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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!
It is worth reminding ourselves of some of the principal recommendations of the Steele Review, because the mists of time may have made us forget! The report was critical of the lack of data collection since 2006 and recommended a return to the collection of ‘tooth-level data’, something which provided an accurate representation of the success of treatments carried out on the NHS, both at an individual and national level. It also recommended that any future payment system should be piloted, which the UDA system was not. Accordingly, a series of pilots are presently being evaluated, but progress has been frustratingly slow, the frustration being apparent when Professor Steele and co-authors of the Review spoke at the BDA Conference in May. However, none of the pilots contains any reference to collection of tooth-level data, something that is important in my view.
There may be another reason why progress has been slow. The complaints about the UDA system, common before and around the time of the publication in 2009, have largely dissipated, and the dentists' representatives, such as the BDA, have had other problems to worry about, such as the hike in the Annual Retention Fee at the GDC. Also, the Government are content. They have manufactured a cash limited system, which is what they wanted, and see no need to hurry into a new contract, when there is little or no adverse publicity about the current system and patients (ie potential voters) are not complaining. In addition, some dentists are happy, because they have learned how to play the system, and the majority of hardworking and honest dentists have come to live with the current perverse arrangements because they are committed to treating NHS patients.
Is a return to fee per item possible? Probably not, because it is difficult to control financially. However, I have argued in the past that a system which is largely based on capitation would work,2 but with an add on of fee per item to bring oral health to a contractually limited number of patients for those dentists who wished to increase their access to NHS dentistry and bring new patients into their practices. They would be contracted to do so. Patients would pay their annual charges for NHS dentistry in a similar way to how, for example, we pay for the road tax for our cars, but instead they would go onto the ‘NHS Dental Website’ (which is still in my imagination!), select their dentist, pay their annual fee and make their review appointment. Alternatively, they would simply go into their dentist's practice and pay their subscription. This would solve some of the problems that seem to be slowing down the current pilots.
Perhaps the new ‘new contract’ will seem clearer a year on. For now, as we approach the end of another year of Dental Update, it is my pleasure to wish all readers everywhere a happy and, above all, peaceful New Year and Season's Greetings and also to thank you for continuing to subscribe to our journal – I hope that you have enjoyed this year's issues. Finally, I should like to thank the Editorial Board for their input and wisdom, our superb authors for sifting through the copious dental literature and telling us what it means by way of the review articles that they write, our peer reviewers for their advice and, finally, all the team at Guildford, led by Angela Stroud, for producing each super issue. Many thanks to all of you.