Will NHS dentist reforms improve patient access and care?
In many parts of the UK finding an NHS dentist is a huge problem. In April 2006 big changes to the way NHS dentistry works were introduced, but the vast majority of dentists are very unhappy with the new system. Will the dentist reforms lead to better access and patient care in the future?
More and more NHS dentists are going private
Dentists are largely self-employed and can choose whether to provide NHS treatments or private treatments, or a mixture of the two. In the early 90s, the amount of money paid to dentists to carry out NHS treatments was cut, prompting many dentists to stop doing any NHS work. Now many people simply cannot find an NHS dentist and are either spending the extra money to go private, or going without care if they cannot afford it.
Under the old system, dentists were paid by the government for every NHS treatment carried out - the more treatments the more money. Under this system dentists spent little time with patients, with no emphasis on preventative care. Dentists prefer to spend more time with patients and like doing complex and modern procedures which are often not available on the NHS.
How does the new NHS dentist system work?
Since April 2006, dentists are paid a flat rate covering the amount of work they are contracted to do each year.
Contracts are agreed with the local PCTs (primary care trusts), which now have responsibility for providing NHS dental care in local areas. They are allocated money each year which must be spent on providing NHS dentistry. The money is divided up among dentists willing to carry out NHS work, who are now contracted to carry out a certain amount of NHS work each year.
Dental work is measured in UDAs (units of dental activity). Dentists now essentially have ‘UDA targets' to meet each year, as agreed in their contract.
New patient charges for NHS dentistry
Most adults will still need to contribute to the cost of their NHS dentistry. Along with the new contracts, a new charging system has been introduced. Before, there were over 400 different prices covering different NHS treatments. Now there are only three possible prices you will pay, depending on the complexity of the work needed (Bands 1, 2 and 3).
The idea is that you will always know how much you should be you charged, and you can be sure your dentist is not charging you for any private work. However, the new system means you pay the same for 3 fillings as 1 filling, making 1 filling bad value for money!
What's wrong with the new NHS dentist system?
Dentists aren't happy with it. 2000 dentists refused to sign the new contracts and left the NHS in April 2006, while many more signed ‘in protest'.
A British Dental Association poll of 394 dentists, about a year after the new contracts started, showed clear dissatisfaction with the system. 85% of dentists asked did not think the new contracts had improved patient access, and 95% did not think the new contracts allowed them to spend more time with patients.
Research published by the Citizen's Advice Bureau indicated that, by September 2006, no more people were seeing an NHS dentist than before April 2006.
In many areas, it seems that the annual PCT budgets were not enough. In early 2007, many dentists were turning away NHS patients, or even being forced to take holidays, because the PCT had no more money to pay for NHS treatment.
So far it seems money has not been effectively targeted at problem areas, where there are few NHS dentists. Citizen's Advice say that the new system has not solved the ‘postcode lottery' of finding an NHS dentist.
What's right with the new NHS dentist system?
One advantage of the new system is that when a dentist goes private, local NHS dental provision should not be lost - as money goes back to the PCT which must then use it to fund alternative NHS services.
Under the new system, if you can't find an NHS dentist in your area, you can go directly to your PCT, who now have the responsibility to find you a dentist (perhaps putting you on a waiting list). There are reports of this working well in many cases, but most people don't know they can contact their PCT for help in this situation. This needs to be better publicised.
Will NHS dentist reforms work?
The Citizen's Advice Bureau believe that the new system will eventually provide better access to NHS dentistry, providing money is properly targeted at areas of greatest need.
It is important that people know they can now approach their local PCT if they cannot find an NHS dentist. There are stories of people getting appointments with dentists which had previously turned them away, after approaching their PCT.
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"I am a principal in a small rural practice which sees both NHS and private patients.. Not all practices are under treating and we pride ourselves on providing a quality NHS service but the press, as usual, make us all out as greedy. However, This year we have managed to reach our target early again, despite trying really hard to spread the work out evenly over the year, demand from our loyal patients has been higher than usual and we have increased our practice hours to try and see mi patients. We can hardly ever take new patients on and we have had to stop seeing NHS check ups until April which is really frustrating and embarrassing for us. When we approach the PCT for more funding, (because we know there are other local practices who won't reach their target), we are literally laughed at for suggesting this. There seems to be absolutely no room for expansion or reduction of your contract, depending on demand, each year which seems bonkers when my business partner has UDAs spare at his other local practice but can't pass them on to us because we are in a different postcode, but same pct. So he will be penalised through a clawback and I will e penalised by not receiving payment for all the patients I could have seen! The pct, meanwhile, are pocketing this clawback money from under performing practices and not ploughing it back into areas with higher demand as the money is no longer ring fenced to dentistry, unless you are a corporate, who strangely seem to be the only lot to get new or further funding around here! I worry that any new contract will be equally inflexible and will decrease dental funding still further, never mind the other problems with the contract that others have mentioned, most of which I agree with! The whole system seems very corrupt to me!"
"as i understand it..patients who present a case where a crown or bridge is needed they are offered a denture instead ?? most patients will take this lump of plastic home & either put it in a drawer & forget about it or throw it away!!!!!! what an absolute waste of money & precious moneys being wasted by an effortless way of cost-cutting !!!! simply ridiculous !! those teeth will eventually end up costing us more in the long run?? go back to the old system!!!!!"
"dear Retired NHS consultant , i'm working as NHS dentist for about 5 years now (qualified abroad) and i have never managed to do a filling on a child in less than ten minutes. you see it takes time to chat and relax the young patient first and then do the filling, no matter how small it is. on the other hand, i have never managed to finish a Root Canal Treatment on a molar in less than 80 minutes. Please, teach me some tricks, cause it seems i'm far too slow . Also, i think you are right saying that this NHS contract is fair. It is a contract that sends a clear message to public : don't be fool going regularly to the dentist.The price for having one filling is the same as having ten fillings,two extractions,scale and polish,radiographs and RCT.So, wait till your mouth becomes a mess and then go to see the dentist.You'll save hundeds of pounds which you can spend on fatty food, alcohol and tobacco.NHS cares about you !! "
"This helps to explain why my dentist was so angry with me today. I've spent a lot of money with him on a private basis, for denture and bridge work, and had a good relationship with him. Discovering that an NHS dentist was also available at his practice, and wanting to economise after spending so much on other treatment, I booked an appointment for some cleaning work. It turned out that the NHS dentist is still on maternity leave, and my usual dentist is treating both NHS and private patients. He started cross-questioning me about how regularly I thought I should have cleaning work done, and criticised me for booking an NHS appointment, 'knowing' that I had a build-up of plaque that I should have had cleaned up on a more regular basis. I didn't know the plaque was that bad -- after all, I can't see inside my own mouth! He was implying that I should have made a private appointment for the work, not an NHS one, to make it more worthwhile to him financially. I pointed out that I'd spent hundreds of pounds with him on denture and bridge work, and that when I recently had to have my bridge put back in at short notice, I was quoted £71 over the phone, but was charged over £100, which I hadn't objected to at the time because I was relieved to get the problem sorted. To be 'told off' like this today was totally unexpected and upsetting -- I'm not sure I can continue with this dentist now. He drilled away some bits of plaque, but in a rather rough, jerky way, which made me feel very uncomfortable. I was glad to get out of the chair after about five minutes. As a private patient he'd treated me with respect -- now, as an NHS patient, I saw a different side to him. I'm not sure I can bear to go back there again. "
"Hooray! The Coalition government have promised to scrap the PCTs and get rid of the New Contract. The dental Profession needs to get its act together and make proposals for changing the system which will be better for the patients as well as for those who provide the treatment. We CANNOT leave it to the incompetence of the CDO or the administrative dentists to produce yet another disastrous contract. Stand up dentists and state your cse!"
"What a pity these comments are on a web site that is unlikely to be read by any politician responsible for policy making in NHS dentistry. Many of the comments already posted by dentists are absolutely correct, especially those of P.Martin (18.2.10) and ANONYMOUS (28.2.09). The (relatively) new dental contract has been a moneyspinner for entrepreneurial dentists running multi-handed practices, who are earning huge sums. For their patients it has been a disaster. No longer does the NHS insist that a course of treatment must render a patient dentally fit; instead it is sufficient to "stabilise" the case i.e. do just enough treatment to clock up 3UDA's then tell the patient to come back for the rest in a few months so that another 3UDA's can be earned. The Primary Care Trust will turn a blind eye, and of course the more "courses of treatment" provided the better it pleases the politicians. Moreover there is practically no policing of the service anyway now that the centrally funded Dental Estimates Board has been done away with. Clearly most dentists have a conscience and are honestly trying to make a flawed system work but nevertheless this contract is an open invitation to fraud. How much has the contract cost the taxpayer? Well, the money spent on NHS dentistry has doubled but the annual number of NHS "courses of treatment" (not to be equated with numbers of patients treated) has only just returned to the pre-contract activity level. I find it hard to believe that such a naively constructed contract can ever have been introduced. Unfortunately there can be going back to the old contract, so our new political overlords will no doubt fudge the issue and dream up some sort of compromise which will be an even bigger and more expensive mess than the present one. This whole exercise has been a costly example of how to wreck a service which, with all its flaws, was actually working quite well. "
Retired NHS consultant
"the only thing wrong with NHS dentistry these days is that the PCT's have way too much power. also dentists should be able to open practices and get funding more easily. other than that the new contract is fine. dentists here are crying about 3 UDAs for a root canal treatment but they look at the floor when u mention the 3 UDAs for a small fill on a child which takes 30 seconds. swings and roundabouts. we should be grateful we're in a profession that is secure and relatively well paid compared to most ppl. "
happy (and grateful) dentist
"I agree with the comment regarding the chief dental officer. He has been rewarded for failure. It was an absolute disgrace that he was officially "honoured""
"My work as a dentist means that I see many patients under the care of different surgeons. It is clear that many have been working to a price for some time. The quality of work is often atrocious. As a profession, we should have said 'enough' years ago instead of pretending a filling will last if it's done for £20 or so. Surgeries, staff and equipment cost money. The NHS says that dentists cannot suggest that the NHS provides anything other than a comprehensive service. The GDC seems to agree. My advice is to see a good, private dentist, and if that's beyond your means, just don't go at all. You'll keep your teeth for longer. I have over 20 years experience in several branches of dentistry, including NHS practice and am all too aware of what has happened after round after round of fee cuts. It's our fault for carrying on."
Disillusioned Dental Surgeon
"I have recently qualified as a dentist from a top london university. I have graduated with an incredible amount of debt after 5 years of constant work/exams and study. Despite this I WANT to work in the NHS, but I feel that not only Has my passion for dentistry been extinguished when I read about the 'NEW' NHS contracts, they have taken the life out of dentistry. It is no longer about quality treatment but only chasing targets of UDA's (this is worse than the treadmill!!) forget the word 'Quality' if you think of using it in the same sentence as NHS. I personally do not see myself remaining in dentistry or in the UK. I am distraught and disillusioned with the future of NHS dentistry!!"
"The contract can only be described as disastrous for patients. Dentists are failing to honour their professional obligation to ensure the dental well being of patients by doing the minimum to gain the UDA band payment leaving untreated disease to be dealt with at future courses of treatment. This is termed 'splitting' in the jargon used by dentists. They can therefore claim multiple fees for what should be one course. For the patient exempted charges there is no financial penalty but for the fee paying patient it can be expensive! 'Gaming' is where the treatment offered is the most profitable option. Extractions instead of restoration mean 3UDA's rather than the 12 UDA's for treatment which would involve much greater time spent plus laboratory charges. Dentists are deliberately harming patients to enhance profits. Multiple root fillings and crowns are virtually unavailable. The dental schools are closing waiting lists as dentists dump the unprofitable work on students. The General Dental Council does nothing to maintain professionalism instead, throwing up a smoke screen to give the impression of ensuring dentists are 'up to date' via Continuing Professional Development which adds to the costs of the dentist thus further exacerbating the problem. An analysis of NHS treatment patterns shows that dentists are gaining up to £300m by consciously harming patients or leaving disease untreated thereby maintaining high income at the cost of their patients health. It is governments' unstated policy to exclude expensive treatments from the NHS. They have succeeded in this, shown by the awarding to the Chief Dental Officer of a 'gong' in the New Years' Honours! A reward for the virtual destruction of a meaningful dental health service. The underlying message is that you'd better look after your teeth yourself because the NHS is NOT going to."
"I am a dentist and this article is biased and inaccurate. On the lod shystem we did not 'spend little time tith our patients and no time on prevetnative measures. thsiis an outrageous accusation and unfounded - fuelled by a coule of contentious TV documentaries during the 90s and preparing the public for thsi present outrageous contract which leaves far less time for the patient. What do you mean one filling is poor value for money...the contract barely provides enough funding for one filling never mind six...think about it. Why do you think dentitst loather this contract? The old systemn wasn't brillian and needed improvement. biut at least most peoplewe able to acheive dental fitness and the general standard of dental care was surprisingly good particularly gioven that we were the worst paid dentists in Europe bar Greece during the 80s and 90s. Contrary to folk belief we were a hard working and conscientious lot despite the high publication of a corrupt minute minority. This contract is far far worse and it breaks my heart to go about and see people in the street with teeth missing. Again you article is as ill informed as it is biased against dentists. With this kind of misinformation circulating it is no wonder that successive governments are getting away with perpetuating the appalling situation for the people in this country who cannot afford private dental treatment."
C A Dunn
"With the new contract, it's much more difficult to focus on the quality of treatment. Rather, dentists are pressurised into doing as many treatments as possible in a given time. This obviously reduces the quality of work that is done. This doesn't benefit the dentists or the patients.
The number of UDA ( units of dental activity) that has to be met each month is putting a lot of stress on dentists.
Money is clawed back from the Primary Care Trust if a certain number of UDAs are not met in a year.
I'm worried about the state of NHS dentistry. More dentists are going private and I personally don't blame them. "
"i am a dental nurse and we dont get a large salary just enough to live on.since the contract we have only had a £15 a month rise.we now have to pay £96 a year to be a nurse,and also pay to go on courses.i think its disgusting.but no one cares about us."
"The new general dental contract has severely damaged the future of dentistry, the majority of practice owners have made this bad situation work for them on the backs of their workers, where the practice owner is paid x amount for a UDA from the PCT only a small proportion will be paid to the actual worker in some cases less than 40% whilst the practice owner will keep the rest for not doing any of the work
I was paid £12.55 per uda by the PCT but when i returned from maternity leave my boss asked me to resign and gave my job to 2 new graduates at a lower rate. He could do this as the PCT's have not given us employment rights even though we are paid just like employees but we pay our taxes as we are still self employed. I was left to find work elsewhere a year later I'm working for £8 per uda a demotion in the NHS after 6 yrs of experience, is this the way the PCT'S are allowing the future dentists to be exploited, can you see what will happen, these new graduates will migrate or become private leaving the patients in need of oral care in the hands of foreign cheap labour. IS THIS THE FUTURE OF NHS DENTISTRY? "
"My husband just had to have 4 fillings done at the Dentist - he is an NHS patient. The Dentist would only do one on the NHS and said he had to pay to have the other 3 done privately!"
"To the comment regarding Dentists having to work for the NHS for 10years before they are given the choice of moving away is a laughable one. Private dentists, yes in theory, may earn alot of money yet you seem to have igorned the fact that alot of this is put back into the government through taxes. You talk of being greedy. Then rather than questioning Dentists why not question why on 1.4% of the NHS funding is being put into dentistry? The new contract of 2006 was implimented to allow dentists to have more time with patients and better care. Yet due to lack of funding dentists were forced to take holiday. The use of the word greedy was directed in completely the wrong direction. efore suggesting such stupid ideas look up the facts. We already have a lack of NHS dentists in this country... by imposing a law that all dentists must work for the NHS for 10 years.. there will be a lack of dentists completely. "
"under the contract dentists earn very good money usually between 100,000 and 175,000 per year but they are greedy. they should have to work for the nhs for at least 10 years after being trained at great cost by the state."
"My Wife's a Dentist who has worked within the NHS since qualifying, but has been seriously demoralised with this new contract. Her practice was told that they were underperforming against their contracted UDA's and would be subject to a clawback of several thousand pounds by the PCT, this resulted in a quite a lot of stress & worry for her & the practice principal, only to be then told they had actually 'overperformed' by the same number of UDA's, but that these units had been lost! So if you underperform the PCT can claim back the monies paid, if you overperform Dentidt's are working for free.
I have to say, that when I looked at the details of the contract, I believed it was more of a tool for the PCT to save money, rather than a re-organistion that would lead to a better service. No 'fair' contract would put an extraction at the same level of UDA's (3) as a root filling.
Not only that, you spend years working within the NHS to build up a patient base and a good practise, to be told that when you retire your contract will be put out to tender, so your practise has practically no value!"