Summary
Unlocking Better Dental Care is a reform initiative focusing on enhancing the National Health Service’s (NHS) dentistry services in England. Managed by the Office of the Chief Dental Officer, the reform prioritizes prevention and self-care, in line with the NHS Long Term Plan principles. This initiative significantly alters the remuneration system, blending capitation and activity to replace the existing Units of Dental Activity (UDA) system. By doing so, it aims to incentivize financial rewards based on patients’ needs and align clinical activity with those who require it most.
The reform also stresses the need for the appropriate use of skill mix in NHS dental care and intends to dismantle administrative barriers impeding dental care professionals from fully utilizing their scope of practice. In 2021, advisory and working groups, comprising representatives from various dental and health organizations, were established to understand the challenges of the existing contract and assess the results of the prototype program.
The initiative recognizes the challenges around access to dental services, particularly in specific constituencies, and the importance of delivering immediate improvements for patients. It is funded by NHS England through a mix of payments from the NHS and patient charges, with certain groups of patients entitled to free dental care. The reform aims to tackle individual, system, and societal barriers to dental care, with measures such as enhancing public awareness and facilitating access to relevant information about NHS care.
However, the impact of the reforms has been a point of contention. While some posit that the changes have resulted in positive outcomes like improved access to dental care across the country, critics argue that the reforms have failed to fully address existing problems, and in some instances, have exacerbated the situation. Despite these challenges, there remains a commitment to achieve an equitable distribution of affordable dental services, with future efforts focused on reducing costs, improving information, ensuring appropriate timing and location of care, and better patient management.
Overview
Unlocking Better Dental Care refers to a reform initiative for the National Health Service (NHS) in England, with a particular focus on enhancing dentistry services. The initiative was managed by the Office of the Chief Dental Officer, providing clinical leadership throughout the program. The central aim of this reform is to prioritize prevention and self-care in accordance with the NHS Long Term Plan principles.
An integral component of this program is the introduction of a remuneration system that blends capitation and activity, moving away from the existing Units of Dental Activity (UDA) system. This new model is expected to reward financial incentives based on patients’ needs and align clinical activity with those who require it most.
In addition, the reform initiative underscores the importance of proper use of skill mix in NHS dental care and intends to remove administrative barriers that hinder dental care professionals from fully exercising their scope of practice. This involves clarifying the regulatory position of dental therapists and hygienists providing direct access to patient care within the NHS primary dental services.
In 2021, advisory and working groups were established to understand the challenges of the existing contract, define the aims of the reform, and assess the results of the prototype program. These groups comprise representatives from various dental and health organizations, including the British Dental Association, Healthwatch, the Office for Health Improvement and Disparities, and others.
The reform aims to address individual, system, and societal barriers to dental care. The individual action includes ensuring access to the relevant information about NHS care, making appointments, agreeing on treatment and costs, receiving the necessary care, and ultimately achieving improved oral health and a satisfactory patient experience.
The State of Dentistry in NHS England Pre-Reform
NHS England has made significant contributions to dentistry, amounting to approximately £2.3 billion in the 2021/2022 period . The NHS dentistry system includes a wide variety of services aimed at maintaining oral health and preventing pain. This involves primary, community, secondary, and tertiary dental services . A key part of the primary care system in England, these primary dental services are complemented by general practice, primary ophthalmic services (eye health), and community pharmacy .
Under the pre-reform model, various registered dental care professionals could offer NHS services, assuming they completed the requisite training outlined by the General Dental Council . This allowed for greater flexibility in patient care, as dental therapists and other professionals in a practice could assess patients, diagnose conditions, and refer to a dentist for more complex treatment needs . However, access to NHS dentistry posed a significant challenge .
Historically, primary care trusts were tasked with ensuring quality NHS dental services, improving oral health, and addressing inequalities . These trusts could establish dental surgeries in needed areas and provide dentists with a stable income, based on a pre-agreed number of patient treatments—referred to as “units of dental activity” . However, the system faced criticism, especially regarding access to dental treatment in regions like Wales, Northern Ireland, and Scotland .
Under this old system, NHS England would allocate funding to Integrated Care Boards based on the dental services provided in 2006 . This model did not factor in the evolving needs of patients or allow for the opening of an NHS course of treatment by therapists . As a result, the old system limited practice growth and stifled the wider application of skill mix theory . Access to and availability of NHS dental appointments became a significant issue, further exacerbating the crisis in NHS dentistry .
In an effort to improve the system, proposals were made to increase the Unit of Dental Activity (UDA) rate and make working for the NHS more attractive . Simultaneously, there were considerations for further contract reform and a reevaluation of the need for NHS dentistry to inform future funding allocations . Yet, despite these efforts, the decline in spending impacted the NHS’s ability to recruit and retain dentists, particularly in underserved areas, potentially leading to a further decrease in access to dental care .
NHS England Dentistry Reform
The NHS England dentistry reform was initiated to tackle the issues related to the delivery of dental care to high needs patients and to improve patient accessibility to NHS care. This reform, described as the first stage of dental reform, was laid out in a letter published by NHS England on 19 July 2022.
Initial Reforms and Stakeholder Reaction
In the initial reforms, a national plan for NHS dentistry services in England was set out by the Department of Health and Social Care and NHS England. However, stakeholders and the Commons Health and Social Care Committee contended that these changes were inadequate, calling for fundamental reforms to the contract. Their suggestions included a shift away from the Units of Dental Activity (UDA) system and a mixed delivery of NHS and private dentistry. Critics argued for a system that takes into account the needs of the patient and the time required to deliver the appropriate level of care.
Dental Contract Changes and Its Implication
Changes to the NHS dental contract, the first in 16 years, was part of these reforms. This meant that NHS dentists were paid more for treating complex cases, such as people needing three or more fillings, improving access to dental care across the country. These changes were built upon the first reforms to the dental contract announced in July 2022, aimed at improving patient access to NHS dental care and aiding dental services to return to pre-pandemic activity levels.
Dental Contract Changes Across England and Wales
The reform also impacted dental contracts in both England and Wales. Prior to the reform, following the introduction of a new contract in April 2006, there was a reduction in the availability of NHS dentistry, with many patients forced to seek more expensive private treatment. The reform therefore sought to redress these issues by ensuring a high quality NHS dental service, improve oral health, and address inequalities.
Contractor Model of Care
In the wake of the reform, NHS primary care services adopted a ‘contractor’ model of care. Nearly all these services were delivered by approximately 11,000 independent dental provider practices in England, which provide a mix of both NHS and private dental care. Many practice owners hold the provider contract with the PCT and the associates work as performers under the contract.
Public Awareness and Inclusion
To enhance public understanding of the reformed NHS dentistry system, NHS England created a group of patient and public voice (PPV) partners and began efforts to raise awareness of the regularity of dental visits and the role of non-dentists (such as dental therapists and hygienists) in patient care.
Outcomes and Impact of the Reform
The reform of the National Health Service (NHS) dentistry in England, which represents the first significant change to the contract since its introduction in 2006, was intended to address numerous challenges facing the dental sector . The focus of the reforms was to improve patient access to NHS dental care and support dental services to return to pre-pandemic levels of activity .
However, the impact of the reforms has been mixed. On one hand, the reforms have resulted in some positive changes. These include paying NHS dentists more for treating more complex cases and improving access to dental care across the country . On the other hand, critics have argued that the government’s initiatives have failed to solve some of the existing problems and, in some cases, have worsened the situation . For instance, fewer new patients have been seen since the plan’s introduction .
Another key criticism of the reforms is that they do not go far enough in transforming the system. Stakeholders and the Commons Health and Social Care Committee have called for fundamental reform, including moving away from the UDA system . There are also concerns that access to dental treatment remains problematic in some parts of the country, with the highest levels of dental disease found in more deprived areas .
The pandemic has inevitably had an impact on the reform work, adding further constraints to the number of people who can be seen in dentistry due to the public health measures that need to be in place to protect staff and patients . To mitigate the impact of these challenges, the government has expressed a commitment to better communication with stakeholders and improving information for patients . Despite these challenges, there is still a belief that an equitable distribution of affordable dental services is achievable .
Moving forward, there are calls to address several systemic and societal barriers to dental care . Some of these include reducing costs, improving information, ensuring appropriate timing and location of care, and managing patients more effectively. Personal actions such as persistence in finding available care are also encouraged . Further, efforts are underway to explore how these barriers may be hindering the provision of prevention in oral health to patients .
Finally, while the impact of the reforms is still being evaluated, there is a recognition of the potential wider role that dental professionals can play in promoting a healthy lifestyle and in identifying people at higher risk of other diseases, such as diabetes or hypertension .
The Joint Plan to Recover and Reform NHS Dentistry
The joint plan to recover and reform NHS dentistry has been published by the NHS and the Department of Health and Social Care (DHSC). The plan is a significant step towards transforming NHS dental services, aiming to alleviate the pressures on dentistry that the NHS has been experiencing for some time. These pressures have been further exacerbated by the COVID-19 pandemic, with dental teams working hard to meet rising demand.
The recovery and reform plan builds on previous initiatives, including the dental recovery plan, which aimed to create up to 2.5 million extra appointments within a year. This initiative has already demonstrated success, with an extra 500 practices offering appointments. The current proposals form part of the government’s larger plan to accelerate the recovery of NHS dentistry post-pandemic and reform its operations. This plan aligns with the aims of the NHS Long Term Workforce Plan, which looks to expand the dental workforce and improve access to NHS dental care, particularly in underserved areas.
In April 2022, NHS practices were given the option to be part of the reform program or return to contractual arrangements based entirely on the delivery of Units of Dental Activity (UDA). Practices participating in the reform will prioritize prevention and needs-based care, transitioning away from routine six-monthly check-ups for all patients.
The plan to recover and reform NHS dentistry also seeks to address barriers to dental care, taking into account individual, system, and societal actions. The aim is to make it easier for patients to seek dental care, from finding relevant information about NHS services to making and attending appointments. To further ease access, the plan proposes that newly qualified dentists should commit to delivering a minimum amount of NHS dental care for a certain number of years after graduating.
Efforts to increase efficiencies and improve digital capacities are also being considered as opportunities in NHS dentistry. To this end, the plan outlines the establishment of a new stakeholder reference group for dentistry and oral health. This group will help identify changes that could significantly benefit practices providing NHS care and their patients. The NHS Long Term Workforce Plan additionally sets out to increase the dental workforce in England by expanding undergraduate dentist training places to a record level.
The plan also focuses on addressing barriers that might be preventing the provision of oral health prevention to patients. These barriers were explored through semi-structured interviews and focus groups involving dentists, policy makers, insurers, and NHS patient participants. The findings from these discussions informed the actions set out in the plan to improve the provision of preventative advice and treatments as part of oral health assessments.
Future Prospects of Dentistry in NHS England
The future of dentistry in NHS England is set to undergo substantial changes to improve access to dental care and the quality of services provided. These changes are aimed at making it easier for higher needs patients to receive the necessary care they require, and to make the NHS a more attractive career choice for dental professionals.
As part of these reforms, the NHS contribution to dentistry is expected to increase. In the financial year 2021/2022, this contribution was around £2.3 billion, highlighting the importance of dentistry in primary care. The new changes to the dental contracts in England are focused on addressing challenges associated with the delivery of care to higher needs patients, and will make it easier for patients to access NHS care. The government is also committed to expanding the dental workforce as part of the NHS Long Term Workforce Plan.
Efforts are also being made to improve patient access to care. The proposed changes in dental policy are geared towards focusing on those patients who need care the most. This shift in focus is intended to enhance patient access to NHS dental care and provide support for dental teams. The government also plans to create up to 2.5 million extra appointments as part of their dental recovery plan.
Lastly, the NHS aims to focus more on prevention and needs-based care. Starting from April 2022, practices were asked to choose between being part of the reform programme or to return to the pre-reform arrangements. This move towards prevention and needs-based care means that practices will move away from routine six-monthly check-ups for all patients.
The NHS England reform has the potential to transform dental care for the better, especially in areas that have been under-served. It seeks to create a more sustainable future for a publicly funded dental service that meets the needs of the population. However, it is also important to note that the success of these reforms will require action at the individual, system and societal levels to address the current barriers to dental care.
The content is provided by Sierra Knightley, Lifelong Health Tips
