Introduction

Successive British Governments have emphasised the need to engage primary care services more formally under the family of care provided by the National Health Service. The introduction of the NHS (Primary Care) Act 1997 encouraged general practitioners and primary care dentists in England to leave their independent practices in favour of a more collective approach based on locally-negotiated contracts, perhaps even involving salaried employment.1 In NHS dentistry, personal dental services pilots were introduced to 'test' the efficacy of the policy. Fifteen first wave and five second wave pilots were subject to study by a Department of Health-funded evaluation over the period 1998 to 2001. The findings from this evaluation, reported here, provide important insights into many of the issues to be explored and tested by the field sites announced in NHS Dentistry: Options for Change.2

Policy Background

Traditionally, general dental practitioners in England providing NHS care have worked as independent contractors on a fee-for-item basis through a nationally negotiated scale of fees. This regime has long been criticised for generating a 'treadmill' effect, resulting in an undesirable emphasis on treatment rather than preventative activity. Despite the introduction of capitation for children in 1990, dissatisfaction with national arrangements, as illustrated by the 1992 'fees dispute', fuelled the search for alternative ways of contracting with dentists to provide NHS dental care. The 1992 Bloomfield report strongly criticised the existing arrangements and recommended that 'locally sensitive' commissioning of services from independent contractor dentists be explored.3

Building on the wider NHS internal market reforms of the time, it was argued that a principal advantage of local contracts was the opportunity to agree incentives to address local health needs and services. Moreover, the approach was seen as a potential way of retaining dentists in the NHS and to address the growing number developing private practices or working for corporate organisations. The retention of NHS dentists is a fundamental concern since shortages have led to growing inequalities in access to primary dental care both geographically and by social class.4 Indeed, recent figures suggest that some 40% of dental practices in 2002 no longer accepted children or adults for continuing care whilst 50% of dentists in the south east of England treated only private patients.5

The Development of Personal Dental Services Pilots

Alternative ways of remunerating dentists were explored in the mid-1990s with the full consultation of the dental profession. Resulting policy recommendations were developed in the 1994 green paper, Improving NHS Dentistry1 and the intention to develop the local commissioning of general dental services was announced in 1995.7

Details of the schemes were outlined in the 1997 white paper, Choice and Opportunity8 and the NHS (Primary Care) Act 1997, provided the legislation to enable PDS to be established.1 Participation in PDS pilots was voluntary and the scheme used a locally negotiated contract between providers (primary care dentists and/or NHS Trusts) and healthcare commissioners (formerly health authorities and now primary care trusts). Fifteen pilots commenced in 1998/99 rising to 54 pilots following the third 'wave' in 2000/1.

The National Evaluation of PDS Pilots

Fifteen first-wave PDS pilots and five second-wave pilots were subject to a Department of Health-funded national evaluation between August 1998 and October 2001.9,10 The purpose of the evaluation was to assist the development of dental primary care by examining the establishment, operation and impact of the pilots. In particular, the evaluation sought to examine those factors that facilitated or prevented change and to assess opinions on the quality and cost of services provided.

Since the purpose of the PDS pilots was to develop new ways of delivering NHS dentistry to tailor local services to meet local needs, the pilots were characterised by considerable diversity in their aims, objectives and structures. Given this uniqueness, the evaluation team was posed with a difficult methodological problem since suitable comparator sites were not available. Assessment of pilot progress, therefore, relied on the extent to which each individual pilot's objectives had been met — goals that had been determined by the pilots themselves in agreement with the Department of Health. Hence, it was impossible for the evaluation to make an assessment of how a PDS pilot's approach compared with alternative forms of delivery. However, the evaluation's design did allow for comparison between pilots on the perceived factors in the process of pilot development that facilitated or hindered progress. Moreover, where data was available, the identification of pre- and post- levels of activity could be monitored. The evaluation's approach was based on research procedures developed by a previous national evaluation of a primary care-based innovation.11 The research employed a combination of qualitative and quantitative research methods with the overall purpose of triangulating the experiences of providers, performers, commissioners, and patients to help assess and explain the progress of the PDS pilots.10

The Characteristics of PDS Pilots

Despite the very different objectives of the PDS pilots in the study, two common characteristics were shared: first, the imperative to improve access to primary dental care and, second, the adoption of remuneration arrangements which moved away from payment on the basis of item-of-service fees. Beyond these general characteristics, the first wave PDS pilots could be categorised into four key types (see Table 1)Table 1):

  • Capitation-based primary dental care pilots formed by multi-practice groups of GDPs;

  • NHS Trust-led primary dental care pilots employing salaried dentists and PCDs;

  • Specialised service pilots sharing a primary care setting and disparate funding arrangements; and

  • Small primary dental care pilots based on single practices and block contracts.

Table 1 PDS pilots in the national evaluation and their key activities
Full size table

The Progress of PDS Pilots

Key respondents from within the PDS pilots commonly reported a new found ability to change the profile of treatment (for example, by doing more preventative work); develop new services to meet local need; and to promote access to NHS dentistry. Indeed, the PDS approach was reported to have enabled providers to encourage preventative care, allowed more time in patient consultations and in treating patients with complex dental needs. Moreover, the PDS system was praised for providing more attractive working conditions for staff associated with removing the 'treadmill effect' experienced under the GDS item-of-service system whilst enabling investment in training and continued professional development. Whilst it remains to be seen whether PDS pilots have improved oral health in needy areas, promotional and educational activities have been advanced. The overwhelming view from within the PDS pilots themselves was that they were at the forefront of creating important future models of primary care dentistry.

Within the four large capitation-based pilots, increases in the proportion of courses of treatment containing no restorative intervention and decreases in the rate of common treatments including teeth filled per registration were reported.14 The changes in treatment behaviour were consistent with the adoption of a less interventionist approach, facilitated by capitation-based remuneration. Two of these pilots aimed to manage and improve access to primary dental care in response to the high level of demand. These pilots experienced increases in registered patients and a reduction in the number of reported access-related complaints by patients to the host health authorities. In contrast, the two other capitation-based pilots aimed to increase service use in areas where a high level of unmet oral health need was identified. However, differences in pilot-specific factors limited the potential for comparison.14

Seven PDS pilots employed a salaried model (Table 1). These pilots were concerned chiefly with improving access to care, particularly to unregistered patients. They were characterised by the integration of traditional GDS activity with former community dental services. Contrary to initial expectations, the evaluation found that dental services were still being directed to the relief of symptoms and to the provision of clinically urgent care rather than providing 'comprehensive' dentistry. This was reported to be a result of a combination of greater than anticipated demand and, in some pilots, recruitment difficulties of both dentists and therapists. The ability of such services to be responsive to unexpected demand for urgent care was, however, seen as a marker of success by commissioners from health authorities that were seeking to provide services in line with the 1999 Prime Ministerial pledge on access to NHS dental care.

Five PDS pilots sought to provide specialist care (traditionally delivered in hospitals) in a primary care setting (Table 1). The focus of these pilots ranged from practice-based minor oral surgery to orthodontics, and from anxiety management to complex restorative care. By taking referrals direct from other dentists, the objective of these pilots was to offer a viable alternative to hospital-based treatment in primary care and hence improve ease of access as well as reduce waiting lists.

All but one of the specialist PDS pilots reported progress in line with these expectations. For example, the Bedfordshire orthodontic pilot reported reduced waiting times for consultation and treatment. The pilot applied set criteria for acceptance for orthodontic care that led to a rise in initial consultations and the limiting of treatment to more complex cases. The criteria used was reported to be acceptable to patients, including those who were advised that treatment could not be offered. Similarly, the Southern Derbyshire PDS pilot for minor oral surgery reported achieving significant gains in access to care, hence addressing hospital waiting lists. Though there may have been a degree of selection in making referrals, patients accepted paying NHS dental charges for surgical treatment that would otherwise have been provided free by hospital services. It was reported that GDC specialist lists, whilst not being an exclusive indicator of dentists' skills, could be used as a starting point for identifying local dentists who might provide care otherwise traditionally provided by consultant-led services.

The views of dentists and professions complementary to dentistry (PCDs)

An objective of the PDS pilot policy was to help develop the roles of nurses, therapists and hygienists to the point where they would take greater delegated responsibilities from dentists and hence develop greater capacity in the system to improve access to dental care. Results from regular face-to-face and survey interviews with dentists and PCDs suggested that a majority of the dentists (61%), but only 35% of the PCDs, felt included in feedback about pilot developments received from the clinical lead of the pilot.12 This finding suggests closer links between dentists in the pilots, and this is emphasised by the level of managerial involvement where 33% of dentists, but just 7% of PCDs, described 'great' or 'significant' involvement in the PDS pilot's decision-making process.12 Indeed, it appears that many pilots had failed to consider how the role of PCDs could be enhanced to help overcome difficulties faced within the pilots such as to facilitate recruitment or create a more dynamic multi-disciplinary team.12

Developing skill mix

Despite these concerns, many pilots reported using their local contract to invest in continued professional development for staff in order to enhance skills, and establish dental 'teams'. The PDS contracts provided both the opportunity and incentive to create new skill mixes that optimised the use of professional staff such as nurses, therapists and hygienists and enabled dentists to concentrate on case management and treat more complex cases. However, in practice, the potential for innovation was not realised, due to a range of factors including the difficulty of providing financially competitive funding for therapist posts.

Developing a 'needs-based' culture

Since providers in PDS pilots receive a stable income based on an up-front capitation or sessional payment (rather than one based on item-of-service) most pilots reported the development of a 'needs-based culture' as opposed to the demand-based operations inherent in the traditional GDS remuneration system. Dentists opting for salaried employment did so to avoid the burden of practice management (either to an NHS Trust or to a dental practice holding a PDS contract). As a result, the terms and conditions of their employment tended to be considerably more flexible allowing for part-time working, paid leave, and investment in training. Having a known income has also allowed dental service providers to plan ahead in the knowledge that their income for the year is secure. Many lead clinicians reported the additional benefits to their patients as a result, including increased consultation times and being able to 'treat the person and not the mouth'.12

Management arrangements and contracts

In general, PDS pilots were managed through informal contact between the former health authority and pilot leads, rather than any strict adherence to the requirements of a local contract. Agreements were simplistic and provided only a limited basis for performance management. Nevertheless, local contracts have provided a framework in which health authorities and dentists have started to address quality issues, which has great potential when compared with the GDS arrangements.

Difficulties relating to the implementation and management of systems for processing activity and cost data were underestimated. Some pilots were still struggling to report routine activity and costs data after two years of operation.14 Not surprisingly, pilots that linked activity to funding made more rapid progress in resolving problems, while some other pilots seemed to attach very little priority to securing a record of their activity. The absence of any management allowance for the pilots undoubtedly inhibited their progress. The difficulties faced by pilots in this regard has implications for the commissioning of dental services by PCTs in the future; often the management of the pilot was left in the hands of a small number of individuals in health authorities and, where relevant, provider trusts. The development of dental expertise within strategic health authorities and primary care trusts (PCTs) is now a key challenge in order to secure effective leadership in the future if local commissioning is to be extended.

User and patient experiences

Within the evaluation, a postal survey was undertaken to identify the impact of PDS on the perceptions of users and patients.13 The research employed a comparison of patients receiving care under PDS, GDS and CDS systems. Patient perceptions suggested that PDS had made little comparative improvement in access to dental services (except for emergency treatment) and that some resentment was expressed from those having to pay NHS charges when the service had been free under the previous community dental service.13

The Legacy of PDS Pilots

Overall, PDS pilots appear to have proven successful ventures. However, compared with its sister initiative — Personal Medical Services — the uptake and roll-out of the PDS approach has remained limited. One reason for this may be the observation that the success of PDS pilots was heavily dependent on the commitment and enthusiasm of a few key individuals, some of which appear to have been 'born' rather than 'made' to work within such systems.15 Thus, whilst the PDS remuneration arrangements have undoubtedly enabled professionals to work in very different ways, it was often reported that fellow dental professionals may not be so attracted to the prospect of being 'managed' under a local contract nor having their income capped. Indeed, the national evaluation uncovered perceptions, both locally and nationally, that suggested a lack of interest and understanding in the philosophy behind PDS. Due to their need to earn income through activity, some regarded PDS pilots as competitors rather than partners, though other recognised their potential to be used to provide urgent care to the unregistered — the sort of complex care that perhaps they would be loathe to take on themselves. Consequently, the rolling-out of a system of locally-based providers may not necessarily be supported by the majority of dental practitioners.

It could be argued that the behaviour of the primary care dental professional in healthcare needs to change if a more comprehensive NHS dental service is to be achieved. Professional dominance against the collective effort has been a characteristic of the system and, generally, authorities have been unable to manage dentists due to their traditionally independent nature and sacrosanct clinical freedom. As a result, authorities tend to be administrative rather than managerial and their decision-making power over consultants has been limited. The PDS arrangements have provided a basis for the pilots to begin the process of changing the culture of primary dental care provision to one based on quality rather than on activity and cost. However, steps towards professional clinical governance with collective responsibility between dentists, consultants, and the range of other complementary professions including representation from the local community, take time. Such a system requires a culture shift amongst existing professionals to share power, yet if achieved, would be a very robust system indeed.

Policy Implications

Many of the lessons learned from the experiment with personal dental services are being taken forward in the recent NHS Dentistry: Options for Change.2 This policy document suggests that alternative methods of remuneration for general dental practitioners should build directly on the experience of the PDS pilots and encourage a 'menu' of payment methods including capitation and salaried options. Importantly, Options for Change re-emphasises how the direct association between payments to dentists and the types of treatment offered to patients needs to be removed in favour of treatment that is clinically-appropriate and protocol-driven. Moreover, it is suggested that primary care trusts should commission such services with the overall threefold objective of securing access, improving oral health and addressing inequalities. Hence, the role of locally-negotiated dental contracts, à la PDS, is likely to become a key feature in the future of primary care dentistry.

Whilst the national evaluation supports the efficacy of the new remuneration methods in dentistry undertaken in the pilots, it is unclear whether the approach can be successfully introduced in other locations, particularly where there may be little or no grass-roots support for working to salaried or capitation-based local contracts. For this reason it is appropriate that Options for Change allows GDS to continue while other models are developed beyond the pioneer PDS pilot stage.