NHS dentistry

NHS dentistry in the United Kingdom is intended to ensure that dental treatment is available to the whole population. However, unlike medical care, charges are made to most people. Dentists act as private contractors to the NHS. In the past their contract with the NHS involved being paid a fee for every item of service that they provided. This form of contract became known as the 'fee-for-item' system. This system of payment eventually led to professional conflicts with many dentists feeling that the system of payments was leading to 'perverse incentives'. These 'perverse incentives' were related to incentives to over-treat patients. However, more crucially, they left little room for prevention in general dental practice.

Scope of the service

According to NHS Choices "All the treatment that your dentist believes is necessary to achieve and maintain good oral health is available on the NHS. This means that the NHS provides any treatment you need to keep your mouth, teeth and gums healthy and free of pain.". This includes if clinically necessary: dentures, crowns and bridges, orthodontistry, root canal treatment, scaling and polishing, and white fillings.

Many dentists who provide NHS services also offer additional services, such as hygienists, for payment. A dentist is allowed to refuse to provide treatment under the NHS and then offer to perform the same treatment privately. However, this practice is far from clear cut, as many dentists do not provide what they are contractually obliged to provide, and instead "upsell" in a process known as gaming.

A revised contract is under discussion in 2013 with greater emphasis on oral health and quality indicators. The British Dental Association is keen to see reform, having campaigned vigorously against the "flawed, target-driven arrangements" introduced in 2006 that are currently in place.

Availability

Following the government's introduction of a new contract in April 2006, NHS dentistry is not as widely available as it once was, with 900,000 fewer patients seeing an NHS dentist in 2008 and 300,000 losing their NHS dentist in a single month. This has forced many patients to pay much higher sums for private treatment, and has been criticised by the British Dental Association as having "failed to improve access to care for patients and failed to allow dentists to provide the modern, preventive care they want to deliver".

Ben Bradshaw when Minister for Health was questioned on Radio 4 in 2007 about the shortfall in NHS dentistry leading to patients unable to access NHS dentists and even resorting to pulling their own teeth out. He suggested that those needing urgent treatment should go to see their GP, prompting the British Medical Association to observe that a General Practitioner was no substitute for a qualified dentist.

There are repeated stories of shortage of NHS dental services in 2013, especially in remote areas such as Skye and Cornwall. Lack of access to emergency dentistry is often seen as contributing to overcrowding in hospital casualty departments.

Charges

Initially NHS dentistry was free at the time of use but charges to patients were introduced in 1951 and have been increased from time to time. The rises have consistently failed to keep pace with inflation.

There are now three standard charges for all NHS dental treatments in England and Wales:

• Band 1 course of treatment – £18.80 (Wales: £13.50) covers an examination, diagnosis (including X-rays), advice on how to prevent future problems, a scale and polish if needed, and application of fluoride varnish or fissure sealant. Band 1 also covers emergency care such as stopping bleeding, trauma, teeth knocked out, severe pain or swelling, even if more than one visit is required.
• Band 2 course of treatment – £51.30 (Wales: £45.00) covers everything listed in Band 1, plus fillings, root canal work or removal of teeth.
• Band 3 course of treatment – £222.50 (Wales: £185.00) covers everything listed in Bands 1 and 2, plus crowns, dentures and bridges.

It was announced in March 2016 that charges in England would rise by 5% in April 2016 and a further 5% in April 2017. The British Dental Association complained: "This unprecedented hike in dental charges will only serve to discourage the patients that are most in need of care."

Dentists are paid in "Units of Dental Activity". Typical values for UDAs are £20-35, and they are paid 1 UDA for a band 1 course of treatment, 3 for a band 2 course of treatment, and 12 for a band 3 course of treatment. Patient charges are deducted from these values. For many treatments, the rate of pay is below the cost of providing the treatment to a modern standard, and as a result, many dentists will refer patients for any unprofitable services.

In Scotland and Northern Ireland, the system works differently and relies upon a mix of capitation payments alongside Item of Service charges. An examination in Scotland is free of charge to the patient, but pays the dentist £8.10. For most other items of treatment, the patient charge is set at 80% of the total fee. The fees paid are approximately one third to one half of what they were in 1948, once adjusted for inflation.

Exemption from Charges

• children under 18,
• people under 19 and in full-time education,
• people who get some Means-tested benefits,
• women who are pregnant or have had a baby in the previous 12 months and have a valid maternity exemption certificate (MatEx) when they start a course of treatment
• People in custody
• people who have a certificate (HC2) entitling them to help under the NHS Low Income Scheme. An HC3 certificate gives some help but not exemption from charges. The effect is that a patient is only asked to pay three times the amount their income exceeds the free treatment level. Any charges paid within three weeks are added together and count as one charge.

History

School dental services provided by local authorities developed slowly after 1907 when the first service of this kind was set up in Cambridge. The Royal Commission on the National Health Service in 1979 reported that local authorities had a statutory duty to make comprehensive dental treatment available to pupils since 1953, but undermanning had prevented the school dental service from delivering it. In 1968 37% of the population of England and Wales over the age of 16 had no natural teeth. In Scotland 44% of the population over 15 in 1972 had none.

There were about 14,000 general dental practitioners doing NHS work in the UK in 1977, employing about 20,000 dental surgery assistants, and 1145 dental hygienists. 46% of adults with some of their own teeth in England and Wales regularly attended a dentist in 1978 compared with 40% in 1968. In 1979 there were about 400 dental consultants in hospital services, mostly based in the 17 undergraduate dental hospitals and one post-graduate institute.

At the inception of the NHS in 1948 there were 3 branches of dental service, and these 3 branches still exist today, although the organisation of services in England has changed much more than in the rest of the UK:

• A local health authority dental service which provided dental inspection and treatment to school children, pre-school children and to pregnant women and mothers of infants under one year old, but is now chiefly Special needs dentistry. These were transferred to the NHS in the 1974 reorganisation. These services employed the whole-time equivalent of about 1,980 dental officers, assisted by 370 dental auxiliaries, 2,900 dental surgery assistants, 70 hygienists and 140 dental technicians in the UK in 1977. They were repeatedly reorganised, like other community services. Most were run by Primary Care Trusts until they were abolished in April 2013.
• A general practitioner service. Proposals for whole time salaried service at health centres came to nothing and almost all General Dental Practitioners are in private practice. Contracts were originally held by Local Executive Councils, and then by their successors Family Practitioner Committees, Family Health Services Authorities and Primary Care Trusts. They are now held by NHS England
• A hospital dental service, with access to specialist maxillo-facial and oral surgeons. Managed originally by Regional Health Authorities they became part of NHS Trusts, mostly in teaching hospitals.

Performance

In June 2015 The consumer group Which? contacted 500 dental surgeries listed on the official NHS Choices website and found that 31% of them were refusing to take on any new NHS patients. They called for the Competition and Markets Authority to intervene to ensure dentists were complying with rules. The British Dental Health Foundation. HealthWatch England said that in some parts of England only a fifth of surgeries were accepting new NHS patients. The chair of the British Dental Association, said the “byzantine system” had failed dentists and patients.

See also

Special needs dentistry