Scarce as a hen's teeth

Public-sector finance: NHS dentists are increasingly rare ... and the way we pay them doesn't help, says Paul Gosling

A further 5 million dental patients could be forced into private treatment as a result of changes in the NHS dental registration system likely to be announced in the near future. This reinforces the findings, released this month, of a poll which indicated that two-thirds of MPs expect NHS dentistry to no longer exist within 10 years, except for children and those on low incomes.

Figures collated by the Labour Party indicate that 2.3 million dental patients left the NHS between April 1994 and October 1995. Dentists argue that low fee income from NHS patients makes the work uneconomic, while de-registrations are boosted by patients who fail to see their dentist for two years and are automatically removed from NHS lists. The Department of Health is negotiating with the dentistry profession to reduce that period to one year.

The Department of Health had hoped the new system would be in place for April this year, but slow progress in negotiations means that this is unlikely to be achieved. But with agreement in principle reached with the British Dental Association, it is expected that the 12 months cut- off period will be in place at some point during the new financial year.

"The money released from that would go into children's dentistry," says Michael Watson, head of practitioner services at the BDA, and a member of the negotiating team. "It is not yet agreed what that would cost. The Treasury are very keen that it doesn't cost any more money, and we are very keen that dentists don't lose any more over it."

The current financial crisis in NHS dentistry dates back to 1992, when NHS annual fees were cut by, according to the BDA, an average of pounds 10,000 per dentist. Since then fees have been subject to further cuts, in real terms, by increases failing to match the rate of inflation. The result is that in many places, from North Wales to the South-east, it is now impossible to become registered as an NHS patient with a dentist.

For the next year the BDA is asking for a 10 per cent fees increase, and the General Dental Practitioners' Association has called for a 50 per cent rise. The Doctors and Dentists Review Body's report, which recommends to government what fee increase should be agreed, is with the Prime Minister, but it is considered unlikely that the increase will be above 3 per cent.

Patients currently meet 80 per cent of the cost of treatment, with the NHS picking up the balance. There is also a capitation element (a payment for the number of patients on a dentist's books), which is greater for children than it is for adults. The cost of this will be reduced when the Department of Health's proposals have been implemented to strike off absent patients earlier. There is no NHS contribution towards the costs of a dentist's salary, or for staff or other practice costs - unlike doctors' surgeries, with which the BDA would like comparability.

Denplan, the largest private dental healthcare providers in the UK, argues that the NHS should adopt a system of capitation in funding dentists, similar to that of its own private plan and that adopted by the States of Jersey. In Jersey, the first pounds 6 of a patient's monthly fee is met by the state, topped up by a patient contribution. Only those aged between 11 and 25 are eligible for the scheme.

Quentin Skinner, managing director of Denplan, says: "The only way to really improve the dental health of the nation is to ensure that NHS dentistry mirrors best practice in the private sector, and introduces a capitation system for all. This will place the emphasis throughout dentistry on preventative care, rather than the drill-and-fill philosophy encouraged by the present NHS funding system which is funded by fee-per-item."

The British Denplan scheme costs members between pounds 5 and pounds 15 per month, and the BDA argues that this level of payment would be unacceptable to both government and individual - whether paid directly or through taxation.

"We would like to see the capitation element increase," says Mr Watson of the BDA, "but where we, and I think the Department of Health, find a problem is where the patient is charged for the extra income. Denplan is talking about an average capitation fee of pounds 100 per year, and who would pay for that? The Government is not going to pay it, and would you get patients to agree to pay it? A lot of people would say they don't like to pay for nothing."

Amolak Singh, secretary of the General Dental Practitioners' Association, says that he would like all NHS finance to be by capitation. "Denplan and Bupa both have a capitation service, which is very good, but could lead to a system of supervised neglect, that is the risk. It is very good provided that there is a system of monitoring."

But the choice between financing through capitation or fee-per-item could soon become irrelevant. On current trends, 20 million people, either through voluntary choice or because of unavailability, will have opted out of NHS dentistry by the turn of the century.