will lead to a general
reduction in value per UDA and thus their income for similar levels
3.3 Traditionally practices grew based on
the perceived demand for that practice's services and new dentists
were then taken on as appropriate. This ability for dynamic expansion
has been removed from practitioners under the new system as their
income is effectively capped. The only alternative left to a practitioner
in many cases to expand their practice is by increased private
3.4 Many vocational dental practitioners
were taken on as associates by their training dental practice
at the end of their period of training. This allowed for further
development of the skills of newly qualified dentists within a
supportive environment. In the vast majority of cases this further
employment cannot now take place as there are not additional funds
available for the expansion of practices in this way.
3.5 Patients are of course no longer registered
with a dentist but attend for only one course of treatment at
which time their relationship with the practice may be terminated.
This move away from the concept of continuing care implied by
registration under the old contract is to be deplored since it
does not encourage regular attendance and a preventive approach.
3.6 The initial period of the new contract
saw some practitioners leaving the NHS and refusing to take up
the new contract. This amount to about 4% of provision. Whilst
not large this could be seen to equate to over one million patients
disenfranchised at this point.
3.7 Whilst recommissioning of the lost UDAs
may have been successfully achieved was in many cases slow to
take place and even slower to come on stream. As a result the
total number of UDAs delivered at the end of year one did not
meet targets and patient's access must have worsened as a result.
4. Numbers of Private Sector Dentists and
the number of patients registered with them
4.1 As seen in 3.6 a number of NHS dentists
totally left the NHS system at the beginning of the contract.
4.2 Since the early months of the contract
the perception is that the number of dentists leaving the system
has reduced, although there are still conversions to private practice
4.3 Current estimates are that six to eight
million attend for dental people privately, some 21% of the total
number of regular attenders.
4.4 Two main threats appear to exist to
ongoing commitment of dentists to the NHS going forward. The first
of these is the perception that their level of income will be
potentially reduced in 2009 when PCTs are free to negotiate revised
UDA amounts. The second of these is the perceived threat to goodwill
value by these changes in 2009. Both of these factors may be considered
likely to influence some dentists to leave the NHS.
4.5 The current patient charge system may
be seen in a number of cases to encourage private dentistry since
the fee payable by the patient privately may be less than that
on the NHS.
5. The work of allied professions
5.1 It is too early to determine the impact
of the wider registration of dental professionals on the skill
mix and delivery of NHS Dentistry.
5.2 Some early indications with effective
"capping" of NHS income was that dentists were choosing
to make less use of dental care professionals with associated
salary cost to deliver their targets. This would potentially have
an adverse effect of both the DCPs, in this case largely hygienists
and therapists, and the level of preventive care provided to patients.
5.3 The reduction of quantity of Band 3,
complex treatments involving laboratory work, has led to many
dental laboratories going out of business or having to drastically
5.4 The lack of commitment to dental technician
training over the last 20 years, combined with an increasing tendency
to have technical work carried out abroad in the new EU accession
countries or the Far East on a lower cost base could lead to almost
annihilation of the dental laboratory industry in the UK.
5.5 Extended duties for the newly registered
dental nurses could help to improve productivity of the scarce
dental workforce but this is unlikely to be embraced by the profession
unless additional funding is also provided.
6. Patient's Access to NHS Dental Care
6.1 Over one million patients were disenfranchised
by the failure of dentist to take up NHS new contract offers.
Whilst this work has been recommissioned it is not always in the
same areas and in many cases has been slow to come on-stream.
6.2 Figures at April 2007 the first anniversary
of the contract showed 50 000 patients less being seen. More worryingly
the latest Department of Health figures show 250 000 less patients
being seen in the two years to September 2007 than in the period
prior to the contract. It is worrying to consider that if this
increase is extrapolated by the end of two full years of the contract
as many as half a million patients may have lost access to care.
6.3 Much work has been carried out by the
Department of Health and PCTs in areas with little or no provision
to commission new contracts and restore NHS Dentistry to areas
where it had become scarce or non-existent.
6.4 Threats of dentists leaving the NHS
in the run up to 2009 are detailed in paragraphs 4.4, 9.3 and
9.4. Whilst the principle is now well established of recommissioning
lost activity there is a considerable time lag until this recommissioned
volume comes on-line and in the meantime patient access is disadvantaged.
6.5 The announcement of an additional 11%
funding for NHS Dentistry in 2008-09 is to be welcomed and it
is hoped that a substantial proportion of this additional income
will go towards addressing improved access.
6.6 There is evidence that the most disadvantaged
in society, those irregular attenders with high oral health needs
are having greater difficulty in accessing dental treatment since
they have large amounts of work to be carried out for the same
fee and are not perceived by the dentist to be economical. A greater
understanding of the economic drivers is needed by both the profession
and PCTs to ensure no patients are disadvantaged in this way.
It is particularly important therefore that PCTs are aware that
new contracts awarded in areas where there has not been previous
previous may need to reflect higher UDA values than those where
the majority of patients are regular attenders. This recognition
clearly only exists in a handful of cases at present.
6.7 Patient charges are now simpler for
the patient to understand but in many cases patients are paying
more for similar items of treatment than prior to the new contract
and this is a disincentive to change.
6.8 Operation of the current charging system
for emergency treatment and continuation of treatment is open
to abuse (in a number of cases encouraged by the PCTs to maximise
charge revenue) and should be reviewed.
7. The quality of care provided to patients
7.1 NHS Dentists in general continue to
provide a high level of care for their patients but drivers have
been introduced by the UDA system in the new contract which have
tended to reduce this quality of care.
7.2 Molar endodontic treatment, taking at
least an hour of chairside time, but attracting only the same
number of UDAs as a simple filling taking 10 minutes has almost
become a thing of the past. Our helpline has multiple calls on
a daily basis from patients who are being denied this conservative
7.3 Levels of extractions are increasing,
almost doubled from the Department's own figures and as a result
we may expect to see an overall decline in the nation's oral health
over a period of time. The dental trade have witnessed significant
increases in the sale of dental forceps supporting this perception.
7.4 Cost neutral models to address this
slant in prescribing have been proposed but are rejected out of
hand by the Department.
7.5 The number of crowns and volume of advanced
restorative treatment being provided within band three has decreased
greatly. Whilst it may be true that the previous system tended
to encourage overt treatment it seems increasingly clear that
the current system is encouraging under treatment. In these days
of evidence based health it is simply not adequate to suggest
that the previous system encouraged over provision and the current
system has things right. The Department has a duty to commission
research to determine the appropriate volumes of treatment to
7.6 Some cases exist where excessive UDA
targets have led to delivery of a poor quality of service and
little attention to diagnosis and such items as smoking cessation.
8. The extent to which dentists are encouraged
to provide preventative care and advice
8.1 Options for change contained promises
for a new focus on prevention to produce long term improvements
in dental health.
8.2 The last minute introduction of volume
measures for treatment in the form of Units of Dental Activity
(UDAs) in an attempt to retain control over dentist's treatment
output meant that this opportunity for prevention was lost since
prevention per se did not attract a payment for UDAs.
8.3 Overall allocation of UDAs was at a
level to commit the dentist to lower levels of activity than in
the previous year. It was the stated intention that this shortfall
of activity be allocated toward preventive treatment. With the
major adaptations required by dentists to work within the new
system, an untried volume measure in UDAs and a requirement to
meet UDA targets by the year end, few if any practitioners have
focused on prevention.
8.4 The development of an Evidence Based
"Toolkit for Prevention" in Primary Dental Care with
the production of which the author of this evidence was involved
is to be welcomed. Extensive distribution of the toolkit to PCT
Commissioners and general dental practitioners should give a basis
for high quality delivery of a preventive approach.
8.5 In the absence of specific funding for
this preventive approach which is resource intensive for the practitioner
it is difficult to see that the impact of this document will be
to deliver increased levels of prevention.
8.6 As the co-ordinator of Mouth Cancer
Awareness Week the Foundation has a particular interest in the
role of practitioners in carrying out regular screening of patients
for mouth cancer, particularly at risk groups. Mouth cancer is
one of the fastest increasing of all cancers and unlike most other
cancers survival rates have not increased over the past thirty
years. This is largely as a result of late detection. It had been
hoped that a new preventive approach would encourage greater and
more detailed screening but pressure to achieve UDA targets has
meant that this has not been seen.
9. Dentist's workloads and incomes
9.1 It is not within the remit of the Foundation
to comment on this item specifically.
9.2 The new system was designed to be workload
neutral, indeed to free up time for prevention. In the event some
practitioners have been challenged to achieve their targets, others
have achieved them early and not been able to provide treatment
at the end of the contract year. This inequitable situation disadvantages
patients and flexibility needs to be introduced into the system
to ensure maximum access by patients.
9.3 Dentists are clearly worried by reallocation
of unused contract funds at lower levels than they are currently
being paid and what the impact of this will be when fee levels
are renegotiated in 2009.
9.4 Control of assignment of contract when
a practice is sold now being vested in the PCT leads to uncertainty
for the practitioner leading up to sale, often at retirement and
this could impact adversely both on the practitioners overall
financial management and provision for retirement and their long
term commitment to the NHS.
9.5 There is an acute lack of NHS orthodontists
both in primary and secondary care and the effect of the new contract
appears to have been to exacerbate what was already an acute problem
as many general dental practitioners who carried out limited orthodontic
treatment no longer do so. It is essential if waiting lists are
to be shortened that further training places for orthodontists
are provided as a matter of urgency. Mechanisms should also be
sought to re-engage general dental practitioners happy to carry
out orthodontics with appropriate payment mechanisms.
10. Recruitment and retention of NHS Dental
10.1 Whilst many practitioners remain disillusioned
about the new system and their future within NHS Dentistry it
is difficult to envisage that it will be an attractive career
option and for the reasons already discussed more dentists are
likely to look to leave the NHS in future years.
11 Recommendations for Action
11.1 Greater dissemination of good practice
to PCTs and further training in the delivery of quality commissioning
leading to quality delivery of care.
11.2 Imposed focus on Strategic Health Authorities
with regard to their role in provision of good quality dental
care for their population.
11.3 Review of distribution function and
workload for Consultants in Dental Public Health.
11.4 Review of current UDA system to encourage
a more preventive approach and to ensure that the system encourages
delivery of quality dental care.
11.5 Research into the appropriate level
of band 3 complex treatments.
11.6 Provision of a specific incentive for
11.7 Institution of a requirement to screen
for mouth cancer.
11.8 Review of the current application of
the patient charge system for treatment continuations and emergency
treatment to reduce patient disadvantage inherent in the current
operation of the charging system.
11.9 Review of the patient charge system
to make this more equitable, this could align with a review of
11.10 Provide practitioner security and
reassurance to stop a drift away to private practice.
11.11 Further training places for orthodontists
should be provided as a matter of urgency.
11.12 Mechanisms to re-engage general dental
practitioners able to provide some orthodontic services should
11.13 More robust systems for out of hours
service need to be introduced in some areas.
Dr Nigel L Carter BDS