Dentistry provided by the National Health Service in the United Kingdom is supposed to ensure that dental treatment is available to the whole population. Most dentistry is provided by private practitioners, most of whom also provide, on a commercial basis, services which the NHS does not provide, largely cosmetic.[1] Most adult patients have to pay some NHS charges, although these are often significantly cheaper than the cost of private dentistry.[2] The majority of people choose NHS dental care rather than private care: as of 2005, the national average proportion of people forced to use private care was 23%.[3] NHS dentistry is not always available and is not managed in the way that other NHS services are managed.[vague]
According to NHS Choices "All the treatment that your dentist believes is necessary to achieve and maintain good oral health is available on the NHS. This means that the NHS provides any treatment you need to keep your mouth, teeth and gums healthy and free of pain".[4] This includes if clinically necessary: dentures, crowns and bridges, orthodontics (under the age of 16/18), root canal treatment, scaling and polishing, white fillings, Emergency Dental Treatments, Children Treatments.
Many dentists who provide NHS services also offer additional services, such as hygienists, for payment. A dentist is not allowed to refuse to provide necessary treatment under the NHS and then offer to perform the same treatment privately.[5]
Availability
NHS dentistry has often struggled to even see 55% of the population in a one-year period.[6]
Following the government's introduction of a new contract in April 2006, NHS dentistry is not as widely available as it once was,[7] with 900,000 fewer patients seeing an NHS dentist in 2008 and 300,000 losing their NHS dentist in a single month.[8] This has forced many patients to pay much higher sums for private treatment,[9] and has been criticised by the British Dental Association as having "failed to improve access to care for patients and failed to allow dentists to provide the modern, preventive care they want to deliver".[8]
Ben Bradshaw, then Minister for Health, was questioned on Radio 4 in 2007 about the shortfall in NHS dentistry leading to patients unable to access NHS dentists and even resorting to pulling their own teeth out. He suggested that those needing urgent treatment should go to see their GP, prompting the British Medical Association to observe that a General Practitioner was no substitute for a qualified dentist.[10]
There are repeated stories of shortage of NHS dental services, especially in remote areas such as Skye[11] and Cornwall.[12] Lack of access to emergency dentistry is often seen as contributing to overcrowding in hospital accident & emergency departments.[13] In May 2007, there was a backlog of 14,000 people unable to register with an NHS dentist in Cornwall. Waiting times for routine appointments were up to eighteen months.[14]
In October 2018 the chairman of general dental practice at the British Dental Association claimed that there was a hostile environment for dental patients. 380,000 patients a year with dental problems were approaching general practitioners, who were not equipped to help. Accessible public-facing information on where to seek care for dental problems was required.[15]
In England in 2019 over 2 million people were missing out on dental treatment. It is estimated that 1.45 million have tried and were unable to get an NHS appointment, others are on waiting lists (0.13 million) or cost discourages them (0.73 million). A further 2 million believe they cannot get a dentist where they live, making it likely that almost one in ten people cannot get a dentist. Dave Cottam of the British Dental Association said there was a, "perfect storm" of failed contracts, recruitment problems and underfunding. Cottam added, "These access problems are no longer affecting a few 'hotspots', but are now the reality for millions across every English region. The public are entitled to access care, but the system is stacked against them. Those losing out are the patients who need us most." The British Dental Association maintains there are serious problems over access to dental treatment in Wales, and similar problems exist on a smaller scale in Northern Ireland and Scotland.[16]
Charges
Initially NHS dentistry was free at the time of use but charges to patients were introduced in 1951 and have been increased, normally every April. Charges vary in different countries of the UK.
As of April2019[update] there were three standard charges for all NHS dental treatments in England[17] and Wales,[18] with prices having increased in England by 5% to:
Band 1 course of treatment – £22.70 in England, £14.30 in Wales; covers an examination, diagnosis (including X-rays), advice on how to prevent future problems, a scale and polish if needed, and application of fluoride varnish or fissure sealant. Band 1 also covers emergency care such as stopping bleeding, trauma, teeth knocked out, severe pain or swelling, even if more than one visit is required.
Band 2 course of treatment – £62.10 in England, £46.00 in Wales; covers everything listed in Band 1, plus fillings, root canal work or removal of teeth.
Band 3 course of treatment – £269.30 in England, £199.10 in Wales; covers everything listed in Bands 1 and 2, plus crowns, dentures and bridges.
Exemptions
Some groups of people are exempt for charges for dental treatment:
women who are pregnant or have had a baby in the previous 12 months and have a valid maternity exemption certificate (MatEx) when they start a course of treatment
People in custody
people who have an HC2 full help certificate entitling them to free dental and other NHS treatment under the NHS Low Income Scheme.
An HC3 limited help certificate reduces payment required, without full exemption. A patient is only required to pay three times the amount their income exceeds the free treatment level. All charges paid within a three-week period are added together and count as one charge.[19]
From 2013 to 2015, 632 patients in Oldham who were in receipt of Universal Credit and therefore entitled to free prescriptions were issued with penalty charge notices, totalling £71,000, because the NHS forms had not been updated to reflect the introduction of Universal Credit.[20] Patients with learning difficulties and with dementia have been issued with penalties because they made honest mistakes ticking the wrong box in complex forms. This has caused stress for the patients and extra work for the dentists trying to sort out the problem.[21] 90% of fines are overturned on appeal. People on low incomes are deterred from seeking dental care that they need because they fear being fined. Dental visits by people on low incomes fell 23% during the four years to 2018.[22]
History
School dental services provided by local authorities developed slowly after 1907 when the first service of this kind was set up in Cambridge.
When the NHS was established in July 1948 dental treatment was free. Demand on the service was enormous. About a quarter of the dentists joined the NHS and by November 1948 83% had joined. Dental health in the UK was worse than that of Germany. In the first nine months of the NHS 4.5 million teeth were removed and 4.2 million teeth were filled. In 1950-1951 65.5 million artificial teeth were fitted.
At the inception of the NHS in 1948 there were three branches of dental service,[23] and these 3 branches still exist today, although the organisation of services in England has changed much more than in the rest of the UK:
A local health authority dental service which provided dental inspection and treatment to school children, pre-school children and to pregnant women and mothers of infants under one year old, but is now chiefly special needs dentistry. These were transferred to the NHS in the 1974 reorganisation. These services employed the whole-time equivalent of about 1,980 dental officers, assisted by 370 dental auxiliaries, 2,900 dental surgery assistants, 70 hygienists and 140 dental technicians in the UK in 1977. They were repeatedly reorganised, like other community services. Most were run by primary care trusts until they were abolished in April 2013.[24]
A hospital dental service, with access to specialist maxillo-facial and oral surgeons. Managed originally by regional health authorities they became part of NHS trusts, mostly in teaching hospitals.
Charges were first introduced in 1951, for dentures and in 1952 for other treatments.[25]
The Royal Commission on the National Health Service in 1979 reported that local authorities had a statutory duty to make comprehensive dental treatment available to pupils since 1953, but understaffing had prevented the school dental service from delivering it. In 1968 37% of the population of England and Wales over the age of 16 had no natural teeth. In Scotland 44% of the population over 15 in 1972 had none.
There were about 14,000 general dental practitioners doing NHS work in the UK in 1977, employing about 20,000 dental surgery assistants, and 1145 dental hygienists. 46% of adults with some of their own teeth in England and Wales regularly attended a dentist in 1978 compared with 40% in 1968. In 1979 there were about 400 dental consultants in hospital services, mostly based in the 17 undergraduate dental hospitals and one post-graduate institute.[24]
In 1948 only 19% of twelve-year-olds had no significant dental decay but in 2003 this had risen to 62%. In 2015 only 6% of the population had no natural teeth.[1]
Contract
Dentists are private contractors to the NHS, which means the dentists buy the building and equip the surgery, hire all the staff and pay all of the running costs including wages, materials and insurances, to provide an NHS dental service.
The contract between the NHS and dentists determines what work is provided for under the NHS, payments to dentists, and charges to patients. The contract is regularly revised. From 1947 dentists were paid for each filling, extraction or other work. In the first two years of the NHS the rates of item of service payments were cut three times. By 2006 there were over 400 items listed. This incentivised fillings and extractions, but not preventative work. In 1990 a new contract introduced capitation payments for treating children up to the age of 16 and registration for adult patients. In 1991-92 the dental budget was overspent by £190 million and the amount paid for each item of treatment was reduced by 7%. This encouraged dentists to move into private work.[26]
The contract introduced in 2006 was said by the British Dental Association in 2016 to be not fit for purpose, rewarding dentists for meeting government targets for treatment and repair, but not for improving patients' oral health.[27] In contrast to general practice, patients in England do not register with a dental practice. Under the 2006 contract they are examined, treated then discharged with a recommendation of when further examination is appropriate. However that is not how patients experience it, nor how practices operate, although it is legally correct. Practices in reality operate a list system and are regularly reported as closed to NHS patients, though open to those who pay privately.[28]
In England providers (the contract holders) are paid in "Units of Dental Activity". Typical values for units are £20-35, and they are paid 1 unit for a band 1 course of treatment, 3 for a band 2 course of treatment, and 12 for a band 3 course of treatment. Patient charges are deducted from these values. The performers (dentists) providing the treatment get a proportion of the payment, usually below 40%, and have to pay laboratory bills such as for the construction of dentures and crowns out of their cut. For many treatments, the rate of pay is below the cost of providing the treatment to a modern standard[citation needed], and as a result, many dentists will refer patients for complex treatments. In 2008 the Parliamentary Health Select Committee investigation found the UDAs were unfit for purpose.
A revised contract was under discussion in 2013 with greater emphasis on oral health and quality indicators.[29] The British Dental Association is keen to see reform, having campaigned vigorously against the "flawed, target-driven arrangements" introduced in 2006 that are currently in place.[30] In 2022, NHS England[31] proposed a number of changes to the contract to reflect the increasing number of high need patients caused by the Covid-19 pandemic.
In Scotland and Northern Ireland, the system works differently and relies upon a mix of capitation payments alongside Item of Service charges. An examination in Scotland is free of charge to the patient, but pays the dentist £8.10. For most other items of treatment, the patient charge is set at 80% of the total fee.[32] The fees paid are approximately one third to one half of what they were in 1948, once adjusted for inflation.[citation needed]
Performance
In June 2015 The consumer group Which? contacted 500 dental surgeries listed on the official NHS Choices website and found that 31% of them were refusing to take on any new NHS patients. They called for the Competition and Markets Authority to intervene to ensure dentists were complying with rules. The British Dental Health Foundation. HealthWatch England said that in some parts of England only a fifth of surgeries were accepting new NHS patients. The chair of the British Dental Association, said the “byzantine system” had failed dentists and patients.[33]
The BDA said that the 2006 contract did not meet its purpose of improving access to NHS dentistry and concentrating on prevention, and had been criticised by patient groups, government, the Health Select Committee and the Chief Dental Officers for England and Wales.[27]
In January 2016, more than 400 dentists signed a letter arguing that the NHS dental system in England is unfit for purpose and are whistleblowing publicly, to warn and expose the centralised failings to develop a proper national dental health and prevention strategy.[34]
In May 2022 the Association of Dental Groups, a trade association. published a report on the gaps in NHS dental provision (or “dental deserts”) in England. It indicated that the number of dentists conducting NHS work in January 2022 was the lowest for a decade. It highlighted the areas of England with the lowest number of NHS dentists per 100,000 population and expressed the need for a levelling up of access. A lack of access to NHS dentistry presents risks not only for oral health, but also in relation to early detection of mouth cancers and type two diabetes.[35]
In July 2022 the British Dental Association released an article that the proposed changes to the NHS contract would do little to stop the exodus of dentists from providing NHS treatment, due to the high displeasure in the system.[36]
Dentistry, also known as dental medicine and oral medicine, is the branch of medicine focused on the teeth, gums, and mouth. It consists of the study, diagnosis, prevention, management, and treatment of diseases, disorders, and conditions of the mouth, most commonly focused on dentition as well as the oral mucosa. Dentistry may also encompass other aspects of the craniofacial complex including the temporomandibular joint. The practitioner is called a dentist.
A dentist, also known as a dental surgeon, is a health care professional who specializes in dentistry, the branch of medicine focused on the teeth, gums, and mouth. The dentist's supporting team aids in providing oral health services. The dental team includes dental assistants, dental hygienists, dental technicians, and sometimes dental therapists.
Dentures are prosthetic devices constructed to replace missing teeth, supported by the surrounding soft and hard tissues of the oral cavity. Conventional dentures are removable. However, there are many denture designs, some of which rely on bonding or clasping onto teeth or dental implants. There are two main categories of dentures, the distinction being whether they fit onto the mandibular arch or on the maxillary arch.
The British Dental Association (BDA) is a registered trade union for dentists in the United Kingdom.
Geriatric dentistry is the delivery of dental care to older adults involving diagnosis, prevention, management and treatment of problems associated with age related diseases. The mouth is referred to as a mirror of overall health, reinforcing that oral health is an integral part of general health. In the elderly population poor oral health has been considered a risk factor for general health problems. Older adults are more susceptible to oral conditions or diseases due to an increase in chronic conditions and physical/mental disabilities. Thus, the elderly form a distinct group in terms of provision of care.
The Dental Professionals Association, previously known as the Dental Practitioners Association and the General Dental Practitioners Association, is a trade union for professionals involved in primary dental care in the United Kingdom. It is based in Harley Street in London.
NHS Scotland, sometimes styled NHSScotland, is the publicly–funded healthcare system in Scotland and one of the four systems that make up the National Health Service in the United Kingdom. It operates 14 territorial NHS boards across Scotland, supported by seven special non-geographic health boards, and Public Health Scotland.
A dental auxiliary is any oral health practitioner other than a dentist & dental hygienist, including the supporting team assisting in dental treatment. They include dental assistants, dental therapists and oral health therapists, dental technologists, and orthodontic auxiliaries. The role of dental auxiliaries is usually set out in regional dental regulations, defining the treatment that can be performed.
Dental insurance is a form of health insurance designed to pay a portion of the costs associated with dental care.
A denturist in the United States and Canada, clinical dental technologist in the United Kingdom and Ireland, dental prosthetist in Australia, or a clinical dental technician in New Zealand is a member of the oral health care team and role as primary oral health care provider who provides an oral health examination, planning treatment, takes impressions of the surrounding oral tissues, constructs and delivers removable oral prosthesis treatment directly to the patient.
Healthcare in the United Kingdom is a devolved matter, with England, Northern Ireland, Scotland and Wales each having their own systems of publicly funded healthcare, funded by and accountable to separate governments and parliaments, together with smaller private sector and voluntary provision. As a result of each country having different policies and priorities, a variety of differences have developed between these systems since devolution.
The NHS Business Services Authority (NHSBSA) is an executive non-departmental public body of the Department of Health and Social Care which provides a number of support services to the National Health Service in England and Wales. It was created on 1 October 2005 following a review by the Department of Health of its "arm's length bodies". It began operating on 1 April 2006, bringing together five previously separate NHS business support organisations.
Dental Public Health (DPH) is a para-clinical specialty of dentistry that deals with the prevention of oral disease and promotion of oral health. Dental public health is involved in the assessment of key dental health needs and coming up with effective solutions to improve the dental health of populations rather than individuals.
The National Health Service (NHS) is the publicly funded healthcare system in England, and one of the four National Health Service systems in the United Kingdom. It is the second largest single-payer healthcare system in the world after the Brazilian Sistema Único de Saúde. Primarily funded by the government from general taxation, and overseen by the Department of Health and Social Care, the NHS provides healthcare to all legal English residents and residents from other regions of the UK, with most services free at the point of use for most people. The NHS also conducts research through the National Institute for Health and Care Research (NIHR).
Healthcare in England is mainly provided by the National Health Service (NHS), a public body that provides healthcare to all permanent residents in England, that is free at the point of use. The body is one of four forming the UK National Health Service as health is a devolved matter; there are differences with the provisions for healthcare elsewhere in the United Kingdom, and in England it is overseen by NHS England. Though the public system dominates healthcare provision in England, private health care and a wide variety of alternative and complementary treatments are available for those willing and able to pay.
The National Health Service (NHS) is the umbrella term for the publicly funded healthcare systems of the United Kingdom, comprising the NHS in England, NHS Scotland and NHS Wales. Health and Social Care in Northern Ireland was created separately and is often locally referred to as "the NHS". The original three systems were established in 1948 as part of major social reforms following the Second World War. The founding principles were that services should be comprehensive, universal and free at the point of delivery—a health service based on clinical need, not ability to pay. Each service provides a comprehensive range of health services, provided without charge for people ordinarily resident in the United Kingdom apart from dental treatment and optical care. In England, NHS patients have to pay prescription charges; some, such as those aged over 60, or those on certain state benefits, are exempt.
Special needs dentistry, also known as special care dentistry, is a dental specialty that deals with the oral health problems of geriatric patients, patients with intellectual disabilities, and patients with other medical, physical, or psychiatric issues.
Dentists in the UK may undertake work under the National Health Service or privately. They may opt for either of these alternatives, or both. A small number of dentists are employed by the NHS but the vast majority are in private practice. UK dentists are regulated by the General Dental Council and the Care Quality Commission.
Private healthcare in the UK, where universal state-funded healthcare is provided by the National Health Service, is a niche market.
mydentist is the largest dental provider in the UK, with around 600 practices. mydentist is a trading style of IDH Group Limited, based in Kearsley. Nilesh Pandya is the Chief Executive of mydentist.
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