How is NHS primary care dentistry organised?
Primary dental services are one of the four pillars of the primary care system in England, along with general practice, primary ophthalmic services (eye health) and community pharmacy. These services use a ‘contractor’ model of care, which means that almost all NHS primary care services are delivered by independent providers contracted to the NHS.
There are around 11,000 independent dental provider practices in England, private businesses that provide a mix of both NHS and private dental care. About three-quarters of these hold contracts to provide NHS services. These practices might be dentists working as individuals or in partnerships or small businesses, although there are also a small number of large corporate dental providers. Dental providers who have a contract to provide NHS funded dental services can also offer private treatment to their patients. All dental practices must be registered with the Care Quality Commission.
There is no national registration system in dentistry like there is in general practice. People do not need to be registered with a dentist to receive NHS care and should be able to go to any dental practice that holds an NHS contract for treatment, without any geographical or boundary restrictions. Dental practices can choose whether they provide NHS treatment to new patients depending on whether they have capacity under the terms of their contract (see below).
Once a patient is accepted for an assessment of their treatment needs the practice cannot refuse to complete the course of treatment. Once the treatment is completed, the dental practice does not have ongoing responsibility for their dental care, though some NHS treatments, such as fillings, crowns and inlays, are covered by a 12-month guarantee. Dental practices have patients they regard as ‘regular attenders’ for the purposes of planning recall appointments. Dental practitioners can prescribe any items listed in the dental practitioners’ formulary, and can issue both NHS and private prescriptions.
Community dental services provide dental care for patients (adults and children) with more specialist needs. This might include people who need services such as general anaesthetics or sedation, orthodontics, or adults and children with particular needs such as physical or learning disabilities, medical conditions, people who are housebound and people experiencing homelessness. Community dental services are provided in a range of settings including mobile clinics, people’s own homes or care homes, hospitals and specialist health centres.
Most secondary care dentistry is provided by NHS hospitals, including the 10 NHS specialist dental hospitals in England. It includes services such as complex oral surgery, oral and maxillofacial pathology, dental and maxillofacial radiology. Secondary and tertiary care dental providers have an important role in providing dentistry training and may also provide emergency primary care dentistry.
How is NHS dentistry commissioned and contracted?
From 2013 to March 2023 NHS England was responsible for commissioning primary and secondary dental care in England, a process led by the primary care commissioning team. From April 2023 integrated care boards (ICBs) took over responsibility for commissioning primary, secondary and community dental services. The change from NHS England to ICBs is intended to enable commissioning and provision of dental care that meets the particular needs of local populations and addresses inequalities oral health and in access to care. Local commissioners use national commissioning standards and guidance to assess local needs, set a minimum standard for services and ensure outcomes and quality measures are included in service specifications and contracts. In order to provide NHS dental services, providers need to hold one of the following NHS contracts.
General dental services (GDS) contracts
These contracts are the most commonly used for NHS primary care dental services and do not usually have an end date. The GDS contract covers ‘mandatory dental services’, which are routine and clinically necessary urgent treatments needed to keep the mouth, teeth and gums healthy and free of pain. GDS contracts can also cover more specialist services, known as ‘advanced mandatory services’ and ‘additional services’, which include more complex extractions, home visits or sedation.
Personal dental services (PDS) contracts
PDS contracts cover specialist primary services such as sedation, orthodontics or home visits but can also include mandatory dental services and are usually time limited for a period of about five years. They make up about 15% of NHS dentistry contracts. A PDS Plus contract was introduced in 2008 and has a different payment mechanism including payments for meeting certain performance indicators such as re-attendance rates. The National Audit Office reported that in March 2020 there were only 36 PDS Plus contracts in place in England.
Other dental care services are commissioned in the following ways
Urgent dental care services
While urgent dental care to patients who are undergoing a course of treatment at the practice within a practice’s normal working hours is provided as part of the GDS contract, other urgent dental care, including out-of-hours care, may be commissioned separately from a range of providers. Patients usually access this type of care by contacting NHS 111 for triage and are then referred to a local provider.
Community dental services (CDS)
Community dental services provide dental care for patients (adults and children) with more specialist needs. This might include people who need services such as general anaesthetics or sedation, orthodontics, or adults and children with particular needs such as physical or learning disabilities, medical conditions, people who are housebound and people experiencing homelessness. Community dental services are provided in a range of settings including mobile clinics, individual homes or residential homes, hospitals, and specialist health centres. Community dental services are usually commissioned from NHS trusts but may also be commissioned from other suitably qualified providers under PDS or GDS contracts.
Secondary care dentistry provided in NHS hospitals
Secondary care dentistry is commissioned from NHS hospitals under the standard NHS contract.
How is payment calculated?
Units of dental activity (UDAs)
Under the GDS contract, payments for primary care dentistry are made for units of dental activity (UDAs), up to a maximum negotiated annual contract value agreed in each dental provider’s contract. There are six bands of treatment, which attract different numbers of UDAs.
Under the GDS contract each provider agrees to provide a set number of units of dental activity (UDAs), for an agreed price from 1 April until 31 March the following year, with the total value of the contract paid in monthly instalments. If the provider does not achieve 96% delivery of their contract activity at year end, following an annual reconciliation process, money for the care that has not been delivered may be recovered by the commissioner.
|Band||Number of UDAs||Includes|
|Band 1||1||Examination, diagnosis and advice|
|Band 2a||3||Everything in band 1, plus additional treatment such as fillings, root canals and extractions|
|*Band 2b||5||Everything in bands 2 where there are three or more fillings/extractions in one course of treatment and/or non-molar root canal treatment to permanent teeth|
|*Band 2c||7||Everything in band 2 plus molar endodontic care to permanent teeth.|
|Band 3||12||Everything in band 2 plus more complex treatment such as crowns, dentures and bridges|
|Urgent||1.2||Examination, assessment, advice and urgent treatment|
*Introduced in October 2022.
The first phase of dental contract reform was completed in July 2022. Changes included the introduction of enhanced UDAs to better reflect the cost of providing more complex treatments currently remunerated under Band 2 and introducing a new national minimum value for each UDA across England. Providers will now be able to be reimbursed for up to 110% of their contract value on a non-recurrent basis, subject to agreement with the commissioner. The reforms also promote longer gaps between checkups for those with good oral health, and have made it easier to use the full range of dental health professionals more effectively to deliver services.
Patient charges for NHS dentistry were introduced in 1951. The money from patient charges is collected by dental practices but is passed to the NHS and in 2021/2022 amounted to £633 million. Some patients are exempt from dental charges including children, pregnant women and new mothers, and those receiving certain low-income benefits. There are no patient charges for secondary and tertiary care dentistry.
|Band||Patient charges at April 2023||Includes|
|Band 1||£25.80||Examination, diagnosis and advice|
|Band 2||£70.70||Everything in band 1, plus additional treatment such as fillings, simple root canals and extractions and simple changes to dentures|
|Band 3||£306.80||Everything in band2 plus more complex treatment such as crowns, mouthguards, dentures and bridges|
|Urgent||£25.80||Emergency appointments or urgent treatment that cannot be postponed|
Who works in dentistry?
Dental services are provided by a multi-disciplinary team. All dentists and dental care professionals (which include dental hygienists, dental nurses, dental technicians, clinical dental technicians and orthodontic therapists) must be registered with the General Dental Council. In February 2023 there were 34,415 registered dentists in England and around 60,000 registered dental care professionals (some of whom hold more than one registered title).
About 85% of the dental workforce work in independent general dental practices. Others work in NHS community services or hospitals.
The normal route to become a qualified dentist is to complete a degree (either BDS or BChD), which is usually a five-year course. Dentists must then register with the General Dental Council before they can practise. Dental graduates trained in the UK then usually undertake dental foundation training for a year, working under supervision in a practice approved by NHS England. Once this is completed they can apply to join the NHS performers list for England if they wish to provide NHS primary care dental services. They may also choose to do further training, known as dental core training, for between one and three years, mostly in dental teaching hospitals, special care and community dental clinics and acute hospitals. This may be followed by a further three to five years of dental specialty training.
Dentists who have qualified overseas need to pass the overseas registration exam to register with the General Dental Council, and if they wish to provide NHS primary care dentistry they must also apply to join the NHS performers list.
Other registered dental care professionals working for a dental provider may also provide NHS services once they have completed the appropriate training set out by the General Dental Council. Recent reforms allow dental therapists and other dental care professionals in a dental practice to assess patients, diagnose common conditions and provide treatment or refer on to a dentist when more complex treatment might be required, rather than patients needing to see a dentist first.
Access to NHS dentistry is a significant challenge. In the British Social Attitudes Survey in 2022, satisfaction with NHS dentistry fell to a low of 27% and dissatisfaction increased to a high of 42%. 24% of respondents said they were ‘very dissatisfied’ with NHS dentistry – a higher proportion than for other health and care services asked about in the survey. Healthwatch England reports that patients frequently raise issues around access to dentistry, and that 7 of 42 integrated care boards reported that they had no dental practices taking new adult NHS patients that they had not previously treated. While people can theoretically be treated by any dentist with an NHS contract, data from 2022 found that people who had been to a particular practice before were much more successful in getting an NHS dental appointment than those who were not previously known to the practice (82% compared with 32%). Younger adults and people from minority ethnic groups were had the lowest levels of success in accessing appointments. A report by BBC News and the British Dental Association in August 2022 found 9 in 10 NHS dental practices across the UK were not accepting new adult patients for NHS treatment.
As well as difficulties in securing an appointment, there are wide disparities in the availability of dental practices providing NHS services. There is also a significant geographical variation in the supply of dentists, with dentists concentrated in cities and around dental hospitals and schools. In addition, the number of dentists willing to provide NHS services is falling.
Particular groups of the population are at risk of poorer dental health and worsening health inequalities. Research has shown that people in more deprived areas and those in vulnerable groups such as, homeless people, looked after children and people from Gypsy, Roma and Traveller communities, face particular difficulties accessing dental care. In addition, over the past 10 years the number of children with dental decay has risen significantly, particularly for those in the highest areas of deprivation.
The Covid-19 pandemic has had a significant impact on primary care dentistry. Routine dentistry was completely suspended for several months in 2020. In January 2022 the government announced the investment of £50 million to provide an additional 35,000 urgent dental care appointments to help to drive services back to pre-pandemic levels.
The second to last paragraph states:
''In addition, over the past 10 years the number of children with dental decay has risen significantly, particularly for those in the highest areas of deprivation.''
This statement is quite misleading. The number of children with dental decay may have increased (not sure if it has?) but it that due to population numbers? The proportion of children experiencing dentaldecay has certainly not increased significantly:
The prevalence of experience of dental decay in five year olds decreased from 30.9% in 2008 to 27.9% in 2012, to 24.7% in 2015 and to 23.3% in 2017. Prevalence remained the same nationally at 23.4% in 2019, and 23.7% in 2022. The first 3 surveys showed a clear trend for lowering prevalence of experience of decay and there was a reduction in oral absolute health inequalities from 2008 to 2015. The surveys in 2017, 2019 and 2022 have not demonstrated any further improvements in prevalence of experience of dentinal decay or inequalities.
Poor oral health increases the risk of physical ill health with increasing evidence of its impact on heart disease diabetes and dementia to name a few! Children with poor oral health and bad teeth are stigmatised and face years of teasing and 'shaming'. I'm hearing that in many areas particularly in the South of England dentists are not taking on any new children and do not provide pregnant women with free services as you would be entitled to as an NHS patient. How common is this and what should be done to ensure every child can access a dentist at a reasonable cost (free for low income families) is it time for sympathetic schools dentists to return?