Report calls for paradigm shift in NHS dentistry

National Health Service (NHS) dentists in the U.K. may be paid by the number of patients they care for and the quality of that care rather than how many procedures they perform, if recommendations from a new review of the NHS dental system become reality.

With the release two weeks ago of the much-anticipated "Steele report," U.K. officials are now pondering how to implement some of the report's far-reaching recommendations.

Commissioned in response to complaints from dentists and patients alike about changes to the NHS dental system made in 2006, the new report calls for even more substantive revisions to the delivery of NHS dental services, with greater emphasis on preventive medicine and quality of care and less on "drill and fill."

"The last few years have been a really turbulent time for everybody involved with dental services," said Barry Cockroft, chief dental officer at the U.K. Department of Health, in a letter sent to NHS dentists on June 22, the day the report was released. "But we have an opportunity now, with this report, the maturing of commissioning, the publication of the evidence-based tool kit, and the significant extra investment in both services and training, to deliver a new strategic vision that can have a major impact on improving the oral health of this country, focusing more clearly on access, quality, and oral health."

The end result, according to the report's authors, could be a paradigm shift in NHS dentistry, away from the current fee-for-service system toward a more long-term, patient-centric approach.

"In 2006, a set of new contracts was introduced for NHS dentists, and at the time we hoped it would mark a change in the way dentistry was delivered," Jimmy Steele, D.D.S., chair of oral health services research at the Newcastle University School of Dental Sciences and lead author on the report, told DrBicuspid.com. "But when it came in, there was a lot of professional disgruntlement about how it was working, and a lot of unhappy dentists."

Many patients were also dissatisfied with the new system. The goal of the 2006 revisions was to put dental care within reach of more people. Instead, 1.2 million fewer people saw a dentist over the following two years than in the previous two years, according to the Department of Health. And many said the main problem was finding and gaining access to NHS dentists in their area.

In fact, while the NHS will spend approximately 2.25 billion pounds on dentistry this year and NHS patients will fund a further 550 million pounds of services through patient charges, the access problem remains "in the public consciousness," according to Dr. Steele. As a result, last year the House of Commons Health Select Committee undertook an investigation into NHS dentistry. Their report, released in November, identified a number of troubling issues, Dr. Steele noted, including the fact that too many people find it difficult to access services and that, when they do, there is unwarranted variation in the quality of the care they receive.

One month later, former U.K. Secretary of State for Health Alan Johnson called on Dr. Steele to spearhead an independent review of NHS dentistry in the hopes of determining how the delivery and quality of those services might be improved. Dr. Steele and his staff spent six months researching existing reports and government data; interviewing dentists, patients, and focus groups nationwide; and working closely with consumer groups, he said.

"Our approach has been to use the existing research to confirm some of the main issues highlighted in the Health Select Committee report," Dr. Steele and his colleagues wrote in their review. "We have then focused on developing a deeper understanding of why people find it difficult to access services and what kind of services they want and need from the NHS, as well as developing a deeper understanding of the supply side -- what drives dentists' behaviors and how the system could work better to support clinicians."

Prevention and education

One of the report's key findings was the realization that the NHS itself does not have a clear idea of what NHS dentistry is supposed to be or what it is trying to achieve, Dr. Steele said.

"NHS is quite effective in delivering health but felt in dentistry it had lost its way in terms of what it was delivering and what should be its end point," he said. "So we tried to define what NHS is all about."

For example, while NHS currently uses a fee-for-service model -- "which has a certain logic but induces a certain behavior, encouraging a lot of procedures to be done," Dr. Steele said -- it's not necessarily appropriate any longer, he added. "We need to get the processes of prevention worked back in."

Under the report's proposals, which are designed to incentivize long-term care, greater financial weight will be placed on looking after the patient's oral health and less on the speed with which dentists can "drill and fill." In addition, NHS dentists could receive more than half their total income from the registration of patients and quality of care payments, with less than half coming from the amount of dental activity carried out.

"We want to move away from fee for service as the primary motivation," Dr. Steele said. "They would still be paid a portion of this but they would also be paid for long-term treatment and the quality of the care they deliver."

Among the report's other recommendations:

• "PCTs [primary care trusts] and the NHS should communicate clearly how people might find a dentist through the most appropriate media and what to expect from a dentist when they get there."
• "We recommend that strong clinical guidelines are developed to support dentists and patients through specific pathways of treatment."
• "We specifically recommend introducing an annual per person registration payment to dentists within the contract to provide greater security for dental practices and greater accountability on all sides."
• "We recommend that personal computers are used in all dental surgeries within three years and are, ultimately, centrally connected to allow clinical data to support shared information on quality and outcomes."

"Professor Steele and his team have clearly listened carefully to patients, dentists, and primary care trusts," said John Milne, chair of the British Dental Association's General Dental Practice Committee. "We have an opportunity to learn from the difficulties of 2006, and it is vital that opportunity is taken."

Pilot programs this fall

The Department of Health and NHS appear to be setting the wheels in motion already. Many of the recommendations from the report will be piloted in dental practices starting this fall for a period of one to two years, according to the health department. Some of the recommendations they will be testing include:

• Linking a significant part of dentists' income to the number of NHS patients registered with them, not just the number of treatments they provide.

• Making dentists more explicitly accountable for providing high-quality and long-lasting treatments (such as fillings and root canals), and supporting dentists to take time to advise patients on preventive care.

• To make it easier to register with a dentist, patients will be able to call NHS Direct or check the NHS Choices Web site for information on local services. In addition, the NHS will be responsible for providing a local help line to help people find an NHS dentist and understand what they are entitled to.

"The report's recommendations appear to be far-reaching," Milne said. "They describe a new approach to dental care that dentists hope will mean a move away from the target-driven arrangements that are currently in place."

The Department of Health will also work with the NHS to develop national quality measures for NHS dentistry and discuss with the dentistry profession how to take forward the recommendation that dentists should provide a longer guarantee for some work and pay for a replacement if the treatment fails prematurely.

"This review is a vision of a better deal for both patients and dentists," said U.K. Secretary of State for Health Andy Burnham in a press release. "It's about making sure that patients can see an NHS dentist who will take long-term responsibility for their care. Access to NHS dentistry is already improving and new NHS dental surgeries are opening up all over the country. I recognize that more needs to be done to bring NHS dentistry up to the standards that patients should expect, and we and the NHS are committed to ensuring that anyone can access high-quality dental services."

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