Reforming NHS dentistry
Authors: Ruth Freeman
Journal: BMJ (2008)

The accompanying analysis article by Thomas and colleagues provides routine data on hospital admissions and case reports to support their assertion that “admissions for surgical drainage of dental abscess are a result of changes in the provision of primary dental care in the United Kingdom.”1 Are Thomas and colleagues correct in their assumption? What have been the effects of the “new contract”—launched in England and Wales in 2006—on NHS dentistry?

The new contract was perceived as a portal to a new era of NHS dentistry. No longer would the general dental practitioner be chained to the “treadmill” of a “fee per item” NHS service but would focus on the prevention of dental caries, periodontal disease, and oral malignancies, thereby allowing for a more stress-free working environment for dentists and patients. Dental educators, dental hygienists, and dental therapists were of central importance in the new contract as providers of expertise in oral health. The essence of the contract was to promote oral health and subsequently increase access to primary dental health care, with dental treatment being conceptualised as a safety net for those who slipped off the prevention high wire.

Funding for NHS dentistry also changed as commissioning was devolved to local primary care trusts. Primary care trusts were provided with government funding to ensure “a high quality NHS dental service and to improve oral health and address inequalities.”2 Primary care trusts were able to place dental surgeries where they were needed and provide dentists with a stable annual income based on an agreed number of complete patient treatments—known as “units of dental activity.” The units of dental activity replaced the old fee per item (piece work) system, which had been considered as an incentive for more invasive and complex treatment.3 A simplified charging system was introduced to help patients gain access to affordable NHS treatment. Thus, all the ingredients were in place to promote accessible and affordable primary dental care. The 2006 contract, the greatest reorganisation of dental services since the beginning of the NHS, was instigated with the best of intentions.

When reports of difficulties in accessing NHS dentistry and of deregistered NHS patients queuing outside new dental surgeries hit the headlines,4 5 the government, the dental profession, and patient groups queried the ability of the new contract to fulfil its potential. Government called for expert opinion in its select committees,6 dentists called for renegotiation, and patient groups showed that despite the new contract the main barriers to NHS dental care remained—as before—costs, availability, and anxiety.7 Most patients who had accessed NHS dental care considered the treatment they received to be of the highest standard.7 So what went wrong?

To answer this question we must revisit “Options for Change,”2 which set out the parameters for the 2006 contract. Primary dental care would be cash limited, with primary care trusts holding the budget. Dental premises—once a retirement nest egg—would no longer be sold with goodwill, thereby reducing dentists’ perceptions of being independent health contractors. Nevertheless, this document made it clear that changes in primary dental care must be “evolutionary”2 rather than revolutionary. The NHS would offer general dental practitioners the choice of various arrangements at different points in their careers rather than continuing with a “one size fits all” approach. Also the changes would not occur suddenly but would evolve over time. 

But despite these intentions, a sudden change did occur in the way dentists were contracted and paid by the NHS. By April 2006, dentists were no longer remunerated on the fee per item basis but by a prescribed number of units of dental activity. As the new dental contract gathered speed, the government’s sensitivity regarding professional anxieties slipped away and the profession’s sensitivities for patients’ anxieties were forgotten. Despite the fact that only 4% of dentists left the NHS,3 it seemed to the public that dentists had abandoned their patients,4 5 and stories of dental extractions with pliers,8 and as reported by Thomas and colleagues, life threatening dental abscesses,1 became the folklore of the new dental contract.

With this degree of misunderstanding between public, patient, the medical profession, and the dental professions are there any grounds for optimism? It would seem that there are some grounds for hope because the government has acknowledged the difficulties experienced by the dental profession, and the extent of culture change involved.5 It has recognised that “The next stage is to move to a more flexible and creative process of local commissioning, based on developing services more fully to meet patient needs. This will require strong engagement locally with public and patient representatives, with dentists and dental teams, and with primary care trust professional executive committees. It is only through this process that primary care trusts and dentists will be able to realise fully the benefits of the reforms in supporting improvements in access, quality and oral health.”3 It seems that we may be at the start of an important dialogue between stakeholders, which will have the ability to give patients a better experience of equitable and affordable NHS dentistry.9

During the first year of the new contract it seemed that it would be impossible to supply an equitable distribution of affordable NHS dentistry to populations in England and Wales. However, by appreciating the problems faced by patients and the profession, which were exacerbated by the speed of reform, the government now recognises the need for better communication between stakeholders. This dialogue should pave the way to accessible NHS dentistry for all.