Stop the rot

NHS dentistry is in trouble; of that There is little doubt.And if action is not taken quickly, the drift towards private practice may be irreversible.British Dental Association chief executive Ian Wylie says reform is now inevitable

NHS dentistry is five years away from effective extinction, warns British Dental Association chief executive Ian Wylie. He fears that without significant change the move towards mixed or private practice - which has seen the market more than triple in value to over£1bn since the mid-1990s - will develop an irreversible momentum.

Three years on from the prime minister's pledge that everybody should have access to an NHS dentist, Mr Wylie's concerns are a sign that many of the issues afflicting dentistry are still to be resolved.

Arguably the most significant problem facing NHS dentistry is rooted in an early-1990s fee cut which Mr Wylie says 'made it impossible for some dentists to continue in the NHS'. The disenchantment with NHS work has grown to the extent that in some areas, the BDA chief executive admits, 'you now have real problems finding NHS dentists'.

There is at last a concerted effort to stem the haemorrhaging of NHS dental work, but have the efforts come too late?

'My nightmare, ' says Mr Wylie, 'is that we work the problems through and in a few years we produce the answers only to find the profession has since wandered off.

'There is now an expectation that NHS dentistry will be reformed. Dentists are willing to suspend disbelief until they see what is available [from the proposed reforms]. But if that reform peters out or is delayed too long, dentists will have seen their colleagues down the road successfully convert to private practice and they'll do the same. If nothing changes, you can wave goodbye to a universal dental service.'

But the reasons the BDA chief executive hopes this will not happen are twofold.

The first is dentists' continuing allegiance to the NHS. Only 2 per cent of the UK's 11,000 dental practices do no NHS work and the proportion of general dental practitioners earning 75 per cent or more of their income from NHS work has remained relatively constant at 60 per cent.

The second reason is that, according to Mr Wylie, 'the government is taking dentistry seriously as part of a modernised primary care system'.

In August this year, the Department of Health published NHS Dentistry: options for change.

This set out three 'big ideas': local commissioning and funding through primary care trusts, new methods of payments for the profession, and an oral health assessment of patients carried out by dentists. This has led in turn to the creation of a major research programme overseen by the Modernisation Agency.

Then, late last month, health secretary Alan Milburn included dentistry in the government's new drive to tackle health inequalities ('cross-government war on inequalities', news, pages 6-7, 28 November).

Speaking at the Faculty of Public Health Medicine, Mr Milburn said: 'In this session of Parliament, we are proposing to legislate for far-reaching reform of NHS dental services. PCTs, with the support of dental public health colleagues, will need to assess local oral health needs, including health inequalities, to meet their new responsibilities for dental services.

Moreover, for the first time since the foundation of the NHS, primary care dentists will be given what is essentially a public health role, with the opportunity to focus on prevention and promotion, as well as treatment.'

The champagne no doubt flowed in the Wylie household that night.

Mr Wylie is married to S¯an Griffiths, president of the faculty.

The use of dentistry as a public health tool makes great sense in Mr Wylie's view.

'The health inequalities in oral health are depressing. These days there is not much that distinguishes the health status of rich and poor children except that you are quite likely to have profound illness in oral health [among children from a deprived background]. Dental hospitals are regularly putting children as young as three under general anaesthetic and removing a dozen milk teeth.'

Alongside, and as part of, this public health role for dentistry, the BDA believes PCTs must first determine the baseline dental services they calculate their population requires.

At present, NHS dentistry carried out by general dental practitioners is commissioned through a national contract. The BDA supports the idea of services being commissioned at a local level by PCTs - as long as that funding is adequate and ring-fenced.

But what to commission? One of the important issues to be tackled is which services should be publicly subsidised and to what extent.Mr Wylie would like to see a consensus reached between the public, the profession and the management of the service as to 'what range of treatments will be in the [NHS] envelope'.

Once this is agreed PCTs 'can talk about how resources should be employed in their local area' - including how to tackle any public health needs.

Mr Wylie believes this conversation should take place between local dental committees and PCT professional executive committees which, it is hoped, would have a dentist leading the discussions.

'Switched-on PCTs will realise that LDCs are the best way to engage the profession. They have the knowledge to provide the solutions.'

Because of the way in which dentists are paid, information on dental treatment patterns are routinely collected.Mr Wylie says this information can be analysed - by PCT public health directors, for example - to give an accurate picture of the dental needs of an area.

'You can take that information to the LDC and say, fithis is the situation, We have got responsibility for it, from next April we'll have money for it. Please take it away and come back to us and we'll start to talk about how to provide solutions to these problemsfl.'

Once the range of services has been determined, the thorny issue of payment will have to be tackled.

Dentists perform nearly 100 types of procedures on NHS patients. Patients who are not exempt pay 80 per cent of the cost up to£360. The fee scale, 'which nobody understands', includes 360 items.

Mr Wylie says many dentists are profoundly unhappy with this piecework approach, claiming it does not sit well with providing patient-focused care designed to prevent as well as tackle disease.

He adds: 'We also know patient charges are a real disincentive to people who are on the boundary of paying - they do not go and they do not take their kids.'

There is a range of alternative payment options being examined at the Modernisation Agency demonstration sites. Suggested ways forward include: salaries as for GPs (an approach much favoured by younger dentists), block contracts, session payments, a simplified fee-per-item scheme, capitation (ie, payment by the number of patients registered), prescriptions, and a prepaid system.

It is important, says Mr Wylie, to have a range of payment options.

For those middle-aged dentists who have grown used to the current system, change is particularly 'scary'. Offering them a 'less radical route' to change and phasing in reforms is the best way to manage the tricky transition period.

The Modernisation Agency initiative is nearly finalised and the 50-odd sites should be up and running in the new year. Some involve individual practices, but others are 'whole PCT pilots'.

As well as examining commissioning and funding regimes, the sites will also examine a range of subjects, including new IT systems and clinical governance structures. There are three other problems that need to be addressed if NHS dentistry is to survive, says Mr Wylie.

The first is that, 'We are not training enough dentists'.As with other medical disciplines, he believes one answer is to develop a multidisciplinary approach in which dental practices 'really use the resources of their hygienists and dental therapists'.Mr Wylie would prefer to see dentists taking a mainly supervisory role, concentrating on the more complex problems and developing treatment plans for routine work.

The next problem stands foursquare in the way of developing this multi-disciplinary approach, according to Mr Wylie. The quality of the dental practice estate is 'poor', largely because any investment has to be provided by the dentists themselves.

The need to develop alternative sources of funding, whether through privately financed schemes or local improvement finance trusts, is pressing if premises able to house multi-disciplinary working are to be developed.

The final problem is much more intangible, but just as important. It is the lack of understanding and trust between dentists and the NHS, for which Mr Wylie says both 'sides'must take responsibility.

Mr Wylie, who has worked in communications in the NHS and local government, was previously director of corporate affairs at the King's Fund, and by his own admission knew little about dentistry.

Since coming to work at the BDA, he has been impressed by the strong professional values demonstrated by dentists and the many examples of innovation he has come across. But he says that the profession's 'weakest point' is its inability to 'get its voice heard'.

He says it has not enthused enough about its own possible contribution or listened to the views of others. As a result, it has not joined the 'NHS tribe'.

As to why this might be, Mr Wylie speculates that like many medical professions, dentists become 'institutionalised', something which he says 'has done the profession a disservice'.

But he hopes that the situation is changing. In the past, dentistry has been 'semi-detached' from the NHS because it was seen as a 'pay and rations issue'.Now, with legislation making dentistry a 'must do', he believes the innovators in both camps will become engaged.

'Dentists, ' he says, 'need to have faith. Managers must take risks.

The prize is worth having.' l