The Big Question: Are NHS dentists failing patients and abusing the new payments system?

(Independent Graphics)

Why are we asking this now?

By the Government's own admission, at least two million patients do not have access to an NHS dentist. The Tories claimed yesterday that the shortage was caused in part by dentists trying to maximise their incomes by splitting courses of treatment and recalling patients weeks after they were first treated so that they can charge twice. The Tories obtained details from Primary Care Trusts which they claim show that up to 6.5m appointments could be freed up for people who don't have an NHS dentist, if the practice were stopped. They also claimed patients fortunate enough to have an NHS dentist are being overcharged by £109m a year for the privilege.

How does the scam work?

The National Institute for Clinical Excellence (Nice) recommends that patients should be called back to their dentist for a check-up at intervals of not less than three months and not more than two years, depending on the state of the patient's teeth. The Government has also said patients only have to pay once for each course of treatment and, if they need further work within two months of completing that course, they do not have to pay anything extra.

The Tories' investigations allegedly revealed that large numbers of dentists are recalling patients after two months, when they can impose an extra charge, but before the three-month limit recommended by Nice. As a result patients are paying extra in charges (£109m, a quarter of the total £475m paid by patients each year) and taking extra appointments (6.5m).

Is this true?

The Department of Health thinks so, though it believes the fiddling is on a smaller scale – it estimated in October that eliminating the practice could free up 800,000 appointments nationwide. The Chief Dental Officer, Barry Cockroft, said he was discussing with PCTs how to halt it. By examining the coding on payment sheets submitted by dentists it is possible to identify those at fault, officials say.

What is the problem with NHS dentistry?

In a sentence, the number of dentists doing NHS work is rising (over 4,000 extra since 1997), the amount of cash going in is increasing (by 11 per cent this year to almost £2bn), but the number of patients treated on the NHS is falling (by 1.2m over the two years to last June). Tony Blair pledged at the Labour Party conference in 1999 that everyone would have access to an NHS dentist but the Department of Health admitted in March 2007 that two million people did not have one. Last week, Alan Johnson, the health secretary, announced an independent inquiry into what has gone wrong – the first admission by the Government that its dental reforms have failed.

Why have the reforms failed?

Because they have driven more dentists to do more private work. The Department of Health has been under fire since it overhauled the dentists' NHS contracts in 2006 to end a perceived "drill and fill" culture. Dentists used to be paid 400 separate fees for each item of treatment, leading to worries about overtreatment. Now they receive an annual income for carrying out an agreed amount of work, based on "units of dental activity", which carries a financial incentive to do less for each patient, leading to worries about under-treatment. And dentists don't like it.

What is wrong with the new payment system?

There are now three NHS price bands, payable by patients, which care intended to cover 80 per cent of the total cost of treatment. They are: £16.20 for an examination with X-ray, £44.60 for one to six fillings or root canal treatment, and £198 for crowns and bridges. Dentists claim that they cannot do work of sufficient quality at these prices. Also if the payment for one filling is the same as the payment for six, they have an incentive to accept the easy patients with good dental health on the NHS and insist that the complex patients who require lots of treatment pay privately. Although they are not allowed to discriminate in this way, it is hard to police. Dentists can refuse a patient NHS treatment by claiming they are saving their NHS budget to treat children and people in pain.

Has the Government been burying itshead in the sand?

Yes. It has placed its faith in the fact that the number of NHS dentists was rising, ignoring the fact that the amount of work they do for the NHS is falling. Between 1999-2000 and 2005-6 there was a 16 per cent fall in the proportion of dentist's earnings made from the NHS, with the biggest fall in younger dentists. Those under 35 earned only just over a third of their income from the NHS in 2005-6. The fall is believed to have accelerated since the introduction of the new contract in 2006. Patients' organisations have warned that the decline could lead to the eventual collapse of NHS dentistry. The health department claims it is due to the rising demand for teeth whitening and other cosmetic treatments, which are only available privately.

Are dentists well paid?

Yes. Those who own their practices made an average of £172,494 before tax, but after practice expenses, in 2006-07, the first year of the new NHS contract. That includes income from private work. The average for all dentists was £96,135. The evidence suggests that dentists who do more private work do not have higher incomes overall but work less hard for the same income. One of the complaints dentists have about the NHS is that it is a treadmill forcing them to do more work for less money.

Do dentists provide high-quality work?

Mostly, but not always. The Dental Law Partnership, the biggest legal firm handling dental claims said the number had increased almost fourfold since 2001 and it had won over £10m for 1,400 patients. Disciplinary hearings against dentists by the General Dental Council doubled between 2004 and 2006 from 31 to 64 and the number of dentists struck off trebled from five to 16. Poor treatment, fraud and unjust claims for payment are the commonest findings against dentists.

How do dentists respond to the Tory allegations?

Peter Ward chief executive of the British Dental Association said: "One of the unexplained changes that appear to have occurred [since the 2006 contract] is a change to treatment patterns. The independent review will need to ensure these changes are properly understood. Patient's treatment needs vary from individual to individual – if patients are being recalled inappropriately, PCTs will need to talk to practitioners to identify why it is happening."

And the patients?

Record numbers are going abroad. The difficulty of finding an NHS dentist and the high costs of private treatment are fuelling a boom in dental tourism. Hungary is the most popular destination. Savings of thousands of pounds have been reported by patients having crowns and implants. British dentists warn that follow-up care is harder to obtain for patients who travel abroad and complain they are increasingly having to sort out complications from treatment provided elsewhere.

Is NHS dentistry just not working?

Yes...

* The number of patients treated on the NHS fell by 1.2 million in 2006-8 compared with 2004-6

* There was a 16 per cent fall in the proportion of dentists' earnings made from the NHS from 2000-2006

* Two million patients who want an NHS dentist do not have access to one

No...

* The number of dentists doing at least some work for the NHS has increased by over 4,000 since 1997

* The amount of cash invested by the Government in NHS dentistry has risen to almost £2bn

* The new NHS contract has simplified payments and reduced treatment costs for those with the worst teeth