Page last updated at 12:23 GMT, Monday, 22 June 2009 13:23 UK

Q&A: NHS dentistry

Dental equipment
Access to NHS dentistry is a long-running problem

Reform of NHS dentistry in 2006 was heralded as a new dawn for the beleaguered service.

But a little over three years on an independent review commissioned by the government recommend another shake-up of the system.

Why was NHS dentistry reformed in the first place?

The changes were introduced in April 2006 in the face of widespread discontent with the previous system, both from patients and dentists.

The main problem was the lack of NHS dentists, leading to difficulties accessing NHS care in some areas.

This resulted in the unforgettable images of patients queuing down the street when new practices opened

There has also been complaints that the fees system was overcomplicated - there were over 400 separate charges for different procedures.

It also meant dentists had a financial incentive for carrying out dental procedures, rather than preventing problems before they developed.

How did the reforms work?

The new contract gave local managers, working for primary care trusts, responsibility for ensuring there were sufficient services available.

The concept of registration was scrapped in favour of dentists being given funding for a set number of courses of treatment.

It was structured so that dentists would get the same amount of money for treating slightly fewer patients.

The hope was that this would end the so-called "drill and fill" culture and encourage dentists to spend more time with patients so they could give them advice on keeping teeth healthy.

The charging system was also reformed, creating three bands of payment covering check-ups, simple procedures such as fillings and extractions and a top level for complex work, including bridges and crowns.

The contract was introduced in England and later adopted in Wales.

In Scotland and Northern Ireland, a slightly different system which reformed the fees paid to dentists, though not those paid by patients, has been introduced.

How were the changes received at the time?

The introduction of the new charging bands meant that in some cases fees for basic work increased.

This prompted criticism from patient groups, but on the whole they were welcoming as they saw the shake-up as a solution to the difficulties in accessing care.

Dentists were less welcoming, suggesting the amount of time available for preventative work was insufficient.

Unions predicted an exodus of dentists into retirement or exclusively private practice.

In the end, 1,000 dentists walked away from NHS work.

Many more signed the contract "in dispute" which meant managers spent months wrangling with the profession about the terms and conditions.

How have the changes worked out since then?

Not very well. The government ordered the independent review after years of criticism from patients, dentists and MPs.

Official NHS statistics show that more than 1m fewer patients visited an NHS dentists in the two years after the introduction of the contract than the two years before.

Last year a report from the House of Commons Health Committee said the contract had failed to resolve the "fundamental problems".

And a poll by the British Dental Association showed 85% of dentists did not feel access had been improved.

There has also been suggestions that the reform has had the unintended consequence of discouraging dentists from carrying out more complex work.

Under the new charging system, dentists get less money for procedures such as crowns and bridges.

In the first year of the contract, the number of these types of treatment fell by a half, while extractions rose.

In Scotland and Northern Ireland, not covered by the changes, the number of complex treatments rose.

Opposition parties have been quick to criticise the government for the problems.

Both have come up with their own policies on NHS dentistry with calls for a return to registration being put forward.

What is being put forward now?

In effect, a complete reworking of the NHS dental contract.

The 2006 deal was based on courses of treatment.

Dentists agreed to do a set amount of courses with local managers and stopped once their allocation had been used up.

But under the latest proposals, dental payment will be divided into three.

There will be a portion linked to the number of patients on a dentist's books, set fees for courses of treatment and a performance-related element for the quality of care.

The government hopes this will be more flexible and avoid a repeat of the situation whereby patients are turned away because there are no NHS slots.

However, there is still much work to be done behind the scenes.

In many ways, what is being proposed is similar to the GP contract which took years to negotiate with unions.

What else was recommended?

The review acknowledged - and the government accepted - that patients often found it difficult to find information on dentists.

Reports have emerged of patients saying they cannot find a dentist when there are actually NHS ones with spaces free.

So NHS trusts have been told to set up helplines to point patients in the direction of local services. NHS Direct will also have the information.

The review also suggested the fees system should be tweaked.

The authors said the three bands should be increased, possibly up to 10.

They said the overly simplistic banding system meant that patients could find themselves paying the same amount for vastly different amounts of care.

This could act as a disincentive to good self-care, they added.

The review also recommended that if a filling or other aspect of dental treatment needed to be replaced or repeated within three years that should be provided free of charge to the patient with the dentist picking up the tab.

This already happens to some extent now, although dentists have charged the NHS for the work.

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