Was fee per item really that bad?

First, welcome to the first ‘themed’ issue of Dental Update. Given that over 80% of our readers are in primary dental care, and that almost all GDPs see some children as patients, it seemed appropriate to publish an issue dedicated, in the main, to paediatric dentistry. Thanks are due to Professor Chris Deery for his part in making this happen: he has written a guest editorial introducing this special issue. Readers will notice that there is a paper which does not relate to paediatric dentistry, namely the paper on oral health issues of migrants. Given the topicality of this subject, I felt that this paper should be published at the earliest opportunity.

Now to the important subject of the remuneration of UK dentists, with emphasis on the Unit of Dental Activity (UDA) system in England and Wales. Sadly, there is now a whole generation of dentists who think that UDAs are the only currency by which dentists are paid for their treatment of NHS patients. For the benefit of that group, before April 2006, NHS dentists throughout the UK were principally paid on a fee per item basis, ie they were paid a fee for each item of treatment that they carried out. This system had worked, reasonably well, for over 50 years, but concerns were being voiced about over treatment, despite the fact that there was a 50-strong team of inspectors who examined patients who had received NHS dental treatment, in order to check that the treatment was (a) necessary and (b) carried out to a satisfactory standard. Concerns were also being voiced about how this system was no longer fit for purpose in an era when the incidence of caries was decreasing. While the latter concern might have some relevance, there was never any evidence of widespread abuse of the system. The more likely reason for the change was that the NHS wanted to be able to estimate exactly how much dentistry was going to cost per annum, and under a fee per item system this was difficult. So, the bizarre UDA system was introduced, and still exists nine years on, despite it being largely condemned in the so-called Steele Review of 2009.1 This system just doesn't make sense, given that the clinician is remunerated the same fee for one filling or ten, and similarly for crowns, root fillings, etc, which, to me, seems perverse in the extreme. Also, the fee for a removable plastic one-tooth denture is the same as that for a three-unit bridge! Furthermore, the UDA fee was not set nationally, but set individually according to the dentist's gross prior to 2006 – in other words those who had a high cost per patient (perhaps because they were cutting a lot of teeth for crowns) received a higher UDA value than those who had a less interventionist approach. I discovered at a recent meeting that some dentists in an affluent area of low need are receiving £36 per UDA, while those in an area of social deprivation and high need (20 miles away) are receiving £20 per UDA. This cannot be right!