Dental services plan - white teeth or pipe dreams
A place on the register of an NHS dentist is gold dust in many parts of the country, with mammoth queues for new practices and many people left disappointed. But the biggest shake-up since the introduction of NHS dentistry is aiming to get the service smiling again.
Key points
* From April 2006, PCTs will be given devolved budgets to commission NHS dental services in an attempt to redress the chronic shortages in some areas.
* Burnley, Pendle and Rossendale PCT has a plan to recruit dentists to the area, including working with Liverpool University dental school.
* Nationally, there are concerns that dental initiatives will get lost in the quagmire of PCT reconfigurations and that the new target-led dental contract will drive many dentists into private practice.
It was almost inevitable that the single biggest shake-up in NHS dental services comes as the health service is undergoing another seismic reshuffle of the organisational furniture.
With around six months to go until primary care trusts in England are given devolved budgets to commission comprehensive NHS dental services, those very PCTs are in the throes of major mergers. With so much on their minds, PCTs may find the rebirth of NHS dentistry in April 2006 a difficult one.
Last month Liberal Democrat health spokesman Steve Webb told his party conference that many dentists were threatening to quit the NHS because of new contracts, which pay on the basis of the number of procedures carried out.
The fears are echoed by the British Dental Association, which says dentists will be put under pressure to carry out as much work as possible to maintain incomes, leaving little time for health promotion.
In July the influential Commons public accounts committee said key milestones had been missed in reforming dentistry - including the planned introduction of a new base contract, which was postponed by six months and was due for publication this month.
However, the final version of the contract is now not expected until January, and there is also a separate active consultation on patient charges. PCTs are currently in discussion with the Department of Health about how much money they each need to be allocated to commission sufficient dental services.
Too much, too soon
The public accounts committee said it was 'extremely concerned' that PCTs were required to take over managing new contracting arrangements 'without ensuring they had the necessary expertise and resources'.
And it is not as if the challenge to make the English mouth a nicer place is going to be easy. Notwithstanding the stereotypical view from across the Atlantic that the UK is a nation beset by bad teeth, a DoH survey in June revealed that nearly a quarter of under-threes had severe decay in their front teeth.
Of these more than half had five or more teeth affected. Coupled with the rising rates of obesity in under 16s, experts fear this marks a reversal in the trend of improvements in youngsters' oral health in the last 30 years.
But the DoH is claiming major dental victories. The target for 25 per cent of all dental practices to be working under personal dental services - salaried dentists' contracts - has already been surpassed. Over 30 per cent of dentists are moving to PDS pilots, which means there are now over 6,000 dentists in 2,200 practices working on this basis. The DoH has increased dentistry funding by 19.3 per cent, which equates to £250m over two years.
Dental undergraduate places are to be increased by 25 per cent from this month, creating an extra 170 student places a year.
The DoH is also engaged in a three-month consultation on replacing the current 400-plus dental charges dentists can levy with a system that will divide costs into three bands, ranging from low to high levels of required treatment.
It says the new system - known as the statement of financial entitlements, which will set in stone nationally determined payments for dentists - will be more transparent and easier to use for patients. It will also be more straightforward for receptionists and practice managers, who usually bear the brunt of patients' billing queries. The department says it will be consulting the BDA on the new pay rates in the next few weeks.
Under the new contract providers will agree to supply a given number of units of dental activity (UDAs) and there will be a formula for calculating how many units each dentist or practice should provide. This formula will be based on the number of courses of treatment they carried out from October 2004 to September this year, less 5 per cent. This reduction represents half of the 10 per cent drop in activity the DoH says is evident across the country as a result of 'new ways of working'.
Allocating funds
Dentists' minimum contract values and associated UDAs will be sent to dentists and PCTs by the end of November. Indicative dental budgets for PCTs for 2006-07 will be sent to PCTs for validation in November.
From April 2006 PCTs will have funds directly allocated to them to commission primary dental services to meet local needs - either from dental practices, dental companies or by providing salaried services themselves. The new contracts will be longer-term agreements replacing the open-ended nature of the current arrangements with an agreed level of service.
The challenge for PCTs is managing the change, keeping dentists on board and then setting up the management infrastructure to operate local commissioning - at the same time as they are undergoing painful and potentially destabilising mergers.
Major tasks include ensuring that contractors comply with patients' charges regulations, compliance with National Institute for Health and Clinical Excellence guidelines, including recall guidelines, setting up in-house complaints systems and putting clinical governance in place.
PCTs are most likely to apply the Healthcare Commission's framework for clinical governance in dentistry. The framework standards describe the quality healthcare organisations will be expected to meet. They are organised in seven domains designed to cover the full spectrum of healthcare as defined in the Health and Social Care (Community Health and Standards) Act 2003:
* safety;
* clinical and cost effectiveness;
* governance;
* patient focus;
* accessible and responsive care;
* care environment and amenities;
* public health.
It is up to dentists to comply with these requirements, but PCTs are already working with them on clinical governance activities - ensuring significant event audit, adverse incident-reporting and continuing professional development. The clinical governance scheme launched in July in Kent, Surrey and Sussex deanery, which delivers postgraduate dental education in the area, has over 100 practices signed up.
Quality assurance in the new system will be monitored through the dental reference service at the Dental Practice Board. This is the statutory body that administers NHS general dental services and is accountable to the DoH and National Assembly for Wales. The General Dental Council, the equivalent of the General Medical Council, will not be directly involved.
As of August this year, the DoH says it has recruited over 850 of a promised 1,000 new dentists, including some from Poland and India. It has also 'brought back' additional capacity from existing dentists.
'Burnley, Pendle and Rossendale PCT covers the former mill towns of Lancashire, where there are 'hot spots' of poor NHS dental coverage but where, for historic reasons, no more than half the population were ever registered with a dentist.
The PCT suffered setbacks last winter when five dentists in two practices decided to opt out of providing NHS care because they were unhappy with the new contract proposals, leaving 7,300 patients without a dentist.
Another blow came when plans to create capacity for 10,000 extra patients in Burnley with premises for six new NHS dentists were rejected by town councillors. Despite planning officers supporting the proposal of private company Independent Dental Holdings, the councillors rejected the plans. They were concerned about the impact on parking and other amenities.
Five-pronged policy
However the PCT has devised a five-pronged dental policy to create nearly 20,000 new dental places within three years.
It focuses on holding onto and expanding existing practices, attracting new dentists and setting up a relationship with Liverpool University dental school so that students are brought into dental surgeries within the PCT to act as assistants. The idea is that young dentists will get practical experience and also realise the area is a nice place in which to live.
The PCT has led the development of dental therapist courses at further education colleges in Blackburn and Lancaster. Once trained, those therapists will be able to carry out minor procedures and provide health promotion advice.
The PCT is also providing guaranteed emergency dental treatment in liaison with NHS Direct. 'We can guarantee almost immediate access to a dentist in an emergency. It might be that a patient would go to a neighbouring town but access would be pretty quick,' says a spokesperson.
Dentist and former DoH dental policy adviser Raj Rattan has first-hand experience of the impact of changes when PDS schemes are rolled out.
'PCTs will need to work closely with local dentists and build relationships based on trust and mutual respect,' says Mr Rattan. 'For those dentists who wish to retain their commitment to the NHS, the challenge is one of change management. Dentists will need to decide how they can best serve the interests of their patients and whether the proposed new arrangements will help or hinder them. The time has come for us to think differently. We will not be able to overcome tomorrow's challenges with yesterday's mind-set.'
Why dentists aren't smiling
Lester Ellman, chair of the British Dental Association's general dental practice committee, doubts whether a comprehensive service can be provided by April 2006. He is sceptical about the government's claims to be on target to recruit almost 1,000 new dentists. 'You hear stories about a dozen dentists being recruited from [continental] Europe in one area and being so disappointed with what they saw that they all went home on the next plane,' he says.
He also says home-grown dentists' disaffection is not simply a matter of pay comparability with the private sector. 'It's the workload they are worried about rather than the pay itself. A recent Inland Revenue study revealed the average pay for a private practice dentist isn't that much higher than an NHS one. One of the reasons people go into private practice is that they have more time with patients - that's the luxury they have and that is why people move away from the NHS.'
He adds: 'The BDA is in talks with the DoH to make sure dentists who work for PCTs do not get swamped because it's not just being set up as an illness service. It's about health promotion as well. It's a well-known maxim that £1 spent on prevention is worth £50 of treatment.'
The BDA is also concerned about technology, which Mr Ellman says is 'nowhere near as advanced as IT in the rest of primary care'.
It is also worried that the patient-charging proposals will prove a disincentive to dentists and patients. 'As it stands, the step between charging at band 1, which is £15, and band 2, which is £41, might be a disincentive as some will see it as an enormous jump.
The BDA says it has not seen much evidence of work on ensuring quality and good governance at PCT level. 'I'm worried about the possibility of making a pig's ear of all this - just as we are setting up NHS dentistry PCTs are going to be merged and re-arranged,' says Mr Ellman. 'I work with the three central Manchester PCTs, where people will be fighting to save their jobs, and not giving 100 per cent of their thoughts to setting up dental services. They might not have a job in six months' time.'
Dentists are also worried that many aspects of their new work life are at present enshrined in draft or consultation document form.
Mr Ellman explains: 'We really haven't even got any concrete figures in terms of funding available for PCTs. There have been some veiled threats of funding being stopped if dentists don't hit targets, which is not really what we want to hear. These things may be driving people away from working in the NHS.
'Dentists are small businesses and all this uncertainty about potential global income is making planning impossible. It could be driving people into the private sector.'
Scarborough unfair
In February last year the seaside town of Scarborough saw scenes reminiscent of food queues in poverty-stricken former Eastern bloc countries.
Over 3,000 residents, some of whom had not consulted a dentist in years, queued for hours to register with a newly opened practice.
Dutch dentist Aria Van Drie was recruited to the practice in New Queen Street by Medimatch, but within two weeks the practice was closed after it was revealed that she was the subject of criminal proceedings in the Netherlands.
While there were no concerns about her dental skills, Ms Van Drie decided to resign. She said coverage had undermined confidence in NHS dentistry.
Concerns about overseas dentists treating patients were compounded when it was revealed that Ms Van Drie's Greek colleague Irene Tsanidou was not registered to practise in the UK.
More than 18 months on, two new dentists have been recruited. Scarborough, Whitby and Ryedale primary care trust dental practice modernisation manager Helen Stokell is proud of the progress that has been made.
She says the PCT had set up its own three-year action plan and is well-placed to provide a comprehensive NHS service from next year.
'We had very low dental registration levels in the PCT and we decided we needed to get over 11,500 patients signed up by 2006. In the last 18 months we have registered 8,000 new patients, so we are well on the way to meeting the target.'
She adds that dental provision would be given a major boost if lobbying for a new dental school at Hull York Medical School is successful.
http://www.hsj.co.uk/nav?page=hsj.news.story&resource=3414783
Key points
* From April 2006, PCTs will be given devolved budgets to commission NHS dental services in an attempt to redress the chronic shortages in some areas.
* Burnley, Pendle and Rossendale PCT has a plan to recruit dentists to the area, including working with Liverpool University dental school.
* Nationally, there are concerns that dental initiatives will get lost in the quagmire of PCT reconfigurations and that the new target-led dental contract will drive many dentists into private practice.
It was almost inevitable that the single biggest shake-up in NHS dental services comes as the health service is undergoing another seismic reshuffle of the organisational furniture.
With around six months to go until primary care trusts in England are given devolved budgets to commission comprehensive NHS dental services, those very PCTs are in the throes of major mergers. With so much on their minds, PCTs may find the rebirth of NHS dentistry in April 2006 a difficult one.
Last month Liberal Democrat health spokesman Steve Webb told his party conference that many dentists were threatening to quit the NHS because of new contracts, which pay on the basis of the number of procedures carried out.
The fears are echoed by the British Dental Association, which says dentists will be put under pressure to carry out as much work as possible to maintain incomes, leaving little time for health promotion.
In July the influential Commons public accounts committee said key milestones had been missed in reforming dentistry - including the planned introduction of a new base contract, which was postponed by six months and was due for publication this month.
However, the final version of the contract is now not expected until January, and there is also a separate active consultation on patient charges. PCTs are currently in discussion with the Department of Health about how much money they each need to be allocated to commission sufficient dental services.
Too much, too soon
The public accounts committee said it was 'extremely concerned' that PCTs were required to take over managing new contracting arrangements 'without ensuring they had the necessary expertise and resources'.
And it is not as if the challenge to make the English mouth a nicer place is going to be easy. Notwithstanding the stereotypical view from across the Atlantic that the UK is a nation beset by bad teeth, a DoH survey in June revealed that nearly a quarter of under-threes had severe decay in their front teeth.
Of these more than half had five or more teeth affected. Coupled with the rising rates of obesity in under 16s, experts fear this marks a reversal in the trend of improvements in youngsters' oral health in the last 30 years.
But the DoH is claiming major dental victories. The target for 25 per cent of all dental practices to be working under personal dental services - salaried dentists' contracts - has already been surpassed. Over 30 per cent of dentists are moving to PDS pilots, which means there are now over 6,000 dentists in 2,200 practices working on this basis. The DoH has increased dentistry funding by 19.3 per cent, which equates to £250m over two years.
Dental undergraduate places are to be increased by 25 per cent from this month, creating an extra 170 student places a year.
The DoH is also engaged in a three-month consultation on replacing the current 400-plus dental charges dentists can levy with a system that will divide costs into three bands, ranging from low to high levels of required treatment.
It says the new system - known as the statement of financial entitlements, which will set in stone nationally determined payments for dentists - will be more transparent and easier to use for patients. It will also be more straightforward for receptionists and practice managers, who usually bear the brunt of patients' billing queries. The department says it will be consulting the BDA on the new pay rates in the next few weeks.
Under the new contract providers will agree to supply a given number of units of dental activity (UDAs) and there will be a formula for calculating how many units each dentist or practice should provide. This formula will be based on the number of courses of treatment they carried out from October 2004 to September this year, less 5 per cent. This reduction represents half of the 10 per cent drop in activity the DoH says is evident across the country as a result of 'new ways of working'.
Allocating funds
Dentists' minimum contract values and associated UDAs will be sent to dentists and PCTs by the end of November. Indicative dental budgets for PCTs for 2006-07 will be sent to PCTs for validation in November.
From April 2006 PCTs will have funds directly allocated to them to commission primary dental services to meet local needs - either from dental practices, dental companies or by providing salaried services themselves. The new contracts will be longer-term agreements replacing the open-ended nature of the current arrangements with an agreed level of service.
The challenge for PCTs is managing the change, keeping dentists on board and then setting up the management infrastructure to operate local commissioning - at the same time as they are undergoing painful and potentially destabilising mergers.
Major tasks include ensuring that contractors comply with patients' charges regulations, compliance with National Institute for Health and Clinical Excellence guidelines, including recall guidelines, setting up in-house complaints systems and putting clinical governance in place.
PCTs are most likely to apply the Healthcare Commission's framework for clinical governance in dentistry. The framework standards describe the quality healthcare organisations will be expected to meet. They are organised in seven domains designed to cover the full spectrum of healthcare as defined in the Health and Social Care (Community Health and Standards) Act 2003:
* safety;
* clinical and cost effectiveness;
* governance;
* patient focus;
* accessible and responsive care;
* care environment and amenities;
* public health.
It is up to dentists to comply with these requirements, but PCTs are already working with them on clinical governance activities - ensuring significant event audit, adverse incident-reporting and continuing professional development. The clinical governance scheme launched in July in Kent, Surrey and Sussex deanery, which delivers postgraduate dental education in the area, has over 100 practices signed up.
Quality assurance in the new system will be monitored through the dental reference service at the Dental Practice Board. This is the statutory body that administers NHS general dental services and is accountable to the DoH and National Assembly for Wales. The General Dental Council, the equivalent of the General Medical Council, will not be directly involved.
As of August this year, the DoH says it has recruited over 850 of a promised 1,000 new dentists, including some from Poland and India. It has also 'brought back' additional capacity from existing dentists.
'Burnley, Pendle and Rossendale PCT covers the former mill towns of Lancashire, where there are 'hot spots' of poor NHS dental coverage but where, for historic reasons, no more than half the population were ever registered with a dentist.
The PCT suffered setbacks last winter when five dentists in two practices decided to opt out of providing NHS care because they were unhappy with the new contract proposals, leaving 7,300 patients without a dentist.
Another blow came when plans to create capacity for 10,000 extra patients in Burnley with premises for six new NHS dentists were rejected by town councillors. Despite planning officers supporting the proposal of private company Independent Dental Holdings, the councillors rejected the plans. They were concerned about the impact on parking and other amenities.
Five-pronged policy
However the PCT has devised a five-pronged dental policy to create nearly 20,000 new dental places within three years.
It focuses on holding onto and expanding existing practices, attracting new dentists and setting up a relationship with Liverpool University dental school so that students are brought into dental surgeries within the PCT to act as assistants. The idea is that young dentists will get practical experience and also realise the area is a nice place in which to live.
The PCT has led the development of dental therapist courses at further education colleges in Blackburn and Lancaster. Once trained, those therapists will be able to carry out minor procedures and provide health promotion advice.
The PCT is also providing guaranteed emergency dental treatment in liaison with NHS Direct. 'We can guarantee almost immediate access to a dentist in an emergency. It might be that a patient would go to a neighbouring town but access would be pretty quick,' says a spokesperson.
Dentist and former DoH dental policy adviser Raj Rattan has first-hand experience of the impact of changes when PDS schemes are rolled out.
'PCTs will need to work closely with local dentists and build relationships based on trust and mutual respect,' says Mr Rattan. 'For those dentists who wish to retain their commitment to the NHS, the challenge is one of change management. Dentists will need to decide how they can best serve the interests of their patients and whether the proposed new arrangements will help or hinder them. The time has come for us to think differently. We will not be able to overcome tomorrow's challenges with yesterday's mind-set.'
Why dentists aren't smiling
Lester Ellman, chair of the British Dental Association's general dental practice committee, doubts whether a comprehensive service can be provided by April 2006. He is sceptical about the government's claims to be on target to recruit almost 1,000 new dentists. 'You hear stories about a dozen dentists being recruited from [continental] Europe in one area and being so disappointed with what they saw that they all went home on the next plane,' he says.
He also says home-grown dentists' disaffection is not simply a matter of pay comparability with the private sector. 'It's the workload they are worried about rather than the pay itself. A recent Inland Revenue study revealed the average pay for a private practice dentist isn't that much higher than an NHS one. One of the reasons people go into private practice is that they have more time with patients - that's the luxury they have and that is why people move away from the NHS.'
He adds: 'The BDA is in talks with the DoH to make sure dentists who work for PCTs do not get swamped because it's not just being set up as an illness service. It's about health promotion as well. It's a well-known maxim that £1 spent on prevention is worth £50 of treatment.'
The BDA is also concerned about technology, which Mr Ellman says is 'nowhere near as advanced as IT in the rest of primary care'.
It is also worried that the patient-charging proposals will prove a disincentive to dentists and patients. 'As it stands, the step between charging at band 1, which is £15, and band 2, which is £41, might be a disincentive as some will see it as an enormous jump.
The BDA says it has not seen much evidence of work on ensuring quality and good governance at PCT level. 'I'm worried about the possibility of making a pig's ear of all this - just as we are setting up NHS dentistry PCTs are going to be merged and re-arranged,' says Mr Ellman. 'I work with the three central Manchester PCTs, where people will be fighting to save their jobs, and not giving 100 per cent of their thoughts to setting up dental services. They might not have a job in six months' time.'
Dentists are also worried that many aspects of their new work life are at present enshrined in draft or consultation document form.
Mr Ellman explains: 'We really haven't even got any concrete figures in terms of funding available for PCTs. There have been some veiled threats of funding being stopped if dentists don't hit targets, which is not really what we want to hear. These things may be driving people away from working in the NHS.
'Dentists are small businesses and all this uncertainty about potential global income is making planning impossible. It could be driving people into the private sector.'
Scarborough unfair
In February last year the seaside town of Scarborough saw scenes reminiscent of food queues in poverty-stricken former Eastern bloc countries.
Over 3,000 residents, some of whom had not consulted a dentist in years, queued for hours to register with a newly opened practice.
Dutch dentist Aria Van Drie was recruited to the practice in New Queen Street by Medimatch, but within two weeks the practice was closed after it was revealed that she was the subject of criminal proceedings in the Netherlands.
While there were no concerns about her dental skills, Ms Van Drie decided to resign. She said coverage had undermined confidence in NHS dentistry.
Concerns about overseas dentists treating patients were compounded when it was revealed that Ms Van Drie's Greek colleague Irene Tsanidou was not registered to practise in the UK.
More than 18 months on, two new dentists have been recruited. Scarborough, Whitby and Ryedale primary care trust dental practice modernisation manager Helen Stokell is proud of the progress that has been made.
She says the PCT had set up its own three-year action plan and is well-placed to provide a comprehensive NHS service from next year.
'We had very low dental registration levels in the PCT and we decided we needed to get over 11,500 patients signed up by 2006. In the last 18 months we have registered 8,000 new patients, so we are well on the way to meeting the target.'
She adds that dental provision would be given a major boost if lobbying for a new dental school at Hull York Medical School is successful.
http://www.hsj.co.uk/nav?page=hsj.news.story&resource=3414783
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