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.