Press Release - Department of Health - Reforming NHS Dentistry:
ensuring effective management of risks
25 November 2004
There is a strong rationale for modernising NHS dentistry, but
significant risks will have to be managed if the new arrangements
announced by the Department of Health are to be effective and
provide value for money, according to the National Audit Office. In
particular, given the scepticism of some dentists compounded by a
lack of detail on how the new system will operate, there is a risk
that dentists will reduce their NHS commitments.
Today’s report to Parliament by head of the NAO Sir John Bourn
points out that modern dental practice emphasises prevention rather
than intervention; but that the current piecework remuneration
system – whereby NHS dentists are paid a fee for each NHS item of
treatment they carry out - does not provide sufficient incentives
for such an approach. Given the overall shortages of dentists and
the difficulties some patients are experiencing in accessing NHS
dental treatment, NHS dentistry needs to provide a more responsive
service.
Under new arrangements announced by the Department of Health in
2003, Primary Care Trusts will be required to commission dental
services and dentists will be paid for delivering local contracts
to meet patients' oral health needs, rather than for each item of
treatment. The Department set an April 2005 target date for
implementation but, in response to consultation, in July 2004
announced that the changes would be implemented from October
2005.
The Primary Care Trusts will be assuming new roles and
responsibilities for implementing the new system, but have little
experience of high street dentistry. They will need to develop
appropriate expertise and resources to implement and manage the new
arrangements and to encourage dentists to maintain and increase
their commitment to NHS dentistry.
The NAO has identified problems of access to NHS dentists,
particularly in some areas. NHS expenditure on high street
dentistry has increased steadily over the years but it has not kept
pace with other NHS spending. While 98.5 per cent of the population
of England and Wales is within 5 miles of a high street dentist
providing NHS services, dentists may not provide a full range of
NHS treatments and many are not registering new NHS patients.
Poor oral health is associated with social deprivation. Some
areas where there are high levels of social deprivation have
relatively few dentists and it can be difficult to attract dentists
to set up practices in these areas and for dentists to sell their
practices. In more affluent areas, patients may experience
difficulties registering for NHS treatments because dentists have
reduced their commitment to NHS dentistry, following the Department
of Health’s decision in 1992 to cuts fees. The NAO point out that,
over the last ten years, private dentistry has grown several-fold,
with over a quarter of adult patients who visit the dentist paying
for some private treatment.
The Department’s 2002 review of the dental workforce found that,
in 2003, there would be an overall shortage of 1,850 dentists,
equivalent to an undersupply of dental time of around 9 per cent of
that required to meet demand. Taking into account the proposed
changes in remuneration and working practices planned as part of
the reforms, the Department has identified that it needs to recruit
the equivalent of 1,000 new dentists by October 2005.
The Department has undertaken a number of initiatives to tackle
the most pressing access difficulties, including opening 47 new NHS
dental access centres in areas where people are experiencing
particular difficulties. To achieve an increase in dentist numbers,
the Department has set ambitious targets for increasing capacity.
These include recruiting dentists from abroad, increasing the NHS
commitment of existing dental practices and increasing the numbers
of dentists in training for the longer term. There is a risk that
these targets will not be net and shortages of dentists will
continue.
The NAO report highlights a number of ways in which NHS
resources are not being used effectively under current
arrangements. The current piecework system of payment encourages
dentists to recall patients at fixed periods, rather than intervals
tailored to patients’ needs. Over half the courses of treatment
provided by dentists are for examinations only or for examinations
plus scaling and polishing. The NAO’s own work shows that, where
funding treatment on a piecework basis is replaced by a salaried or
capitation system, the number of treatments such as fillings tend
to fall by at least 10 per cent, and the changes in treatment
patterns do not seem to impact on oral health – although there is a
need for research on the long-term effects.
The NAO report highlights the risk that, following the
introduction of the new system, dentists may still choose to reduce
their NHS commitments but, given that dentists are being guaranteed
gross earnings for three years, this may not happen until the end
of this period.
The report identifies other risks. These include the fact that
Primary Care Trusts have little experience of high street
dentistry; that capacity freed up under the new system might not be
utilised to the benefit of the NHS; that ‘under treatment’ might
replace ‘over treatment’ as a perverse incentive; that patients
will not understand their entitlements, what services are available
on the NHS and for what they are paying; and that, with a move
towards prevention and fewer treatments, overall charge income
might fall.
Sir John Bourn said today:
"The Department of Health is pursuing an ambitious
programme to reform NHS dentistry. There are good reasons to
modernise the system but it is vital that the Department gets it
right. I have identified significant risks that will need to be
carefully managed.
"In the light of concerns by dentists and the NHS, the
Department’s decision to postpone the introduction of the new
arrangements to October of next year is welcome. It now needs to be
more transparent about its plans and its timetable for managing the
change process to achieve the new date – and ensure that these are
conveyed to dentists and their patients."
Notes for Editors:
- In 2003-04 the Department of Health paid £1.8 billion in fees
to around 19,300 high street dentists (some 18,300 of whom operated
under the General Dental Services contract and the rest under the
Personal Dental Services contract), together with specialist
hospital and community dental services for the provision of NHS
dental treatment. Patients contributed a further £0.5 billion
through patient charges.
- Fundamental to the introduction and stability of the new
system, to be implemented from October 2005, is the new base
contract which guarantees gross earnings for three years provided
the dentist provides the same degree of NHS commitment. There will
also be a new simplified system of patient charges. There have,
however, been delays in announcing the details of the arrangements
including the content of the new base contract and the new system
of patient charges.
- Press notices and reports are available from the date of
publication on the NAO website at www.nao.org.uk.
Hard copies can be obtained from The Stationery Office on 0845 702
3474.
- The Comptroller and Auditor General, Sir John Bourn, is the
head of the National Audit Office which employs some 800 staff. He
and the NAO are totally independent of Government. He certifies the
accounts of all Government departments and a wide range of other
public sector bodies; and he has statutory authority to report to
Parliament on the economy, efficiency and effectiveness with which
departments and other bodies have used their resources.
Press Notice 68/04
All enquiries to Barry Lester, NAO Press Office:
Tel: 020 7798 7937
Mobile: 07748 181692