The withdrawal of dentists from the NHS is due to frustration over pay, over the limited time they can allocate to each patient and over the inferior quality of materials they are able to use.
In April the government reaffirmed its commitment to the NHS, while unveiling plans for reform. It made clear that everyone who wanted dental treatment on the NHS was entitled to it, even though that might mean travelling to get it. The Department of Health maintains that despite large scale deregistration of patients by dentists in the past few years, there are more NHS dentists and more NHS patients now than three years ago. The figures are at odds with dentists' experience. Denplan, the market leader in private dental care, estimates that 850 patients are being deregistered from the NHS every day. It conducted a survey among dentists a year ago which found that 90 per cent treated patients on the NHS in 1989, by last year the figure had dropped to 60 per cent and by 1999 the proportion was expected to drop to 30 per cent.
The reforms of last April have not changed dentists' thinking, according to Denplan and other providers of private care plans. Although the government backed away from some ideas in its previous Green Paper, most notably the recommendation to make most non-exempt adults pay 100 per cent of their NHS treatment costs, it reiterated that it wanted better value for money for the pounds l billion spent annually on NHS dentistry.
Dentists are particularly concerned about plans to introduce more rigorous prior approval procedures which in the words of Gerald Malone, Minister for Health, "will ensure that general dental services provide only those treatments which are clinically essential and for which there is no clinically acceptable, less costly, alternative".
Dentists worry that this means standards will be cut and more red tape introduced. David Shapiro, of private dental plan Complete Direct Care (CDC), said, "The increase in paperwork will make it impossible for dentists to stay in the NHS." Crossing the divide from NHS to private practice is not as drastic a step for patients as it once was. Non-exempt adults are charged 80 per cent of their NHS costs, so the increase for private treatment is not usually punishing. The spread of capitation schemes helps ease the pain by smoothing payments to monthly amounts for long term preventative and continuing dental care.
Unlike insurance, which is taken out in the hope it will not be needed, capitation gives patients what they pay for. Most plans include supplementary insurance cover for emergency treatment and treatment resulting from injury. There are several plans available from dentists, which vary in detail in how they charge and what they cover.
Denplan, owned by medical insurer Private Patients Plan, has signed up 5,500 dentists - a quarter of UK dentists - and 630,000 patients. It has five fee categories with discounts for children and other groups. More than 90 per cent of patients pay between pounds 5-pounds 15 a month. Unlike some of its competitors, Denplan does not offer lower prices for less care, but puts patients in a fee band according to the state of their teeth and location of the practice.
CDC has more than 800 dentists and 60,000 patients. It stresses its low administration charge at 98 pence a month and lack of joining fee. Dentists set their own fees and and charge each patient a different amount or everyone the same. Average charges to patients outside London are pounds 8 and inside London are pounds 10.50.
BUPA Dental Cover entered the market at the start of last year, some eight years behind Denplan, but has signed up 2,650 dentists and 45,000 patients. There is nothing to stop dentists offering both Denplan and BUPA and many do.
BUPA has five fee bands, with dentists choosing what to charge according to the state of a patient's mouth and their own overheads. Patients can choose to exclude expensive treatment to reduce monthly payments. The average monthly subscription is pounds 11, says BUPA.
Norwich Union also launched a capitation scheme at the start of last year, but it determines fee levels rather than the dentist. It offers four levels of cover and three cost areas depending on location. Plan One, which covers check-ups, scale and polish, X-rays and emergency cover costs pounds 5.85 a month in cheaper locations. Plan Four, which includes bridgework and dentures, costs pounds 16.90 in ritzy areas.
Clindent levies no administration charge, but makes its money through the pounds 24 annual insurance fee for protection against accident, sickness, redundancy or trauma to teeth. Densure, with 70 dentists and 3,000 patients, like Norwich Union offers set price plans allowing the patient to choose the level of care required.
As well as an expanding individual market, corporate dental plans are growing in popularity. Employers see dental cover as a valuable perk to offer employees, mostly on an insurance basis. Alternatively, employers will offer to meet a proportion of employees' dental costs on a co-payment basis or negotiate a bulk discount with dental practices, but employees pay their own way.