By Karen Taylor, Director, Centre for Health Solutions
Last week I presented my views on developments in the UK dental market to an informal gathering of dentists and investors. While I should probably have declined, having not done any primary research on this subject since I led the National Audit Office (NAO) report on Reforming NHS Dentistry in 2004,1 I was intrigued to find out what has been happening in the intervening years. Indeed, my original research and the resulting report from the Public Accounts Committee (PAC) in April 20052 had a big impact on my own views on maintaining good oral health and the role of dentistry in prevention. The recent NHS Long Term Plan (LTP), which rightly emphasises the importance of prevention, is mostly silent on dentistry.
Key facts about dentistry at the time of the NAO report
Dental services have been available throughout the NHS since its creation in 1948. However, most dentists aren’t employed by the NHS but operate as independent contractors, choosing where to locate their premises and how much, if any, NHS treatment to provide. In 2003–04 total expenditure on dentistry in England was some £3.8 billion, of which £2.3 billion was NHS funded and an estimated £1.5 billion privately funded. The NHS also recovered £0.5 billion of NHS funded activity from patient charges.3
The NAO and PAC findings in 2004 and 2005
Between 1992 and 2002 there was an increase in the number of patients experiencing difficulties in accessing NHS dentistry, largely due to many dentists reducing their NHS commitment and expanding their private work. Over the same period there had been a growing demand to reform the dental remuneration system, in which dentists were paid per item of treatment provided, a system believed to encourage intervention and over treatment rather than prevention.
In 2003, the Government announced major changes to NHS dentistry, giving Primary Care Trusts (PCTs) responsibility for commissioning NHS dental services in response to local needs, and using NHS contracts to influence where dental practices were located. The target date for implementation was initially October 2005.
The NAO and PAC reports highlighted serious concerns over the planned contract implementation timetable and, while acknowledging the need for a new contract to incentivise dentists to provide more responsive NHS funded services, identified a number of serious concerns, including:
- PCTs lack of experience of high street dentistry
- the urgent need to incentivise dentists to increase their commitment to NHS dentistry
- poor oral health linked to social deprivation (children in parts of northern England had twice the level of dental decay of children in other parts of the country), and areas with high levels of social deprivation had fewer dentists and difficulties attracting dentists to set up practices
- patients in more affluent areas experiencing difficulties registering for NHS treatments due to dentists in these areas reducing their NHS commitments
- an estimated shortage of around 1,000 dentists and some two million people who wanted to register with an NHS dentist, unable to do so
- the risk that dentists might still choose to reduce their NHS commitments
- changes to the historical system of patients paying for over 400 items of treatment, to paying for a small number of price bands, still constituted ‘payment for activity’ but risked ‘under treatment’ replacing ‘over treatment’
- that patients would not understand their entitlements, what services were available and what they were paying for.
The PAC concluded that the radical upheaval to the historical system of charging could have unintended consequences for dentists’ willingness to provide treatment and for patients’ willingness to pay. Following the PAC hearing, in April 2005, the Secretary of State for Health announced delays to implementation of the new contract until April 2006, to enable public consultation on the proposals, including the revision to patient charges, while allowing PCTs time to prepare for their new roles.4
What happened next?
From 2010, as the global financial crisis took effect and the new Coalition Government came into power, the funding of and priorities for the NHS changed. In response to continued problems in access to NHS dentistry, the Coalition Government committed to increasing dental access and improving oral health through reform of the 2006 dental contract.5 The debate and contention around Health Act 2012 also deflected media and political attention to other higher profile issues, despite evidence of increased numbers of patients struggling to access NHS dentistry. Moreover, the most dominant health policy initiative in 2014, the NHS Five Year Forward View, made no mention of dentistry or dental services despite its focus on prevention.6
By 2014, the NHS was spending around £3.4 billion per year on dental services; the value of the private market was estimated at £2.3 billion per year.7 Yet a report on the State of Children’s Oral Health in England 2015 found that while children’s oral health rates had improved, significant regional and social inequalities in children’s dental health persisted – with almost a third of five-year-olds suffering tooth decay. Indeed, tooth decay was the most common reason why five- to nine-year-olds were admitted to hospital, many having multiple tooth extractions under general anaesthesia – despite tooth decay being mostly preventable.8
The Government acknowledged that significant reform was needed, citing the remuneration system which, like its predecessor, was wholly activity-based and had failed to incentivise prevention.9 Consequently, in 2016, 100 dental practices were selected to take part in a Dental Prototype Agreement Scheme, to road test a new NHS dental contract focused on disease prevention. An evaluation of the first year of prototyping saw a reduction in tooth decay through incentivising dentists to offer comprehensive oral health assessments and self-care plans on top of traditional treatments. However, it also identified a number of problems and therefore extended the pilots to another 50 practices, with launch planned for 2018.10
The latest date for implementation is now April 2020. Meanwhile, uncertainty surrounding the future of NHS dentistry is having a detrimental effect on the profession. Specifically, a ‘massive difference in morale’ between private and NHS dentists has led to dentists leaving or reducing their NHS commitment in response to erosion of NHS funding and a preference to treat private patients; there is a prevailing view that the NHS contract has become almost untenable.11
So what did the 2019 NHS Long Term Plan (LTP) say about dentistry?
The LTP, published in January 2019, had full backing of the Government, who committed an additional £20.5 billion funding in support of the sustainability and transformation of the NHS.12 A quarter of this funding is promised to primary care, including immediate reforms to the payment system to move funding away from activity-based payments and ensure a majority of funding is population-based. However, despite the continuing problems with NHS dentistry and inequalities in children’s oral health, there is no mention of a coherent strategy for dental services nor any commitment for additional NHS dentistry funding. There are three short references to dentistry: on children’s oral health, an initiative supporting dentists to see more children from a younger age in highly deprived areas; recognition of the need to improve the oral health of care home; and a similar recognition of the need to improve the oral health of children with learning difficulties.13
More than a decade since the NAO and PAC reports, the situation in 2019 appears remarkably similar to what I found when examining the plans for ‘Reforming NHS dentistry’ in 2004. The NHS versus private dilemma remains a recurring theme, something that does not often happen in other areas of NHS funded healthcare.
Although the 2006 contract was meant to sort this out, clearly it did not. While somewhat reassuring to see that the new proposals have a more detailed focus on prevention, there have been over a decade of patient access challenges and a significant loss of morale in the NHS dental workforce. The Future of Work in general and the lack of any real reference to NHS dentistry in the NHS LTP suggests there is an urgent need to do more to improve NHS dental services and the oral health of all our children.