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Walking the talk
11th Jan 2007
Chief Dental Officer for England Barry Cockcroft believes the changes have been a success
England’s CDO Barry Cockcroft tells Dentistry his latest plans for the profession and explains why he continues to believe the new reforms are positive. Interview by Penny Palmer What are your plans to take dentistry in the UK forward? My remit is to advise Ministers and my colleagues in government on measures that we can take to improve the oral health of the country and reduce health inequalities. I also provide professional advice on services to patients and a range of professional issues. I believe the most effective measure for reducing dental decay is water fluoridation. Legislative changes now give the local NHS greater opportunities to take this forward where there is local public support, and it is an important part of my role to ensure that Strategic Healthcare Authorities (SHAs) and Primary Care Trusts (PCTs) receive appropriate support and advice on this issue. With NHS dentistry, we now have a more locally flexible contract, within an overall national framework. This allows the NHS to reflect the needs of people requiring dental care in their area. We have recruited and are training more dentists for the future, and now PCTs are generally reporting no problems finding dentists keen to take on more work or open new practices. What are your plans with regard to water fluoridation? We have amended the legislation to make SHAs responsible for deciding if an area should be fluoridated, subject to local consultation. I would like to see all SHAs with high levels of dental disease undertaking consultations, but it is the government’s policy that these decisions are taken locally. From a wider perspective, the incidence of dental decay is dependent on three things – diet, education and the availability of fluoride. Our Oral Health Plan for England Choosing Better Oral Health focuses on these issues and we are continuing to provide support and advice to the NHS in all these areas. What has happened to the £100m that the Health Minister announced for dentistry? Has anyone received anything yet, and what is the criteria to qualify for this? The £100m has been allocated to SHAs, £40m in the first year and £60m in the second. I visit many areas where PCTs are discussing with Local Dental Committees (LDCs) and others how most effectively to deploy this money. Our guidance to the NHS on how this is to be used is on the CDO website in the ‘What’s New’ section. Some dentists say the new contract was introduced without consultation or negotiation. What is your response to them? The process of information dissemination that went on between 2003 and 2006 was probably the most intense period of consultation with the profession there has ever been. We certainly fed in suggestions received from dentists during this period and also amended the regulations after we had published these in draft form. We met many times with the British Dental Association (BDA) over the period when we were developing these regulations. The BDA always took the view that they were merely acting in an advisory capacity, not negotiating. Many dentists are angry and despondent with the new contract, what are your plans to turn them around? Significant change always brings uncertainty and that is not comfortable, but it does also bring opportunities. It is human nature to recall the advantages of the old system rather than its disadvantages. We recognise there is more we need to do to support the NHS, and the profession in delivering the intended benefits of the new system. That is partly why we established an implementation review group, bringing together professional, NHS and patient representatives to review the impact of the changes and to identify any possible improvements. Working positively with the NHS is the best way to improve mutual perspectives and understanding – key voices in dentistry can appear to be negative and reluctant to change. I hope that dentist leaders can help dentists adapt to the changed environment, and continue to develop collaborative working relationships with the NHS locally. I was very encouraged by the LDC conference survey, which showed the vast majority of LDCs considered they had a good working relationship with their PCT. Why is it taking so long for dentists to sort out their contracts? Around a third of contracts were signed in dispute, and the most recent data shows that at the end of September almost 60% of these disputes have been resolved. The good news is that in over 99% of cases the dentists involved have decided to continue with their contract. There is still clearly further to go, but I believe this shows positive progress. The signing in dispute arrangement has enabled dentists to continue receiving payment, and patients to continue receiving services whilst some of these difficult issues are in the process of being resolved. Why are some PCTs refusing to increase UDAs to practices that have used them all up? The contracts that were offered to practices were based in most cases on the levels of activity carried out during the 12 months of the reference year, minus the 5% reduction for dentists moving from the old GDS. If a practice has already carried out broadly the same number of courses of treatment as it did during the reference period, this raises fundamental questions about how services are being planned and delivered over the year. If PCTs agreed to increase contracts and service levels for practices that deliver their annual contract requirement early, this would work against many of the intended benefits of the new regime (such as freeing up time and capacity to enable dentists to spend more time with patients and spend more time on prevention). PCTs are being encouraged to perform an oral health needs assessment in their areas, and the development of future dental services should be based on this assessment. There were also cases where practices had unusually low earnings and activity during the reference year, and PCTs faced some very difficult commissioning choices. In some cases, PCTs made a decision to use spare funding to commission new or expanded services in a different part of their locality. This was one of the most difficult aspects of the transition, but it is also one of the fundamental principles of the reforms, i.e. giving PCTs flexibility to develop services in ways that reflect local needs and priorities. A survey from the HSA said 24% of the 1,056 respondents surveyed resist seeking dental treatment because of the new treatment charges. The same survey revealed that 12% of people thought the NHS would improve, with 30% believing the service will vanish altogether. What is your response to this? Feedback from patients has been broadly supportive of the new arrangements. Dentists, and especially receptionists, responsible for taking money seem to like the simplicity. Over the change from the old system to the new system, there are bound to be some examples of winners and losers, but overall the new system is clearer and fairer for patients. In surveys such as this the response is often influenced by media coverage. We have many examples now where PCTs have significant growth in services and responses to tenders suggest this will continue. The media is not interested in positive stories, but we are already seeing an increase in NHS dentistry capacity as a result of these changes. Many dentists are convinced that this new contract was rolled out with a view to eliminating NHS dentistry altogether, what would you say to them? I would ask them why they thought the government had increased annual investment in NHS dentistry by £400m since 2003/04, why Ministers have announced £100m capital investment in NHS dentistry, why we have invested in a 25% increase in dental training with effectively two new dental schools in England, and why areas like Lincolnshire, which have traditionally suffered major access difficulties, are now able to significantly expand NHS services. Giving PCTs the statutory duty to commission NHS dentistry for their area was also a momentous step. How do you see the future of NHS and private dentistry? I have always been completely consistent on this point. People need to be able to make well-informed choices between NHS and private dentistry. This was the object of the government’s response to the Office of Fair Trading Report on private dentistry, which led, among other reforms, to the establishment of the GDC’s Dental Complaints Service. Patient demand for cosmetic dentistry has increased significantly over the last 10 years, and that certainly reflects the extra importance patients attach to their dental health and appearance in this modern era. It is completely appropriate for a dentist with an NHS contract to provide private treatment, which is outside the scope of the NHS. Under the old GDS system, if a dentist decided to reduce their NHS commitment, then the money from the contract returned to the centre, and it could not be used locally to make up for the reduction. This meant reduced availability to NHS dentistry in that area. The new system, where the money is retained by the PCT to commission replacement services, is already working well. So if a dentist moves to the private sector there is no reduction in the level of NHS service provision. My own view is that NHS and private dentistry ought to be complementary, not in competition. In the lead up to April 2006, some people were telling dentists they now had to choose between being NHS or private. That was not the case then and is not the case now. Is there anything else that you would like to add? When I joined the Department of Health in 2002, I said that we needed to address three very fundamental issues to make dental services function for the benefit of everyone. These were ensuring sufficient funding and workforce levels, and putting in place a system that enables increased funding and increased workforce to have the desired impact. I believe we have made major steps forward in addressing all three of these issues. I accept there is further to go. And I accept that change can be disconcerting. But I believe that we now have a much stronger basis on which the NHS and the profession can work together to build and improve services for the future.
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