the big story

Published: 11/11/2004, Volume II4, No. 5931 Page 12 13

Photos of hundreds queuing for an NHS dentist are not an image a modern service wants to project.But is handing the problem over to PCTs the answer? Daloni Carlisle reports

In February this year, the public queued around the block when a new dentist opened up lists to NHS patients. It is not a sight anyone in the Department of Health wants to see again.

Around half the English population are not registered with a dentist and the Daily Mail claims that nine in 10 dental practices will not take NHS patients - and will only take children on the NHS if their parents elect to be private patients. The government's plan for addressing this is called Modernising NHS Dentistry and involves handing over£1.2bn to primary care trusts and making them responsible for commissioning dentistry, including outof-hours services.

Alongside this there will be recruitment of 1,000 new dentists, investment of£50m in capital programmes to improve dental surgeries, a 25 per cent rise in training places, a 19.8 per cent increase (£250m) in the national budget. Crucially, there will also be a revised contract that will see dentists abandon the old fee-fortreatment treadmill (general dental services) and replace it with a system that rewards them for looking after a population's dental health (personal dental services).

The DoH has invested£9m in a dental access team now working with the 16 most challenged primary care trusts in the country.

Health minister Rosie Winterton has been visiting them weekly over the past few months. And if the messages reaching her are anything like those reaching HSJ, she should be seriously worried.

As a member of the DoH central team puts it: 'Primary care trusts do not have the manpower to push this through. They do not have the money to recruit dental practices.'

Capacity in PCTs is certainly a major threat to the modernisation programme. A typical PCT will have one or two people working on dental services and an average of 32 practices.

As they attempt to persuade local dentists to increase their NHS quota and move from GDS to PDS before October 2005, PCT staff have to visit every practice several times, often to review complex figures.

'In two of the PCTs I cover that work is going alongside the quality and outcome framework visits for general practice - and they involve a three-day visit to each GP, ' the DoH dental access facilitator adds.

Camilla Lambert, director of primary care in Isle ofWight PCT - where only 22 per cent of adults are registered with an NHS dentist - is familiar with the scenario.

'We have one full-time dental commissioner and a support post here, but we will be increasing that using some of the DoH allocation. There is a lot of intensive legwork we need to do before 2008 (when PCTs will have a free hand in commissioning rather than being tied to pre-2005 contract rates).We need to get on top of data monitoring, for example.'

Ah yes, data monitoring.

'Changing from fee per item to paying dentists a fixed sum for looking after a population - It is a positive concept, ' says a PCT commissioner working across several PCTs in southern England. 'But we are extremely unclear in PCTs about how we will monitor it.'

Dentists, he says, have several ways they could use the system.

For example, PCTs will be funded in 2005 against a base line measured in 2003-04. Dentists will have their income guaranteed for three years from October 2005.

Now, suppose a dentist is doing a certain number of crowns that require, say,£10,000 of laboratory work to support it.He will be paid the£10,000 under the transitional arrangements.

'But suppose that dentist then switches his clinical judgement and does lots of big fillings instead, ' asks our wary commissioner. 'Will he pocket the£10,000? Will we be able to monitor that and challenge it?'

That should become clear as the new base contract is agreed, socalled because it will allow PCTs a base on which to engage their local workforce on PDS contracts. It has been under negotiation for more than 12 months and has been delayed from April to October 2005 already.A draft was slammed by dentists last month, with the British Dental Association saying it did not meet the objective it was supposed to achieve.

'Up to now we have been an observer but There is a recognition that we need to take a more active role, ' says NHS Confederation manager Elaine Cohen. Last week the confederation expanded its role to become an employers' organisation.

'I do sympathise with commissioners. The idea is that the base contact will define what the monitoring arrangements will be. But There is a lack of clarity as the negotiations are not complete.'

But this is not the commissioners' only worry. The£50m capital investment is designed to be used by PCTs to sway dental practices over to PDS long before the October 2005 deadline. It is been partially successful. In some areas - for example Hambledon and Richmondshire PCT in Yorkshire - half the dentists providing NHS services are ready to sign up to PDS contracts. Overall, the BDA says around 800 out of 9,000 practices have moved to PDS.

Andrew Harris, manager of South West Peninsula's options for change programme - the modernisation programme the DoH launched in 2002 in a bid to try new ways of working - works with 11 PCTs and 47 dental practices across Devon and Cornwall.

They are field-testing the programme, with PCTs commissioning services from dentists who work under PDS contracts.

'It is too early to give facts and figures as some of the practices have only been operating the new system for three months, ' he says.

'But anecdotally they say they like it. They are able to concentrate on meeting patients' needs rather than how much income the practice will get for each visit.'

But for some the development cash creates problems, according to one commissioner: 'We can go round our practices and upgrade them and persuade them to sign up 1,000 new patients. Then in October 2005 we will not have the revenue to pay for treatment.'

The DoH facilitator agrees. 'If you use the access funding That is been allocated by the DoH There is nothing left in the pot to incentivise practices to come across to the new arrangements, ' she says.

And many dentists are not champing at the bit, ready to come back into the NHS fold.

'They are wary after the way they were treated in 1992, ' says one director of primary care.

That was when the Conservative government, having imposed a new contract in 1990, unilaterally cut fees by 7 per cent, prompting the exodus of dentists from the NHS.

HSJ has come across a number of areas where dentists are pulling out - with the potential to further restrict NHS dentistry and leave PCTs with a responsibility that they cannot fulfil.

'I am having problems getting some of the dentists to sign up to new contracts, ' says one director of dentistry. 'They want to know what they will be earning next week or they are not going to play.'

There is, however, a silver lining for PCTs. 'If dentists do pull out of the NHS, we get to keep the money. That is one good thing, ' says Natalie Wood, director of primary care at East Hampshire PCT.

Meanwhile, the BDA reports that PCTs are pulling back.

'We have got members ready to sign up to PDS but they say that PCTs are unwilling, largely because of the financial situation, ' says Lester Ellman, chair of the BDA's general dental practice committee.

The final risk to success characterised by PCTs is whether they can employ 1,000 extra dentists in time. The heaviest emphasis is on international recruitment with Ms Winterton last week announcing the recruitment of 30 Polish dentists.

Next on the list is India, and so far 1,200 dentists have registered an interest in the DoH's central recruitment scheme.

With only 11 months to go there is a huge amount left to tackle and there is a real possibility that come October 2005 there will be even fewer dentists working in the NHS. But by that time it will no longer be central government's responsibility. No wonder PCTs are nervous.

A look inside: dentistry dates

1948 Birth of NHS dentistry; dentists paid a fee per treatment.

1987 Training places cut by 10 per cent; two dental schools closed.

1990 New contract: different fee arrangements (children and adults).

1992 7 per cent fee cut.Exodus of dentists from NHS begins.

1998 PD - where dentists are paid for looking after a population - piloted in the NHS.

1999 Tony Blair pledge: within two years all NHS patients will have access to NHS dentist.

2003 Health and Social Care Act shifts commissioning to PCTs.

June 2004 NHS Dentistry: delivering change , a report from the chief dental officer, outlines a new contract to end fee per treatment and replace with treatment on the basis of clinical need from October 2005.Pledges investment of£250m over 2003-04, and an increase in NHS of 1,000 whole- time equivalent dentists.

July 2004 Bath University study suggests NHS in England is short of 5,200 dentists.

Oct 2005 NHS budget for dentistry to be devolved to PCTs.