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07 February 2024 | Country Update
Dentistry recovery plan for England
5.12. Dental care
Dental services in the United Kingdom consist of a three-part system: general dental services in the community; secondary and tertiary dental services in acute hospitals for difficult problems; and community dental services in clinics and nursing homes, provided for those who cannot use general dental services, and also in schools to screen children for problems (Cylus et al., 2015). Local commissioning groups must ensure that NHS dental care is available within the geographic area for which they are responsible. Charges exist to access dental care in all United Kingdom constituent countries. In England, a three-tiered charging bands system exists to cap charges for NHS dental care dependent on the complexity of the treatment received (see section 3.4.1 Cost sharing (user charges)). Wales also uses a three tiered charging bands system, although with slightly lower charges than in England (Welsh Government, 2021c). As of 2020/2021, patients pay up to 80% of the cost of treatment up to a maximum of £384 (€453) per course of treatment in both Scotland and Northern Ireland. Many people are eligible for exemptions from dental charges including pregnant women, children and those on low incomes (see section 3.4.1 Cost sharing (user charges)). For individuals who access dental services privately, they pay for private dental care through private insurance plans or directly out of pocket.
Dental services for NHS patients have historically been reimbursed on a fee-for-service basis (Cylus et al., 2015). Dentists may subcontract their work, which results in some dentists being providers (they contract with the NHS), providing performers (they contract with the NHS and deliver services) and performers (they deliver services but do not contract with the NHS). There is broad consensus that the historical payment systems for dental care did not sufficiently incentivize prevention of poor oral health. As a result, dental contracts have been subject to recent reform across the United Kingdom. For example, in England and Wales to encourage a more preventive approach, several prototype contract models have been piloted incorporating capitation and pay-for-performance reimbursement (UK Government, 2018a). An initial evaluation has indicated promising results in terms of improving quality, incentivizing prevention and maintaining access (UK Government, 2018a).
NHS England and the Department of Health and Social Care published Faster, simpler and fairer: our plan to recover and reform NHS dentistry [1]. The policy aimed to respond to a long-term trend where a large and growing proportion of the population are unable to access the National Health Service’s primary dental care, due to low participation of dentists in the state-supported system.
This document promised a higher minimum (GBP 28) level for the “Unit of Dental Activity”, the simple base unit at which dental activity is paid. This is a response to a situation where an unreformed contract means some areas of the country pay far less than others, leading to highly uneven access. It also committed to bonus payments for treating patients who had not been seen in the preceding two years, in order to incentivise addressing the problem of people outside the state system, and introduced dental vans as a travelling solution for isolated areas with poor access while more progress could be made.
On workforce, the plan reiterated a commitment to a 40% increase in training of dental therapists and other associate professionals, as well as dentists themselves, by 2031/32. It introduced GBP 20 000 “golden hellos” for 240 posts in priority areas, and announced a consultation on mandatory public sector work requirements for dentistry graduates. Accompanying guidance stated that it was permissible for dental therapists and other professionals to open and close courses of NHS treatment, something previously often understood to require a fully qualified dentist.
The plan also contained oral hygiene outreach activities in nurseries and child support centres, and teams in school to apply preventative fluoride varnish to 160 000 children. There will be consultation on an expansion of water fluoridation, initially to the north-east of England.
The plan confirmed a pledge for longer term reform to the dental contract. It was criticised by experts and key institutions, including the Health and Social Care Committee of the UK Parliament, for delaying these larger reforms [2]. The existing contract has not been changed since 2006 despite being widely perceived as deeply flawed [3]. Its limitations have been associated with a long-term decline in access, a shift of staff and patients to the self-pay private sector, and a lack of incentives for prevention.