nhs dentistry: delivering change - the...

NHS Dentistry:Delivering Change

Report by the Chief Dental Officer(England) July 2004

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Title NHS Dentistry: Delivering ChangeReport by the Chief Dental Officer (England)

Author OCDO

Publication date 16 Jul 2004

Target Audience PCT CEs, NHS Trusts CEs, SHA CEs, WDCCEs, Directors of PH, General DentalPractitioners

Circulation list

Description Progress made in improving oral health,need to address remaining inequalities,combination of preventive measures(eg selective fluoridation schemes) anddelegation of commissioning of generaldental services to PCTs to achieve generalimprovements in oral health and access toNHS dentistry

Cross Ref NHS Dentistry: Options for Change

Superceded Doc N/A

Action required SHAs/WDCs/PCTs to reference inconnection with the contribution they aremaking to the Department led initiative toimprove access to NHS dentistry

Timing N/A

Contact Details Professor Raman BediChief Dental Officer, EnglandRoom 332 Wellington House133-155 Waterloo RoadLondon SE1 8UG020 7972 3995http://www.dh.gov.uk/AboutUs/HeadsofProfession/ChiefDentalOfficer

For recipient use

Foreword 1

Key facts 2

1. Introduction 3

2. Improving access and oral health for patients 6

3. A fair deal for dentists and their teams 18

Timeline 23

Annex A: NHS dental access centres 25

Annex B: NHS dental treatments 26

NHS DENTISTRY: DELIVERING CHANGE III

Contents

In 2002, we publishedNHS Dentistry: Optionsfor Change, whichoutlined the policy forreforming NHS dentalservices. The aim ofthis document is tofocus on deliveringthat change.

The vision is to build an NHS dental servicethat:

l offers access to high quality treatment forpatients when they need to see a dentist

l focuses on preventing disease so thateveryone, and in particular children, canenjoy healthy teeth for life

l gives a fair deal to dentists and their teamsand improves their working lives.

Oral health for both adults and children isbetter than it has ever been since recordsbegan. However, poor oral health is still tooclosely linked to deprivation.

The Department of Health is committed toinvesting in and reforming NHS dentistry toensure that everyone can have access totreatment when they need it.

We must provide better access to NHSdentistry and higher quality treatment for thosewho have dental problems while recognisingthat, in the long-term, prevention is the realkey to healthier teeth and gums.

The way to improve both oral health andaccess is to immediately increase the numberof NHS dentists and, in the medium andlonger term, introduce a new set of workingarrangements that make more effective use ofNHS resources and make NHS dentistry moreattractive to dentists.

We have put in place immediate measures toimprove recruitment and retention of dentists,with the equivalent of 1,000 extra NHSdentists being recruited by October 2005,and made funds available to meet additionalservice costs. In the medium term we willalso increase the number of dentists we traineach year.

We are also working with dentists to developand test new working arrangements that trulybenefit patients and continue to fairly rewarddentists and their teams. This has taken sometime but they are now ready to be introducednationally from October 2005.

We are confident that the new workingarrangements, supported by extra investmentof over £250 million a year from 2005-06, anincrease of 19.3% over two years, will delivergreater access for patients, a higher qualityservice, and a better deal for dentists.

PROFESSOR RAMAN BEDIChief Dental Officer for EnglandDepartment of Health

NHS DENTISTRY: DELIVERING CHANGE 1

Foreword

Where we are

1 Everyone can see an NHS dentist whenthey need emergency or urgent treatment.

2 We have tackled access difficulties inparticular parts of the country by opening47 new NHS dental access centres.

3 The fall in the proportion of peopleregistered with an NHS dentist has beenstopped and it has been stable since 1998.

4 People do not have to be registered with adentist to access NHS dentistry.Registration was introduced in 1990 andonly 50% of the adult population has everattended an NHS dentist over the current15 month registration period.

5 There are over 19,000 dentists in primarycare, which is more than ever before, butmany spend a lower proportion of their timeon NHS work.

6 This leaves some people unable to get theroutine treatment they want on the NHS,unless they are prepared and able to travel.

7 We have expanded the total number ofdental therapist training places from 50 to200.

8 The NHS dentistry budget has not beenreduced. However, it is affected by the fallin the proportion of dentists doing NHSwork.

9 Oral health in England is improvinggenerally and oral health in 12-year-olds isthe best in Europe.

10 Inequalities still exist – children in parts ofthe north of England have on average twiceas much dental decay as children in otherparts of the country.

Delivering change

l From 2005-06, investment in NHS dentistrywill be running at over £250 million a yearextra compared with 2003-04 – an increaseof 19.3% over two years.

l The NHS workforce will be increased bythe equivalent of 1,000 dentists by October2005, allowing an extra two million peopleto be treated.

l Training places for dentists will expand by170 from 2005, an increase of 25%,supported by up to £80 million capitalinvestment over four years.

l A new contract for dentists will beintroduced from October 2005.

l Access to the full range of NHS care will beimproved, as dentists will no longer be tiedto fees for individual treatments, but will beable to decide treatment on the basis ofclinical need.

2 NHS DENTISTRY: DELIVERING CHANGE

Key facts

This report sets out the vision of how we planto benefit patients in England through:

l greater access to NHS dentistry

l improving oral health

l reforming and improving NHS dentalservices.

Access to NHS dental services

There are over 19,000 dentists in primary care,which is more than ever before. But, they arespending a lower proportion of their time onNHS work. This leaves some people unableto get the routine treatment they want on theNHS, unless they are prepared and ableto travel.

Some of the most pressing access difficultieshave been tackled. Forty seven new NHSdental access centres have been opened inareas where people are experiencing particulardifficulties, and these are now treating over300,000 new NHS patients a year. An NHSSupport Team backed by £9 million isworking with those primary care trusts (PCTs)

facing the greatest challenges in improvingdental access and a further £50 million hasbeen made available to the NHS to improveaccess. But more needs to be done.

Oral health today

Oral health in this country is better now than ithas ever been. The 2003 National Survey ofChild Dental Health shows that tooth decay in12 to 15-year-old children is at its lowest levelsince surveys began and, according tonational and World Health Organization tablesfor 2003, 12-year-olds in England now havethe best dental health in Europe.

Adult oral health has also improveddramatically since the 1960s. The most recentNational Adult Survey shows that adults nowenjoy the best oral health for over 30 years.

This is the result of advances in medicalscience over the last few decades which haveimproved our understanding of how to preventtooth decay. The use of fluoride toothpaste,which became widespread in the 1970s, betternutrition, the work of dentists and their teams,and increased public awareness of dentalhealth issues have also helped to improve oralhealth.

But the pattern is not the same across allsections of our society. Poor dental health andpoverty are also still inextricably linked andchildren in parts of the north of England have,on average, twice as much dental decay asothers.

INTRODUCTION 3

1. Introduction

Reforming and improving NHSdental services

The key to improving both oral health andaccess is to create a new way of payingdentists – who are in the main independentcontractors – supported by extra investment.

In order for the new system to work, we needto simplify the system of patient charges. TheNHS Dentistry Patient Charges WorkingGroup, which involved experts from nationalpatient, consumer and dentist organisations,has made recommendations to Ministers whichare currently being considered.

The reforms will benefit everyone, especiallychildren and young people, through greateremphasis on preventing disease. Good dentalhealth in childhood is the key to healthier teethin adults. Most of the work we have done toour teeth as adults is to repair or replacefillings so the benefits of greater preventionare doubly important. Over half of our childrenand young adults are decay free now, and weaim to reduce this even further through givingdentists more time and greater incentives tofocus on health education and prevention.

In addition, for the first time, PCTs – the localorganisations that run the NHS – have beengiven the responsibility for oral public health,and they are now required to work withdentists to deliver improvements. This willenable oral health to become an integral partof local health services, delivered not onlythrough the dental surgery, but also throughhealth visitors and other parts of primaryhealth care.

Delivering the reforms

The new system of NHS dentistry will beunderpinned by increased investment, a largerdental workforce and more effective ways ofworking.

Over £250 million a year will be added tothe national dentistry budget from 2005-06,compared to equivalent spend in 2003-04.This will be an increase of 19.3%, over twoyears, compared with a growth of 17.8% in

overall NHS revenue resources over the sameperiod. Annual spending on NHS dentalservices will go up from £1.3 to £1.6 billion –after taking into account extra costs arisingfrom a technical change in the charging ofemployers’ superannuation contributions.Income from patient charges will continue toprovide additional resources and up to £80million extra capital over four years will beavailable to support the expansion in dentalundergraduate places. The revenue costs ofthese extra places will build up each year until2010-11 when they will be £29 million a year.

In addition, we are recruiting more dentists now.By October 2005 we will have increased theNHS workforce by the equivalent of 1,000dentists – some new recruits and some fromcommissioning new capacity from existingdentists. This new resource will be targeted atareas where there are gaps in provision and willallow an extra two million people to be treated.

We are also introducing other structuralmeasures to improve access. In 1987, a reviewof the dental workforce resulted in the closureof two dental schools in England and reducedthe number of dentists being trained by 10%.We are expanding the number of trainingplaces for dentists by 170 from 2005 onwards,an increase of 25% on the existing total.

We will also ensure that the skills of the wholedental team are used more appropriately.Just as in GP surgeries, where practice nursesundertake health checks and other aspectsof basic health care, dental hygienists andtherapists will increasingly do the less complexwork. To help with this we are training moredental therapists and in September we areopening the first, dedicated academy forprofessionals complementary to dentistry, suchas dental therapists, nurses and hygienists.This expands the total number of dentaltherapist training places from 50 to 200.

These changes provide a real opportunityto create a modern dental health servicedesigned to meet people’s needs today. Onewhich will improve dental health across thewhole population. We are committed to

4 INTRODUCTION

working with patients and dentists, nationallyand locally, to ensure we deliver the vision ofan NHS dental service that offers access tohigh quality treatment when needed, focuseson prevention, and gives a fair deal to thevaluable professionals who are at its heart.

INTRODUCTION 5

Earlier this year The NHS Improvement Planoutlined how we have been successful inimproving access and quality for patientsacross the wider NHS through a combinationof investment and reform.

We are now applying this approach to NHSdental services. However, there is still a longway to go.

The reforms that we are introducing willbenefit patients by:

l improving access, wherever people live

l improving oral health for everyone

l tackling oral health inequalities, so we domore for those most in need.

This will be achieved through working withdentists to transform the current system intoone that meets people’s needs today.

Access to NHS dental services

There are over 19,000 dentists in primary care.This is more than ever before, and almost allof them do some NHS work. They currentlycomplete some 150,000 courses of treatmentfor NHS patients every day. But they areincreasingly spending a lower proportion oftheir time on NHS work, and there areparticular shortages in some areas.

Number of dentists in General andPersonal Dental Services contracts(England):

1998 17,200

1999 17,800

2000 18,200

2001 18,800

2002 19,000

2003 19,300

The fall in the number of people able toregister with an NHS dentist has beenstopped and numbers have been stable since1998 (Figure 1). However, the system ofregistration, under which dentists are paida monthly payment for ‘continuing care’ ofregistered patients, needs to be reformedas it encourages dentists to focus on a list ofhealthy patients for whom they perform regularcheck-ups in order to ensure a consistent levelof income.

6 IMPROVING ACCESS AND ORAL HEALTH FOR PATIENTS

2. Improving access and oral health for patients

People do not have to be registered with adentist to access NHS dentistry. Registrationwas introduced in 1990 and only 50% of theadult population has ever attended an NHSdentist over the current 15 month registrationperiod. Under the current contract patients areautomatically removed from their dentist’s list ifthey have not re-registered in that period.

While urgent and emergency NHS dental careis still available to all who need it, within areasonable distance of home, some peoplenow can’t get the routine treatment they wanton the NHS unless they are prepared and ableto travel.

Treating patients privately has become moreattractive to dentists. The higher charges ofprivate dentistry enable dentists to see fewerpatients and so spend more time with each.In addition, the increased demand for purelycosmetic dentistry, which is usually notprovided by the NHS, means there is anexpanding private market.

The current system is at the root of theproblem. It was devised in 1948 for post-warBritain, where levels of oral health were poorand people needed extensive routinetreatment.

Around 50% of visits to a dentist under thecurrent working arrangements involve either:

l an inspection and no treatment

l an inspection, and scale and polish.

Some of this work could be done by otherdental health professionals or simply lessfrequently – freeing dentists up to focus moreon prevention, quality and more complextreatment.

In addition, under the current arrangements,the NHS is unable to influence the availabilityof NHS dentists in any given area whichmakes it even harder to tackle particularshortages.

IMPROVING ACCESS AND ORAL HEALTH FOR PATIENTS 7

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Figure 1: Adult Registration, England – September each year

The change in the registration period from 24 to 15 months in September 1996 caused registration numbers to fall betweenNovember 1997 and August 1998. The light blue line shows pre-1998 registrations rescaled to a 15 month period.

The Prime Minister’s pledge in 1999 rightly putthe focus on access to NHS dentistry. Some ofthe most pressing access difficulties havebeen addressed. Forty seven new NHS dentalaccess centres have been strategicallytargeted in areas where access is mostdifficult. They are supported by some£37.2 million a year and are currently treatingabout 300,000 patients who previously wereunable to access treatment by NHS dentists.In addition, some £10 million of ‘Investing inDentistry’ funding was used to extend accessto more patients during 1998-2000.

Some £50m is also being invested nowto provide extra capacity locally, with anadditional £9m targeted at supporting themost challenged PCTs through a new NHSDentistry Support Team. The team is workingwith PCTs to draw up action plans to fillvacancies in dental practices in their area.

Increasing the numbers of NHSdentists

We need to expand the numbers of dentistsand other dental health professionals.

In the short term, we will recruit the equivalentof 1,000 dentists by October 2005, allowingan extra two million people to be treated byan NHS dentist. The increase will come fromcommissioning new capacity, new ways ofworking, international recruitment and dentistsreturning to work after a career break. We areworking with strategic health authorities(SHAs) to ensure that additional capacityis targeted at areas of greatest need.

l We have an agreement with the GeneralDental Council to speed up the process ofregistration for overseas dentists. Thismeans that, by the end of 2004, all dentistswaiting to take the International QualifyingExam, which is a pre-requisite of practicefor non-EU nationals, will have been giventhe opportunity to sit the exam.

l We are also making it easier for dentists toreturn to work in the NHS. We will achievethis by making their career more attractiveby introducing more flexible workingoptions. We have recently started a seriesof advertisements in the national pressdesigned to alert dentists who are nolonger practising to our ‘Keeping in Touch’scheme, aimed at encouraging them toreturn to work. In addition, we have set upa dedicated network of recruitment andretention advisers within each SHA toco-ordinate this activity.

In the longer term we aim to increase thenumber of dentists by:

l From October 2005, expanding the numberof training places for dentists by 170, anincrease of 25% on the existing total. Thiswill more than reverse the impact of theclosure of two dental schools in Englandwhich was announced in 1987.

l Enabling dentists and their teams to workdifferently by freeing up dentists’ time throughincreasing the numbers of dental therapistsand dental hygienists. We are currentlyrecruiting students for the first, stand-aloneschool for professionals complementary todentistry which will open in Portsmouth inSeptember, following an investment of £5million. This will help to expand the totalnumber of places from 50 to 200 and meanswe train more dental therapists than anyother European country. The first of thesenewly-qualified therapists will be joining theworkforce in 2006.

Currently dentists undertake many routinetasks that could be carried out by others in thedental team. We are looking at how the skillsof the wider dental team can best be deployedto maximise the efficient use of availableresources.

We aim to change working customs andpractices so that dentists can focus on thetechnically demanding work for which theytrained, while others in the dental team canundertake the routine, less complex aspects



How we are helping dentists return to work

The Keeping in Touch Scheme (KITS) for dentists on career or maternity breaks, or longerterm absence, who are intending to return to practice:

l Keeps you in touch with clinical and professional developments

l Provides annual allowances towards enabling you to retain your name on the Dentists’Register and maintain registration with your professional indemnity society (with reducedfees while you’re not working)

l Offers subscription to a professional association and journal, and other professionalexpenses

l Offers ongoing access to and support from dedicated Retaining and Returning Advisors

l Provides continuing professional development – including access to a free courseprovided by the post-graduate dental deaneries.

When you’re ready to start work again – the Returning to Practice in NHS DentistryScheme offers all the support you’ve had on KITS, as well as:

l ‘Welcome Back Grant’ of up to £4,000, to help towards any additional costs of returningto practice

l Free refresher courses and hands-on training

l Continued professional development support and access, and protected and paid-fortraining time (unrelated to earnings so as not to disadvantage part-time dentists)

l Guidance and support to help you return to a ‘training approved’ practice.

The Flexible Retirement Scheme offers you the opportunity to work at a pace to suit you:

l Choose to work part-time in preparation for full-time retirement

l Work for limited periods when your skills are particularly in demand.

The benefits of a working partnership with the NHS include access for all to local childcareco-ordinators, and to the NHS Pension Scheme, as well as support for flexible workingoptions.

To talk to an advisor or receive free literature, call the Dentists’ Careers Response Lineon 0845 6060655.

of patient care. Dental therapists, who are ableto do fillings and extract deciduous teeth, havea key role to play in the dental team, andincreasingly dental hygienists are undergoingjoint training courses which gives them theoption of working as dental therapists.

While some progress has already been made,we need to make further increases in thenumbers of professionals complementary todentistry to achieve these changes.

In addition, the National Institute for ClinicalExcellence is expected to issue final guidanceto the NHS on dental recall intervals later thisyear. Its preliminary report suggests that achange in recall intervals – currently patientscan be recalled for a check-up every sixmonths, no matter what their dental health –should be made. This would free up dentiststo see more patients and to focus moreon prevention.


Helping dentists return to practice

Liz Robb wouldn’t strike you as being someone who would bedaunted by much in life. She and her husband, Geoff, lived insouthern Africa for over 20 years with their two sons, Charles,15, and Alexander, 18. Liz, a UK graduate, worked verysuccessfully first as a partner for 15 years in a dental practicewith seven other dentists, and then as the founder director ofChildline – Zimbabwe, now the largest local children’s charityin that country.

The family moved to Britain 18 months ago. One of the firstthings she did was to contact the local university in Bristol tofind out about options for former dental professionals to restarttheir careers.

“I was absolutely terrified – I hadn’t picked up a drill for fiveyears. The university put me in contact with the person running the Keeping in TouchScheme (KITS) who was extremely supportive and encouraging from the beginning.

“Very soon after joining the KITS Scheme, I learned about the ‘Getting Back to Practice’courses being held across the country, and applied to join one at King’s College, London.

“Fortunately the first person I treated for a tooth extraction said that it was the least painfultreatment he’d ever had. That and the rest of the well-designed course gave me a hugeboost. In fact, I was actually incredibly surprised by how quickly everything came back to me.

“It was quite strange when it came to finding a job once I’d completed the course. But I soonrealised that it wasn’t only my skills as a dentist that were in demand. An added advantagewas the life experience I was able to bring to a new practice.”

Liz Robb at Midsomer NortonNHS Dental Access Centre

Oral health in children

Dental health in children is better than it hasbeen since records began. National surveys ofchildren’s dental health have been conductedevery 10 years since 1973, with assessment ofprimary teeth measured in five-year-oldchildren and assessment of permanent teethmeasured in 12 and 15-year-olds.


Offering flexible working arrangements

Kerry Edwards worked as a dentist for six years beforebecoming a full-time mother to Ben, seven, and Jessamy, five.She never envisaged a return to dentistry, despite her husbandrunning a busy orthodontic practice. Six months ago, however,she returned to work alongside him in Bath.

“The longer I wasn’t working, the less confident I became that Iwould be able to go back. Then I saw an advertisement for theKeeping in Touch Scheme.

“Through the scheme I found I could keep up my continuingprofessional development through help with courses,subscriptions to professional journals and on-going membershipof a defence society. I was updated regularly with news of various courses by the South West Postgraduate Deanery andcould pick out those I was particularly interested in, which theywould pay for.

“Initially I was quite nervous after so long away from my profession, especially at one of thefirst conferences I attended. But as a qualified dentist, I was welcomed by my colleagues. Ialso found that through these and other KITS activities and the constant reassurance of mycontacts at KITS, my confidence increased as my skills and knowledge returned.

“Once I’d made my decision to return to dentistry, I was very fortunate to be offered a placeon an orthodontic course.

“Now, after five years away from dentistry, I’ve been working two days a week for six months– and I’m very glad I’ve come back.”

Kerry Edwards at the CircusOrthodontic Practice in Bath

There has been a dramatic improvement indental health in primary teeth over the last40 years, but there is still a long way togo (Figure 2). Currently some six out of 10children starting school have never knowndecay but we still rank seventh best in Europewhen it comes to dental health among five-year-olds. The greater part of this fall in dentaldecay occurred between 1973 and 1983,largely due to the widespread introduction offluoride toothpaste, and over the last 20 yearsthe improvement has been at a slower rate.In 1983, 48% of five-year-olds had no toothdecay, and this increased to 54% in 1993and 56% in 2003.

Under the national dental health educationinitiative Brushing for Life, which theGovernment has funded with £1 million overthree years, health visitors help parents andcarers get into the habit of brushing theiryoung children’s teeth twice daily with fluoridetoothpaste. They give out packs containing atoothbrush, toothpaste and explanatory leafletto the parents and carers of young childrenwhen they attend for a health developmentcheck – at eight months, 18 months and threeyears. In 2003, this programme was extended

to all Sure Start areas in England covering themain areas of social deprivation and 350,000children are involved in it.

There has been a rapid and sustainedimprovement in dental health among olderchildren (Figure 2). In 1973, 93% of 12-year-old children had tooth decay. A decade later,this had dropped to 79% and by 2003 it hadfallen even further to an historic low of 38%.The average number of decayed, missing orfilled teeth in 12-year-olds surveyed in 2003was 0.7, compared to five some 30 yearsearlier. Levels of oral health among this agegroup are now the best in Europe (Figure 3).


1973 1983 1993 2003

D(d

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UK Figure 200315 year olds

Figure 2: Average decayed, missing and filled teeth per child in England

Figures are for the average number of decayed, missing and filled deciduous teeth for five-year-olds and the averagenumber of decayed, missing and filled permanent teeth in 12 and 15-year-olds. Figures taken from the NationalChildren’s Dental Health Survey, carried out in 2003.

Oral health in adults

Adult oral health has also improveddramatically since the 1960s when surveysbegan. The most recent national Adult DentalHealth Survey, in 1998, shows that adults nowenjoy the best dental health for 30 years andthe percentage of adults with no teeth hasfallen from 37% in 1968 to 12% in 1998.

However, many adults, especially older ones,still need complex dental treatment. Olderpatients are now less likely to have fulldentures, but they are more likely to havecrowns or large numbers of fillings. Thismeans that dental care of older people is agrowing priority for the NHS.

The good news is that younger people havemuch less heavily filled teeth and will requireless dental care in the future. To keep this lowlevel of restoration in these younger groups, itis imperative that NHS dentists adopt modern,preventative models of care rather than themore traditional models of care based onrestorative treatment.

In 1998, 50% of the middle-aged populationhad teeth with fillings. In this group, it isimportant to prevent recurrent disease andthey will benefit from the new focus onimproving oral health as much as children.However, this will not stop their existing fillingswearing out and requiring work.

Oral health inequalities

Not everyone has benefited from the generalimprovement because poor oral health is stillclosely linked to economic deprivation, socialexclusion and cultural differences.

Local NHS surveys demonstrate that diseaseis more prevalent in certain sections of thepopulation, especially in Manchester,Liverpool, Leeds, Sheffield and inner cityLondon. Children in parts of the north ofEngland have, on average, twice as muchdental decay as children in other parts of thecountry. Adults in the north of England aretwice as likely to have no natural teeth asthose in the south and there are higher levelsof disease in some communities. Differencesin feeding, weaning and diet, and culturaldifferences, can also affect levels of toothdecay among children.


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Figure 3: Average decayed, missing and filled teeth for 12-year-old children in Westernand Eastern Europe

Improving the system

Work to reform NHS dental services isprogressing well and, following consultationon the new arrangements with dentists, andtrials of the new working arrangements, theGovernment has decided to end the existingGeneral Dental Services contract andintroduce the new working arrangementsfor all dental practices from October 2005.

A new system of NHS charges will need tocome into effect at the same time. The NHSDentistry: Patient Charges Working Group,chaired by Harry Cayton, the Department ofHealth’s Director for Patients and the Public,and involving experts from national patient,consumer and dentist organisations, hasmade its report to Ministers and it is currentlybeing considered.

The aim of the review was to:

l improve clarity, affordability and equityfor patients

l streamline the current system of chargingwhile not changing the overall yield fromcharges

l reduce the administrative burden on dentists

l ensure that charges are not a barrier togood clinical practice and promotion oforal health.

Improving prevention and quality

As the benefits of the new system start to takehold, dentists will be able to refocus their careto disease prevention. We will see dentists


Seeing more patients faster

Orthodontist John Evans, in Bedford, employs a practicemanager, three part-time nurses and a receptionist. Over 200patients a year are provided with braces at the practice.

In 1998 patients were having to wait up to three years for aninitial appointment. John recalls: “By transferring to a new wayof working, we were able to set aside time to see all thepatients on the list and introduce a system to identify thosepatients most in need of treatment.”

The cut in waiting times enabled them to take a more proactiveapproach to care. “We now have new nurses who have beentrained in dental radiography and in dental health education. More time is spent with my patients considering treatment options. We also regularly monitor the quality of our work.

“Under the old system I spent my life filling in forms. Now, because of the new paymentstructure, I no longer associate what I will do for a patient with how much I earn, and thismakes for a much healthier relationship. We are truly delighted with our new way of working.”

Catherine Warne (15) has had extensive treatment at the practice. She says: “Once I sawMr Evans I got the braces very quickly and he has told me that if I have a problem I can gostraight back. I don’t have to worry about it.” Her mother Mary Warne is full of praise for theservice the family has received. “Mr Evans is very accessible. When you ring up you don’thave to wait, when you go in for an appointment you never have to wait, and it is veryefficient.”

John Evans at his orthodonticpractice

and PCTs leading a range of local initiativesto improve health education and preventionof tooth decay among parents and children,through schools, health centres and othercommunity services. The new arrangements

will mean services can be co-ordinated acrossprimary, secondary and social care so peoplein deprived communities, which have thepoorest oral health, will receive more adviceand support.


Creating a more responsive service

Three years ago, Ben Atkins bought Rocky Lane – a single-handed dental practice in theMonton suburb of Manchester. Now he employs five dentists, with a sixth about to start.

Project manager Howard Atkins explains: “At first we were just like every other dental practice.Patients had to ring up to book an appointment, there were problems getting through to thebusy reception desk, especially on Monday mornings when everyone had toothache. Butpatients have very busy lives so we modernised the whole system to cater for them.”

Now the Rocky Lane patients can see the appointments book on the Internet andcommunicate with the practice by email 24 hours a day, seven days a week, 365 days a year.

The practice is also proactively improving access to NHS dentistry by first borrowing a mobilesurgery from their local primary care trust and then buying one of their own. The new surgeryhas enabled the team to take on 250 new patients every month while continuing to servetheir existing patients. They operate a double shift in each surgery, with one team workingfrom 8am till 1.45pm, and the second from 2.15pm till 8pm.

Amanda Kirk has recently rejoined the practice after not visiting a dentist for seven or eightyears. She found it by searching the Internet and was amazed to find an email questionnaire.“I filled it in and then they actually contacted me at home. They said: ‘What would be the besttime for you to come in?’ I start work very early so this was great for me. I gave them a timeand they confirmed my appointment via email.”

Ben Atkins andMatt Mee fromRocky LanePractice in Montonemphasise theimportance oforal hygiene to theLancashire CountyCricket ClubAcademy Playersat the Old TraffordGround. Theplayers were givenlarge supplies ofsugar free gumfor match days

PCTs will be able to work with dentists to:

l link oral health promotion to general healthinitiatives – such as the school drinking waterprogrammes, the five-a-day fruit andvegetable campaign, and healthy snacks inschools

l provide specific advice to patients on dietand nutrition in relation to oral health, takinginto account cultural and religious beliefs

l ensure patients are involved in choosingthe most appropriate dental care

l promote water fluoridation, whereappropriate, and provide information topatients and the public about its benefits

l promote twice daily use of fluoridetoothpaste in areas of poor dental health

l encourage parents to brush the teeth oftheir children as soon as teeth emerge intothe mouth and to supervise their children’stooth brushing up to age six


A new way of working

Dentist Richard Ablett has been with the Scrafton and Bondpractice in South Tyneside since 1990, and a partner since2000. There are three surgeries, two in South Shields, one inJarrow, and between them they have approximately 20,000patients, of whom 30% are children. There are 13 dentists,three nurses and two dental hygienists. The practice is currentlyan Options for Change field site.

Richard says that one of the key improvements has been instaff development, enabling them to introduce new ways ofworking which free dentists up to treat more patients and domore health education and prevention work.

He says: “In recent years we have expanded enormously, taking on more associates, hygienists, nurses and vocationaltrainees. Each year we train one new graduate to certificate

level and this scheme has enabled us to recruit several new dentists. We are also currentlytraining our nurses in oral health education and smoking cessation and soon we hope tointroduce sessions dedicated to preventative dentistry.”

Dentists have already delegated oral health instruction to nurses and hygienists. Plans are inplace to further improve access for patients by reducing the number of missed appointmentsand following new clinical guidelines soon to be published by the National Institute for ClinicalExcellence.

Richard explains: “Appointments at six-monthly intervals may not be right for all patients. Weare planning to offer more flexible appointments, depending on individual treatment needs.We are looking closely at recall periods and we will introduce an automated reminder.”

Joyce Graham is one of Richard’s patients. She says: “I have been going to the practice formany years. I find it an excellent service. They take good care of their patients and I alwaysget an appointment when I want one.”

Richard Ablett at his SouthTyneside practice

l provide patients who smoke or chew tobaccowith advice on the risks to health generallyand to oral health in particular, and to referthem to smoking cessation specialists

l ensure that people in vulnerable groupshave equal access to dental services

l encourage patients to have a dentalcheck-up at regular intervals, in line withevidence-based guidelines and tailored totheir individual dental disease risk factors

l encourage regular dental attendance bypeople at higher risk from oral cancer,especially tobacco and betel users andheavy drinkers

l ensure all patients are examined for pre-malignancy and oral cancer

l ensure that a dental disease riskassessment is carried out for all patients toidentify those at higher risk of developingdental caries, periodontal disease or oralcancer and ensure they are offeredpreventative advice.

In addition, the 2003 Water Act requires watercompanies to agree to requests from SHAs tofluoridate their water supply where they canshow the local population is in favour. TheSystematic Review of Water Fluoridation,carried out by the University of York, showsthat fluoridation increased the number ofchildren without tooth decay by 15%. Thisshows there are clear benefits from fluoridationof public water supplies over and above thoseoffered by other health interventions.Fluoridation is a great equaliser which benefitsall children, irrespective of social disadvantageor privilege, and we can expect this factoralone to influence dental health outcomesacross the population over the next decade.


We are committed to working with dentists andtheir teams to rebuild and restore NHSdentistry. We will achieve this by:

l introducing new working arrangements

l ensuring a fair deal for dentists and theirteams.

New working arrangements

The new working arrangements – effectivelynew contracts for dentists – will be introducedfrom October 2005. An extra £9 million isbeing made available to help dental practicesprepare.

The development of the new system started in1998 with the establishment of new PersonalDental Services (PDS) contracts for dental

practices. These are locally negotiatedcontracts between practices and PCTs whichallow flexibility from the national GeneralDental Services (GDS) contract and itspiecework payment system. As a result, PDSpractices were able to test new ways ofdelivering NHS dental care and rewardingdentists, as well as improving access.

These showed that through paying dentists ina different way, their NHS commitment couldbe maintained and increased. PDS has provedso popular that there are now over 1,500dentists in more than 750 practices, out of atotal of around 9,000 practices, voluntarilyworking in this way, and the numbers areincreasing each month.

Following the success of the PDS pilots, in2002 we published NHS Dentistry: Options forChange, which set out joint proposals, fromdentists, patients and the Government, for theradical reform of NHS dentistry. We alsobegan to test further, with the profession, thedifferent ways of removing the link betweenthe payment to the dentist and the treatmentprovided, and to explore ways of reducingbureaucracy and making better use of theskills of the wider dental team.

With the NHS Modernisation Agency, we setup a programme of Options for Change ‘fieldsites’ covering 210 practices. Dentists whosigned up to become field sites told us theywanted to improve their working lives and thequality of the care received by patients.

18 A FAIR DEAL FOR DENTISTS AND THEIR TEAMS

3. A fair deal for dentists and their teams

The Health and Social Care Act 2003 gavePCTs the responsibility for primary dentalservices. This means they now have a legalobligation to ensure the delivery of high qualitydental services to meet all reasonablerequirements within their area.

Under the new system, PCTs will also begiven responsibility for the current NHS budgetfor dentistry, which is due to grow to £1.6billion, and they will undertake ‘localcommissioning’. This involves them agreeinglocal contracts with dentists or other providers,or employing dentists on their own staff, tomeet the needs of their population. It alsomeans that the local NHS keeps the money itwould have spent on dentistry if a dentistdecides to leave the NHS, which makes iteasier to recruit a new dentist to take theirplace. PDS contracts will continue, but theywill become an integral part of the newworking arrangements.

PCTs already have responsibility forcommissioning primary medical care and for80% of the NHS budget. The move to localcommissioning of NHS primary dental servicesis part of this process. Financial resources forNHS dental services will be devolved to PCTsfrom October 2005. The financial year 2004-05is a preparatory year so we will be consultingPCTs on indicative financial allocations fordentistry for 2004-05 and 2005-06, as well as

issuing proposed 2005-06 contract values fordentists, based on their most recent grossearnings. This will enable PCTs to engage inmeaningful dialogue with dentists on the newworking arrangements.

Fundamental to the introduction and stabilityof the new system will be the new basecontract that PCTs will offer general dentalpractitioners. This is based on PDS and isbeing developed jointly with the British DentalAssociation. It will offer financial security topractices as gross earnings will be guaranteedfor three years, provided the practicecontinues to provide the same degree of NHScommitment.

PCTs are now in a position to offer dentistsappropriate local commissioning contractingarrangements, under PDS, which will givefinancial security to their practices and enabledentists to plan ahead of the October 2005timetable. Any practice which wishes to willbe supported to move into PDS in advance ofOctober 2005. We will shortly publish guidancefor dentists and PCTs to streamline thisconversion process.

A FAIR DEAL FOR DENTISTS AND THEIR TEAMS 19

Options for Change

Since the first sites went live in October 2003, the overwhelming response from those whohave changed the way they practise is that it has improved their working lives and they wouldnot go back to the old system. In reviews of sites which have been working for over sixmonths, 100% reported that breaking away from the ‘fee per item of treatment’ system hadgiven them more time with their patients, even taking into account the time taken to adjustto the new ways of working.

Seventy per cent of the sites have now offered additional commitment and time to the NHS.Furthermore, 65% of all sites working on developing different ways of paying dentists havereceived expressions of interest from other practices that want to work under newarrangements as soon as possible. By removing the monetary incentive to provide as manyitems of treatment as possible, they have seen a reduction of about 10% in the amount ofrestorative treatment provided by dentists.


A higher quality service

More time with patients and fewer problems with recruitmentare among the benefits of the new working arrangementsaccording to David Langman.

Principal dentist David and his wife Anne-Louise run two dentalpractices in Stratford-upon-Avon and nearby Wellesbourne. “Ihave felt that to cost a professional person’s work down to thelast penny, as the General Dental Services system did, was notthe way a caring profession should be funded,” he said. “I feltconfident we would give a better service to our patients andattract dentists to the practice with a different structure.

“We now see patients less frequently, but they are able to havemore time at their appointments,” he said. “Instead of five to 10 minutes every six months we allow 15 minutes every nine to 12months, enabling us to discuss their needs more fully. We have

also found that we are more relaxed, not demanding to fill every second and not demandingto charge for every missed appointment.

“We have no difficulty in recruiting. The General Dental Services system was difficult tomanage – associate dentists found that their income fluctuated on a monthly basis, and it didnot encourage dentists back into the profession.

“The PCTs are really keen to help get NHS dentistry back on the map. Apart from some ITteething problems, which we’ve now resolved, we are really enjoying the experience.”

Dentist David Langman anddental nurse SamanthaMcConnell treat a patient

More time for patients

One dentist who has had plenty of time to see thenew system working is Richard Bootle, in Bredbury,Stockport.

Richard made the move in October 2003 and is in nodoubt that it was time for change. “The General DentalServices system has become archaic and it is bad forpatients and dentists,” he says. “The most beneficialpart of the new system has been gaining the flexibilityto deliver effective dental care where it is needed, which is better for dentists and patients alike.

“As far as the patients are concerned the only changes they have noticed are positive ones.They are now able to spend more time with the dentist or dental professionals.

“There have also been benefits not directly related to the project. For instance, the team feel theyhave been listened to and can make improvements to both their work time and to patient care.”

Richard Bootle at Bredbury Family DentalPractice in Stockport

Benefits for dentists and their teams

As the new arrangements develop, thebenefits of greater integration within the widerNHS should become evident. PCTs will beable to provide assistance and support topractices, including financial assistance, aswell as setting an agreed strategic directionfor the area.

The key benefits are:

l more time to spend with patients

l more time to devote to improving qualityand developing further the evidence basefor dentistry

l less bureaucracy

l less work pressure

l predictability of income

l the security of being able to agree anongoing contract value with the PCT ratherthan relying on a fee per treatment system

l the ability to plan and invest in thebusiness, knowing that financial flows aresecure

l enhanced opportunity for training andcareer development

l the ability to work more closely with thewider NHS to provide more convenient andpersonal services for patients and a widerrange of health initiatives

l the opportunity for practices to beintegrated with the NHS’ NationalProgramme for IT

l the chance to modernise premises inconjunction with the NHS.

A FAIR DEAL FOR DENTISTS AND THEIR TEAMS 21

Improving working lives

Tony Prowde says dentists should find out what ison offer before criticising new working arrangements.

The principal dentist at Clifton Moor Dental Centre inYork became involved in a ‘field site’ as he saw it asa way of improving the funding arrangements for hisnew practice.

“The Options of Change report seemed to offer achange which would get us away from ‘high volume’ NHS dentistry and enable us to provide better qualitycare for patients,” he says. “We are now able to

devote the actual time to doing a task rather than thinking of the financial constraints of thefee system.

“I have been happy to explain the changes to my patients. So much media coverage isfocused on why local dentists are ‘going private’ and patients are very surprised andinterested to hear about the new arrangements.”

While running a practice remains stressful at times, things have improved. He says: “Stresslevels are improving. I would recommend other dentists to find out what is on offer beforeknocking change.”

Tony Prowde at Clifton Moor Dental Centrein York

Salaried dentists

Salaried dentists are an important and integralpart of NHS dentistry. The new workingarrangements will have a direct impact onthese services and so a fundamental reviewwas initiated which will make its initialrecommendations to Ministers in 2004.

The Salaried Primary Dental Care Service(SPDCS) review is part of a 10% pay deal forall SPDCS staff spread over a three yearperiod. The agreement also included theestablishment of a £5 million capitalmodernisation fund, specifically for theSPDCS, which is being distributed during2004-05 to provide targeted support,particularly for those services which have notpreviously received central capital support.

The review covers all SPDCS staff employedby the NHS, those working in communitydental services, salaried PDS pilots, dentalaccess centres and salaried general dentalpractitioners.

The review looks at education, training, careerstructures, leadership and managementissues, in light of the anticipated new world ofdentistry and in the context of widerdevelopments in the NHS in order to furtherimprove quality of care.

l For further information on NHS dentistrygo towww.dh.gov.uk/AboutUs/HeadsofProfession/ChiefDentalOfficer


1948 General Dental Services (GDS)contract set up to provide NHSdentistry. Dentists are rewardedon a piecework system to meetthe high levels of dental decay.

1955 First UK water fluoridationschemes.

1968 First national assessment ofdental health in adults. Now every10 years.

1973 First national assessment ofdental health in children. Nowevery 10 years.

1987 Review of the dental workforce,covering dentists but not thewider dental team, results inclosure of two dental schools inEngland, from 1992, and reducesthe number of dentists beingtrained by 10%.

1990 New NHS contract for dentistsintroduces different feearrangements for adults andchildren, and new incentives,without testing. It also introducesregistration for patients.

1992 New contract costs rise rapidlyand a seven per cent fee cut isimposed by Government. Theprivate sector starts to grow.

1993 Report by Sir Kenneth Bloomfieldsuggests changes to the feesystem and other aspects of NHSdentistry.

1994 The White Paper Improving NHSDentistry published in response tothe findings of the Bloomfield andhealth committee reports. An oralhealth strategy is published,setting national targets.

1997 The Primary Care Act enablespiloting of Personal DentalServices (PDS), giving PCTs,for the first time, the ability toorganise dental services to meetlocal needs.

1998 PDS pilots are introduced and thefirst NHS dental access centresare developed.

‘Investing in Dentistry’ capitalfunding of £10 million distributedto practices to extend access tomore patients by 2000.

2000 Modernising NHS Dentistry –Implementing the NHS Planpublished. A funding packageleads to the expansion of NHSdental access centres to 47.

A Systematic Review of WaterFluoridation published by theUniversity of York.


Timeline

2002 NHS Dentistry: Options forChange, a joint report involvinginput from the profession, patientsand Government, published. Setsout a radical new way to deliverdental care.

2003 The Health and Social Care Act,which gives PCTs a duty tocommission NHS dentistry,passed. Also an amendment tothe Water Act to allow SHAs toassess the health need and publicopinion with regard to introducingcommunity-based waterfluoridation.

An NHS Dentistry Support Teamset up with funding of £9m overtwo years to tackle areas withparticular access difficulties andfurther funding of £50m toincrease local capacity.

The Department of Health’sDirector for Patients and thePublic asked to review patientcharges.

The Government announcesa £30 million investment indentistry IT.

2004 Profession’s representativebodies consulted on theFramework Proposals for the newarrangements.

Announcement that access andoral health are to be improvedfrom 2005 through:

l Investing over £250 million ayear extra in NHS dentistryfrom 2005-06 alongside theintroduction of a new set ofworking arrangements.

l Increasing the NHS workforceand capacity by the equivalentof 1,000 dentists, by October2005, allowing an extra twomillion people to be treated byan NHS dentist.

l Increasing training places by170 – a 25% growth.


Avon

Barnet, Enfield and Haringey

Bedfordshire and Slough

Brighton and Hove

Bromley

Bury and Rochdale

Bury St Edmonds and West Suffolk

Central Southampton

Cornwall

East and West Surrey

East Kent

Gloucestershire (2)

Hereford

Hull and East Riding

Kings Lynn and Wisbech

Leicester

Lincolnshire

Manchester (2)

Milton Keynes

Morecambe Bay

North Merseyside (Liverpool)

North Merseyside (St Helen’s)

North Staffordshire

North and East Devon

Newcastle and North Tyneside

North Cumbria

North Norfolk

Northamptonshire

Nottingham

Oxfordshire

Peterborough

Plymouth

Portsmouth and South East Hampshire

South Staffordshire

Scarborough

Shropshire

Solihull

Somerset

South Cheshire

Swindon

Walsall

Warrington and Halton

Warwickshire

Wolverhampton

Worcestershire


Annex A: NHS dental access centres

All treatment necessary to maintain oral healthis available on the NHS and dentists cannotrefuse any necessary treatment to a registeredpatient.

Patients liable for dental charges pay 80% ofthe dentists’ fee. Fees range from £3.50 forone X-ray, to £297.70 for a fixed orthodonticappliance – ‘train tracks’ braces. Themaximum patient charge is £378 for onecourse of treatment.

NHS treatment does not include purelycosmetic procedures such as tooth whitening.Complex tooth-coloured fillings on back teethare not permitted primarily because they aregenerally less reliable than silver amalgam.

The 400 most commonly provided treatments– and the fees paid for them – are set out in astatement circulated to dentists.

Other treatments may be provided with theapproval of the national Dental Practice Board.

Some treatments are provided by the NHSthrough the hospital dental service only.

Some treatments are provided free to allpatients. These include denture repairs, arrestof haemorrhage, removal of sutures, homevisits, and attendance to open the surgery inan emergency.


Annex B: NHS dental treatments

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