The Independent Review of NHS Dental Services: Our analysis

Access – a missed opportunity?

The review has missed the opportunity to consider access to NHS dentistry – a major public concern. The review team abstained from a full consideration of access on the basis that a Which? survey indicated that 88 per cent of people who had tried to find an NHS dentist in the past two years had been successful, and that the Department of Health has an ongoing work programme in this area. The terms of reference for the review included a request to examine how access could be improved, and the team could have provided independent scrutiny of whether the Department’s policies to improve access are proving effective.

What patients can expect from NHS dentistry

The review team found that patients are particularly confused about what is and is not available to them on the NHS and identified clarification of what the NHS offers as a priority.

The promise of a continuing care relationship that is based on the idea of registration appears to be little different from the relationship most patients think they already have with their dentist.

The charges patients pay for NHS treatment have significant implications for access, equity and public perceptions of NHS dentistry. Professor Steele proposes that a full review of the current system of charges is deferred until after the new contractual arrangements have been piloted and evaluated.

Based on the review’s recommendations it seems unlikely that patients and the public will be much clearer about what they can expect to receive on the NHS, what will require co-payment and what will need to be funded entirely privately.

Making advanced care conditional on good behaviour

The proposal that advanced, complex care such as crowns and molar root treatments should be provided as part of the NHS package only where there is a ‘stable and low-risk oral environment’ appears to introduce conditions to NHS entitlement. It means you can receive NHS care for these treatments only if your dentist decides that you are able and willing to look after your teeth afterwards. This proposal could be highly controversial, and further detail is required to flesh out how this might be managed in practice, particularly given the current general lack of evidence-based clinical guidelines in dentistry.

The new contract – a promising ‘blend’ of incentives

The proposal to combine a continuing care capitation payment with payments for quality and activity seems sensible. Research tells us that ‘blends’ of incentives can reduce the perverse effects of pure systems, in this case potentially counter-balancing any incentives to over- or under-treat. However, the NHS contract does not operate in a vacuum; most dentists who provide NHS work also provide private work and the likely impact of these new incentives on dentists’ behaviour has to be considered in that context. The proposed pilots will provide a valuable opportunity to evaluate this interaction in practice.

Quality – how will it all join up?

The aspiration to collect more information on the treatments dentists provide and the quality of those treatments will bring dentistry into line with the policy direction in the rest of the NHS following the NHS Next Stage Review in 2008.

However, there is a danger of duplication with existing and emerging quality measurement and assurance systems and the potential for integration and co-ordination must be considered in detail. It has not been made clear whether and how the proposed new measures of quality processes and outcomes will relate to:

• quality criteria and measurements required for registration with the Care Quality Commission from 2011 and the production of Quality Accounts (subject to legislation)
• the ‘enhanced clinical data set’ required by the Dental References Service as part of the NHS Business Authority
• the voluntary Good Practice Scheme run by the British Dental Association
• the requirements of the revalidation scheme currently being developed by the General Dental Council.

The proposal that dentists and not commissioners should bear the cost of any replacement restorations (such as fillings) required within three years of the original treatment introduces a provider ‘warranty’ not seen before in the NHS. The NHS has begun to shift the costs of failures to providers in the case of ‘never events’ – preventable errors in treatment which result in serious harm or death – for which commissioners will not reimburse providers. It will be interesting to see whether the idea of warranties is considered appropriate for other areas of NHS care. 

Funding –  challenge of implementation

Moving PCTs’ funding allocations for dentistry towards a formula based on need rather than historical patterns of activity is a necessary development, and one already given support by the Chief Dental Officer and the government during the Select Committee inquiry in 2008. The challenge will come when moving towards targets involves reducing dental budgets for some PCTs during a time of general squeeze on public sector budgets.

Overall the principles of the proposed reforms – in particular to remunerate dental providers on the basis of continuity of care and quality as well as of activity and to base funding allocations on need – seem to be the right ones. The pilots provide an excellent opportunity to examine whether these changes can produce a shift in the focus of care towards prevention.