Select Committee on Health Minutes of Evidence

Memorandum by the General Dental Practitioners Association (D 29)



  The General Dental Practitioners Association (GDPA) is one of the two Trade Unions in Dentistry. The GDPA was founded in 1954 to represent, only, the General Dental Practitioner (GDP)—the high street dentist.


  2.1  This document had been awaited for several years and the wait only resulted, for the most part, in the expected—doing nothing of significance. What is most surprising about it is the manner in which it differs, so markedly, from the overall NHS Plan which contained admissions of long-term underfunding and the promise of monies to rectify this.

  2.2  The overriding principle for judging the value of this document is:

  Does it propose measures that will achieve the prime directive which is to entice a majority of general dental practitioners to increase their commitment to the dental NHS?

  The present access problems stem entirely from the steady reduction of the time GDPs are prepared to donate to the dental NHS and it is only a reversal of their attitude that will bring about the desired rectification of the problem.

  2.3  GDPs know that 100 per cent NHS dentistry is not economically viable and that the rewards pale into insignificance when compared with those they experience in private practice. Not jut financial, although these are paramount, but mental and physical—which come from the ability to provide treatment to a standard that enables GDPs to get satisfaction from, and have pride in, the work they do.

  2.4  Does this strategy deal with the problems? No!

  Will it succeed in the prime objective? No!

  2.5  It does make some admissions, some of which deal with fairness and equity which have been the cornerstones of GDPA policy for many years. The GDPA has maintained that the principle of a national fee scale, which takes no cognisance of local conditions and results in financial punishment for those whose dedication is of the highest, cannot be just. Therefore, both Equalisation of Expenses Ratios—[which means that where local costs are above the average (such as in London as an example) resulting in reduced reward for the same item of service carried out elsewhere]—and Deprivation Payments—[concerns the fact that although the item of service fee applies to a specific treatment classification, the work involved is not the same in areas of social deprivation, where caries, for example, is gross and extensive and the treatment involves a much greater expenditure of time]—require incremental payments to bring nearer the goal of parity of reward.

  2.6  The Dental Strategy document offers a "loyalty bonus" as a solution but this has already been achieved via the Review Body on Doctors and Dentists Remuneration (DDRB) and does not address the problem properly. The previous Select Committee understood the issues well as shown by their Report of 1992-93. We draw attention especially to paragraphs 198, 200, 201, 202 and 203.

  2.7  We regarded these increments for pay parity to be a partial, temporary solution whilst awaiting the arrival of a strategic plan which would tackle the underlying, root cause and, preferably, offer a totally new system. A plan which would do away with the twiddling and fiddling with a system that was initiated as an interim measure in 1948. As the Secretary of State for Health writes in his foreword: "NHS dentistry has served the country well for over 50 years. Just like the rest of the NHS, it now needs to modernise".

  This is that plan and it does not even mention the primary areas for modernisation which are in its methodology and the levels of practitioner reward—and, in honesty, the strategy can only be classed as a failure and a waste of all our time!

  2.8  Through political eyes it would seem that the key objective, feature No 1 is to keep the Prime Minister's September 1999 commitment "NHS dentistry shall be available by September 2001, to everyone if and when they need it".

  2.9  This does not mean that dentistry, as an entirety, is to be available, but that the relief of pain shall be the prime criterion. Thus a great deal of emphasis (and of the money too) is aimed at the formation of "dental access" "drop in" centres. We, along with all other dental organisations, have demonstrated in the past, that the only financially efficient provider of primary dental health care is the "ordinary" GDP.


  3.1  The GDPA submitted to this Government, on its accession, an extensive briefing paper and also a "think piece" entitled "If the NHS had not been invented would it be created today—and in what form?"

  In these papers we suggested:

    (a)  that circumstances today leave the public with the view that government's obligation is only needed for those of the socially deprived; and

    (b)  that nobody, and that includes government, can have what they are not prepared to pay for.

  3.2  The responses to the Bloomfield Report all echoed this latter feeling and the General Dental Services Committee's response suggested that if no additional monies were to be provided then prioritisation, by class, for treatment should be instituted. It was envisaged that there would not be sufficient money to pay for those who did not receive relief from statutory payments.

  3.3  As previously commented above, the institution of Equalisation of Expenses ratios, Deprivation Payments and Loyalty Payments were needed:

    (a)  to reward and retain those GDPs working in the high cost, socially deprived areas—but only if no overall restructuring of the dental NHS was carried out; and

    (b)  to enable government to carry out its obligations to the poor and needy.

  3.4  The Nuffield Group published an unsolicited paper on the subject of the use of ancillary staff for dentistry.

  Even though they themselves inserted several caveats including that the introduction of ancillary staff could not be countenanced without radical change of the system of remuneration for NHS GDPs and that there was no proof, whatsoever, that there would be any money saving by their introduction this was seized upon by Government as "dentists are too expensive to do dentistry" and costs could be brought down by their employment.

  Nobody would claim that the dilution of the profession by this means would lead to a raising of quality yet this plan includes this as part of a chapter which states that its target is that of the NHS being "more clinically effective and more cost effective".

  3.5  There is a mass of statistical evidence which proves beyond doubt, that the most efficient and cost effective method of providing treatment to patients is via the general dental service provided by GDPs. Most of this evidence the Departments of Health have ignored, denying the fact of the immense capital costs outlay that is involved in the provision of a dental practice. It is, in fact, only of very recent times that DDRB have appreciated its extent and have expressed some concern when we showed that sum to be in excess of £150,000.

  3.6  In advocating the foundation of 50 "drop in" centres, the Government, in this plan, is expecting a cost of between £500,000 and £1 million each. This excludes the revenue costs which will also be much greater than they expect. It would appear to be a lesson Governments have yet to learn—the hard and expensive way. It is going to prove to be very expensive window dressing—so much more could have been achieved with the money if it had gone to the right place and with the right spirit.

  3.7  Mr Blair, the Prime Minister, stated in the House of Commons when introducing The Plan for the NHS as a whole "that it suffered from years of underfunding" and that he was "going to increase spending by a third over the next five years".

  If this were to be applied to the dental NHS this would correspond to at least an additional £500 million.

  3.8  As the GDS is provided by GDPs who are independent, private sub-contractors without any governmental funding as to their practice capital and revenue costs this should have, reasonably, resulted in paying GDPs 33 per cent more (even if this low level figure of underfunding was accepted by reducing the level of dental underfunding to that of the NHS in general).

  3.9  This plan ignores any mention of paying all GDPs more via a raised item of service fee-scale. In fact it offers nothing to GDPs in general except peer review, clinical governance mandatory postgraduate education and re-registration.

  It mentions only some local incentives and loyalty pay (whose existence has already been established and which accounts for £20 million of the total figure of £100 million mentioned in the document).

  3.10  There is no mention of any goal which involves increasing the fee-scale by an amount that would be of significance and which would stand any chance of enticing those GDPs (who comprise 90 per cent of profession) to increase their dental NHS commitment despite the admission of the great fall in the commitment of GDPs to the NHS.

  Nor does the plan call for an order of increased spending that would be in the same ballpark as that which Mr Blair stated to be necessary.

  Nor does it meet with the Secretary of State for Health's foreword ". . . and makes sure that the development of dental services in England will be consistent with, and a core part of, the NHS plan".

  3.11  There is no mention of the important subject of standards of treatment nor, more importantly, of the question of raising them. Chapter 4 "Improving Quality" concerns itself with:

    (a)  clearer information for patients as to their rights;

    (b)  strengthening self regulation of the profession (although the "self" part seems destined to be diminished (4.22) by re-organising the GDC to have more lay members;

    (c)  the implementation of clinical governance; and

    (d)  continuing to tackle fraud.

  3.12  We feel it would be appropriate to include some of the comments from Chapter 1 of the very recently published 30th Report of the Doctors' and Dentists' Review Body on Remuneration.

    —  "We particularly welcome the acknowledgement in the Plan (NHS Plan) of the underfunding and staff shortages the professions have raised with us over recent years."

    —  "With the exception of the retention of dentists in the NHS we see no evidence at present of major retention problems among our remit groups."

    —  "We are glad to see that the Health Departments have acknowledged that, increasingly, GDPs are reducing their commitment to NHS work."

    —  "The retention of GDPs in the NHS and their motivation do not appear to us to be improving. We consider that in order to meet the commitments in Modernising NHS Dentistry it is important to encourage GDPs' retention in the GDS and introduce measures to increase their motivation."

    —  "It seems to us that the survey [DDRB commissioned BMRB International to carry out a survey on its behalf] into GDPs hours of work and workload support some of the concerns the profession has raised with us about GDPs' workload and its subsequent impact on GDPs retention in the NHS and on their morale. We believe that the survey's findings tend to support the professions' assertion that the GDPs' reducing commitment to GDS dentistry stems, in large part, from a desire to alleviate the pressures under which they are working in the GDS."

    —  [Research done by the GDPA shows that GDPs in most of the civilised world have a workload of 10 to 12 patients a day, four and a half days per week (against 30 to 40 per day for a UK, NHS GDP) for a standard of living much higher than that which NHS GDPs enjoy today.]

    —  "We continue in the belief that a comprehensive fee relativity exercise is long overdue and that such an exercise should re-evaluate treatment timings having regard to quality objectives, clinical developments and patient expectation."

  This is a précis of part of what the DDRB diagnoses as being wrong with the dental NHS and anyone who reads the dental strategy document will readily see that nothing is done to redress the ills.


  4.1  To make the NHS (and by implication the dental NHS) something "to be proud of and the envy of the world" was Mr Blair's stated intention. To do this a great deal more money is required—most of it for substantially increasing what GDPs are paid for the treatment they provide—and it is obvious, the Government has no intention of so doing!

  The plan, both by its contents and its omissions, make this abundantly clear. Rather, it would seem, the Government would prefer to redefine its role and commitment on the lines that its obligation is to provide treatment only for emergencies and for those unable to afford the private fees.

  4.2  That the service is to be of a "first aid service" type is clearly demonstrated not only by the lack of mention concerning standards of treatment, which figured so loudly in Mr Blair's Commons statement, but also by the intention to establish, at great cost, NHS Direct (the dentists finding bureau) and NHS Dental Access centres. The declared purpose of Access centres is to provide treatment for unregistered patients (3.18) and thus defeating the other declared objective of improving the nation's dental health by continuing care and prevention.

  The remainder of the money is aimed at local incentives primarily to deal with the areas of social deprivation—in an effort to retain manpower, partially compensating for the effects of high costs and higher time expenditure that those GDPs suffer.

  4.3  There is also the intention (4.30) to tighten "prior approval" for advanced and complex treatments for such "treatments are sometimes given when they are not justified". Additionally, in respect to orthodontics, (4.34) "This will concentrate valuable NHS resources more on the cases of greatest clinical need and less on purely cosmetic work". Some abnormalities are more important than others and, despite the effect they may have on the body and person as a whole, should not be classed as treatment worthy, it would appear—even by the new Professionals Complementary to Dentistry (PCDs).

  The emphasis for the widespread use of "cheaper" ancillaries who will, no doubt, be used as the main manpower source for these centres, compounds this evidence (4.44).

  4.4  By these methods, and by the lack of any effort to tackle the root cause of the problem, the main body of the dental NHS will be allowed to wither and perish.

  4.5  Examining the inferences, suggests that Government will, in its second term, seek to have a "nationalised" dental health service with its emphasis on pain eradication—to the detriment of the existing sub-contracted service.

  It will accept a minimal obligation, such as exists for Ophthalmics, carried out by and run by employees of local Primary Care Trusts, in conjunction with Health Authorities, in their own premises and will leave the "private sector" to deal with the bulk of the population.

  In the socially deprived areas, where demand and obligation will be greatest, we believe that local authorities will arrive at individual contracts of a purchaser/provider nature or may even acquire existing practices, converting the incumbents to a salaried basis or place a contract with a group owned practice probably on a sessional basis.

  4.6  This document suggests that patients are called for check-ups too frequently and that many scale and polishes (at a gross cost to the NHS of £122 million) are provided without clinical justification (4.37 and 4.38). It goes on to say—"It is possible that this treatment could be provided more clinically effectively and cost effectively—and both patients' and dentists' time better spent—by recalling patients at intervals which match their individual needs more closely."

  Many patients need to be seen four or six times a year (example: cases of poor gum conditions) and as GDPs cannot claim for this the DoH assumes that it does not happen.

  In paragraph 4.39 it suggests that there should be discussions which "will cover the question of how to make the best use of the time freed up—for example by treating more new patients".

  4.7  Whilst we appreciate that Government has an obligation to scrutinise public expenditure dentists resent this lack of trust.

  This destroys morale and drives GDPs to reduce their NHS commitment.


  5.1  More money, in adequate amounts, made available from central public funds would solve the problems virtually absolutely. Rewarded at a proper level (not an outrageous one) most of the problems would be managed within the compass of whatever system was to be operated.

  5.2  We would suggest that an net income of the order of £65,000 per annum for an agreed, designated, workload liability would see a huge reversal of the trend of haemorrhage of personnel from the dental NHS.

  This can be brought about in a number of ways:

    (a)  to bring the fee-scale nearer to that which applies in the private sector. This should give an incentive for those already remaining to stay as well as those who are beginning to start therein.

    (b)  The acquisition of ownership of the practices (as was the original intention) and placing GDPs into a similar contract to that of GMPs.

    (c)  An alteration in the methodology and level of financial reward. If some of the Bloomfield and Select Committee recommendations were activated—such as the reimbursement of fixed and staff costs—then reward for actual labour can be made nearer to equal.

    (d)  The possibility of the introduction of an adequately funded and remunerated, sessionally based scheme should not be discounted.

  If this were coupled to some further direct reimbursement, say of rent, as already existing with rates, plus Deprivation Pay increments (similar to Jarman Index) the goal could be achieved. It was an ill sold previous idea—too nebulous and supposedly cost neutral ever to have found the support of the profession. It did not mean that it was totally unacceptable—for it is the system by which consultants are paid!

  5.3  However, if no further monies are to be forthcoming then the maxim must be:


  5.4  It must be accepted that the dental NHS cannot offer a full range of treatments if it wishes to stay within its financial limitations. GDPs cannot go on subsidising the dental NHS.

    (a)  In its response to the Report of Sir Kenneth Bloomfield the profession, accepting the implied reality, suggested that the available monies be targeted to produce a "core service" either by population type or by treatment type or by a combination of both.

  The profession expressed its willingness to discuss this, in depth, further although its tendency was to population type. This was defined as prioritising with children at the head and then the poor etc.

    (b)  Some monies must be made available to rectify the inequalities of high deprivation and high costs so that a targeting of available money goes to the areas of population most in need of treatment and the retaining of the manpower to provide it.

    (c)  Alternatively, the GDPA has for many years advocated a "Grant in aid" solution. The title is misleading but the core of its suggestion is that of a credit system whereby very basic treatment costs are provided for everyone but that the patient is given the option to pay an additional sum towards the cost of higher quality or more advanced treatment.

  It can be exampled by Ophthalmic provision today. The patient (if eligible) can pay additionally for better frames or "varilux" lenses. The GDPA recommendation is that all are eligible to a basic degree and can opt to pay extra.

  This system is similar to that which pertains in France.

  5.5  The list above refers to alterations to the status quo but other alternatives exist.

    (a)  Government could redefine its obligations to the NHS.

  If the NHS did not exist would it be invented in its present form? Circumstances and social conditions have changed considerably since 1948 and it is extremely unlikely that the dental NHS would have included a format that included availability to all—just as "free at the point of delivery" no longer exists. The latest NHS Plan hints that the Government may have this in mind with a service provided by state owned practices (Access Centres and Drop in Centres) assisted by local contracts with selected practices concentrating on the areas of social deprivation.

    (b)  An alternative methodology one could consider is the institution of a totally private arrangement for treatment with the patients being able to claim a refund from public funds, in varying degrees, according to their tax code number. This is the principle of the German Health Service.

    (c)  Another alternative would encompass a scheme for compulsory insurance for dental treatment with the public purse liable only for the premiums of those unable to pay—such as those on income support.

  Whether this compulsory insurance is provided by the private sector or by the government itself is a political decision. As can be seen from the figures in Appendix 1 there is little difference. Similarly, the who should pay is a political decision.

  Should those in work pay the premium for their families? Should others pay partially depending on their ability to pay? Should a liability to pay be allied to their tax code number? Should it be tax deductible?

  The answer to such questions is not for us.

  5.6  At first sight these proposals might seem impractical, but closer examination reveals an impressive logicality. Let us look at some of the bullet points for solutions 5.5(b) and (c).

    —  Why should there by any necessity for government to be involved in the provision of health care other than to make certain that all have the wherewithal to achieve it?

    —  Why should government involve itself in the vast costs of administration at both national and local levels, quality checking and anti-fraud investigations when this can be easily left to others including the patients themselves?

    —  In short, why should the provision of dental health care be nationalised?

  5.7  Which ever way that it is decided, government should be involved (but only as a less than major partner) in the regulation of the fee-scale which should be negotiated by the profession and the insurers on an annual basis. There is now a third party—corporate dentistry—involved in dentistry whose existence would act as a market regulator.

  The level of the premium should also be subject to government control.

  5.8  If a negotiated fee-scale level is determined at an acceptable basic level and the treatments allowable specified, then patients would be free to choose their preferred provider and what level of quality of treatment they require a long as they are prepared to shoulder the excess liability.

  Governmental responsibility, in this scheme, is reduced still further—and more of the onus is put where it should belong—with the patient.

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