Select Committee on Health First Report


Dental Remuneration[116]

During the first 40 years of the NHS General Dental Service dentists (GDPs), working as independent practitioners, provided all NHS dental care on a fee-per-item basis. Initially fees were set on the basis of the time spent providing services. But already in 1949 this had led to unsustainably high earnings as dentists responded to the huge demand for free services. Fee cuts and charges for some forms of care were imposed.

Addressing the problem in 1960, a Royal Commission noted that, although the number of treatments had risen, the amount of time dentists spent providing them (a measure of effort) had not changed correspondingly. Advances in technique and technology had allowed greater productivity without greater effort. The Commission recommended that the fee-per-item of service approach should stay, but that simple increases in the number of procedures undertaken should no longer, of themselves, result in dentists earning more.

This laid the basis for the current GDS remuneration system. This is a "process of negotiation, forecast and calculation"[117] in which the NHS fee is not a price for a particular treatment (as it might appear) but an element in an equation designed to deliver a certain quantum of net income, given practice expenses.

It works as follows:

  • The Doctors and Dentists Review Body examines the work of the profession annually and recommends a level of remuneration for the average dentist. Since 1994 this has been expressed as a percentage of the fees.

  • Given this advice and taking into account the overall amount of resource available for NHS dentistry, the Government sets a level for that remuneration.

  • The Dental Rates Study Group then forecasts the likely average practice expenses of GDS dentists in the coming year, adjusts the figure for previous under- or over- payments of expenses, and sets a fee scale that will provide average net remuneration at the level set by the Government. The forecast of expenses is, in part, based on the likely incidence of particular treatments in the coming year.

In theory dentists as a group can thus be rewarded for increased productivity, an increase distributed to all through the fee scale. But to get that increase, based on forecast levels of activity, an individual dentist has to match those activity levels—or beat them if he/she wishes get a higher than average increase. Moreover adjustments because of, for example, previous forecasting inaccuracies, mean that in practice fee levels are either "declining or increasing very slowly"[118]—a further incentive to increase turnover.

The result is as follows:

  • In the current year forecast levels of activity are exceeded as individual dentists attempt to beat the forecast average to increase their income

  • For the coming year the DDRB recommends a level of remuneration based on the increase in the workload of GDPs evidenced by their increased output

  • The DRSG sets the fee levels for the coming year, based on the same output that prompted the DDRB's recommendation in the first place, plus an expected percentage productivity rise, plus any adjustment for previous under- or over-payments in previous years. The net result: fee levels rise imperceptibly if at all

  • GDPs, knowing that their reward for increased activity is related to the average level of activity for the whole profession, are encouraged yet again to beat the forecast levels of activity

This system is known to the profession as the treadmill.

In 1991 the remuneration system was described by the then Secretary of State for Health as "this discredited funding system". It was further criticised in the 1993 review undertaken by Sir Kenneth Bloomfield, who cited a number of inherent weaknesses, including:

  • the concept and practical effect of a system based on the arithmetic notion of the average dentist;

  • the lack of prioritisation;

  • the incentives and effects of a system based on a fee for item of service approach.

Reporting in the same year the then Health Committee also commented that:

    "the present system of remuneration for dentists seems to have an inherent leaning towards instability which threatens to undermine the commitment of dental practitioners to the NHS," and that "the productivity incentives in the current system exert pressure on the quality of care."[119]

The 1994 DoH document Improving NHS Dentistry proposed two alternatives:

    i)    sessional fees with the treatments available categorised along lines suggested by the Health Committee Report, i.e.:
  • diagnostic and preventive services (free to all)
  • maintenance services (free to those who attend regularly)
  • advanced treatments (100% charge to those who can afford to pay)

    ii)   a fee-based system with a fee for every procedure carried out on adult patients and an amended capitation fee for children. DoH noted that 'this option has the disadvantage of retaining many of the disincentives and failings identified by Bloomfield and the Select Committee'.

However, it is this second alternative that persists today. The remuneration system therefore 'still rewards quantity and not quality.'[120]

116   Material in this section is sourced from HC (1992-93) 264 and Sir Kenneth Bloomfield: Fundamental Review of Dental Remuneration, HMSO (1992) Back

117   HC (1992-93) 264. Back

118   HC (1992-93) 264. Back

119   HC (1992-93) 264, paras 103, 114. Back

120   BDA News, December 2000. Back

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