Dentist Contract with Nhs by ujy16181

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									Transforming NHS dentistry
Innovating for higher standards and greater access to care

1. Summary
Conservatives are committed to working with front-line NHS professionals to
deliver world class healthcare for people. We want to transform NHS dentistry,
from a service currently in seemingly terminal decline to one people can trust, and
which delivers high standards of care to everyone who needs it.

Labour’s approach to micro-managing the NHS has been especially damaging for
dentistry. Bureaucratic changes in 2006 severed the patient-dentist relationship by
stopping people registering with local practices, instead contracting dentists to
perform fixed units of treatment every year. This was disastrous: perverse
incentives now force dentists to skip essential preventative care to meet short-term
targets for curative treatments. Oral health has declined, skewing resources to fewer
and fewer patients – a million people have lost access to an NHS dentist already.

We are proposing to scrap Labour’s bureaucratic dental contract and restore the
right for patients to register with dentists. To achieve this, we will use two stages of
innovative reform designed to tackle the long-term drivers of bad oral health and
the rising cost of remedial treatments.

First, micro-management will be replaced by new incentives that reward dental
professionals for providing essential preventative care and other innovations that
improve oral health and deliver better value for money. We will also remove the
perverse incentives that drive dentists to provide unnecessary treatments, providing
enough capacity to restore access to dentists for the million people that lost it due to
Labour’s botched reforms and yielding long-term cost and health benefits. Then, as
capacity builds, we will move to patient registration, strengthened by giving people
access to new information about the results dentists achieve, empowering their
choices over which ones best meet their needs.

Our reforms will not only tackle the immediate crisis in access to NHS dental care.
They will build a sustainable system where more effective incentives and more
empowered patient choices drive a virtuous cycle of increased access to care and
value for money for taxpayers.

1.1. Our plan for reform

We believe patients should have an established relationship with their dentist, much as
they do with their GP. This is the best way to ensure patients receive the care they need,
and for dentists to be given the incentives they need to provide the preventative care
essential for improving the oral health of their patients over the long term. It would also



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reduce the rising current costs of curative and emergency treatment. We want to scrap
the disastrous target-driven dentistry contract Labour created in 2006.

A way forward cannot be achieved by simply throwing more money into an unreformed
and failing system. That is why we are consulting on a series of innovative measures to
build in the essential preventative care and financial discipline that will allow us to move,
in two clear stages, to a new system based on patient registration.

1.2. Tackling the immediate crisis: the first stage of our improvements

We will immediately introduce strong new incentives to deliver far better preventative
care, improving oral health and delivering better value for money, thereby freeing
capacity. We will remove the perverse incentives that drive dentists to deliver
unnecessary treatments. We will also introduce new powers and freedoms, new training
arrangements and new commissioning practices that will stem the flow of dentists and
other dental professionals out of the NHS. This will, at the very least, create enough
capacity to restore access to an NHS dentist for the million people that lost it due to
Labour’s botched reforms. Over time, we hope this increased access will double to two
million more patients as our reforms progress. This will prepare the ground to move from
Labour’s bureaucratic system to one driven by patients’ needs.

a) The power and freedom to deliver better preventative care

   •   Preventative care incentives. Every £1 spent on giving a patient preventative
       dental treatment can save at least £8 in curative work, but Labour’s target-based
       system has driven this essential care out of the NHS. We will reform dentists’
       contracts to provide strong incentives to provide this care.

   •   Extra help for schoolchildren. We will allow for far greater innovation in
       delivering oral health initiatives for young children. This will include freeing £17
       million from already-planned spending increases to allow all five-year-old
       schoolchildren an oral health check-up. Screening and advice for schoolchildren
       has been almost wiped out under Labour, yet it is proven to yield huge health
       benefits and cost savings over the long term.

   •   Restoring access to an NHS dentist for the million patients who lost it since
       the introduction of Labour’s bureaucratic system. By freeing dentists to
       deliver better preventative care we can tackle the perverse incentives created by
       Labour’s contract, whereby patients are recalled for routine check-ups just weeks
       after treatment and without clinical need. NHS data shows that when these
       unnecessary slots are freed up, we can create enough capacity to achieve, at the
       very least, access to care for a million extra patients.

   •   Giving dentists the freedom to charge patients who repeatedly miss
       appointments. The ability to introduce charges to tackle the problem of repeat
       missed appointments was taken away by Labour, but our consultations with the
       dental profession show that reinstating this freedom could significantly reduce
       waste, allowing well over 100,000 additional patients to access NHS dentists.


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b) Supporting and trusting dental professionals

   •   Removing barriers to setting up and selling new practices. Labour’s short-
       term funding contracts mean dentists often cannot attract the investment they need
       to start up new practices, or to maintain or sell existing ones. We will look at
       longer-term deals that provide the certainty investors need to buy into NHS
       dentistry.

   •   Five-year tie-ins to the NHS for taxpayer-trained dentists. It costs the NHS
       around £170,000 to train a dentist, but many feel forced to abandon the service for
       the private sector – or in some cases are actually being poached – at no cost to
       private firms. We propose that those who take public bursaries for dental training
       should do at least five years’ work for the NHS in return.

   •   Smarter commissioning. We will open up commissioning to allow a wider range
       of professionals, such as hygienists and oral health educators, to be used to
       support improvements in NHS dentistry. This will be especially useful for
       allowing innovative preventative advice strategies to emerge, for example.

1.3. Moving to patient registration: completing our reforms

As the virtuous cycle of improvement brought about by our value for money reforms
increases capacity within the NHS system, we propose to break with Labour’s system
altogether. Over the longer term, we want to secure a system widely supported by dentists
and patients which allows people to register with a practice. A system of registration for
patients is an approach that has widespread support, including the endorsement of the
British Dental Association.

In essence, this would mean that each NHS dentist would have a list of patients for whom
they are responsible. The number of patients on the list would form, at least partially, the
means by which dentists would be paid, replacing the current fixed treatment quotas.
Dentists will be positively incentivised to improve oral health outcomes, not meet
bureaucratic targets for individual procedures.

We are determined not to create unnecessary upheaval and will not repeat the
Government’s mistake of overhauling NHS dentistry without properly testing any
changes first. We will therefore allow the two systems of treatment quotas and patients
registration to exist in parallel for a time. However, to ensure we move as quickly as is
practical to a full registration system, we aim to replace the Government’s failed contract
with a registration-based one when dentists come to the end of their contract periods




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2. Why we urgently need change
Labour’s ill-thought through changes to NHS dentistry have thrown it into crisis. Not
enough people who need an NHS dentist can find one and the fundamental relationship
between patient and dentist was undermined when the Government abolished patient
registration in 2006.

Furthermore, those able to see a dentist are often not receiving the care they need because
of poor incentives in the way dentists are paid for the treatment they deliver. Throughout
their time in office, Labour’s approach to running the NHS has been through bureaucratic
government intervention, with officials setting targets attempting to control activities that
should be managed by healthcare professionals. The result across the NHS has been to
create perverse financial incentives that have damaged patient care while causing costs to
rise unnecessarily, and this is exactly what has happened with NHS dentistry.


2.1. Perverse incentives: how the system fails patients and dentists

In 2006, under the provisions of a new contract for NHS dentists, Labour introduced a
target-based system. The contract now pays dentists for performing an annual allotment
of ‘units of dental activity’ (UDAs), with services commissioned through the local
Primary Care Trust. The NHS can claw back funding if the target level of activity is not
met, but there is no reward for exceeding expected performance.

A major problem with this system, and a key reason why costs have risen while access to
an NHS dentist has fallen, is that essential preventative care has been effectively designed
out of the service – despite the fact that it produces huge cost and health benefits – due to
the emergence of target-driven perverse incentives.

Labour’s new contract had the aim of increasing both access and the focus on
preventative work. In March 2006, the Government convened an Implementation
Review Group, which identified four success criteria for the reforms. These included
delivering improvements to the patient experience and improving the working lives of
dentists.1 The Department of Health stated that the key test would be ‘their ability to
support improved patient access.’2 According to the Government’s own objectives, then,
the contract has been a dismal failure.

It is typical of Labour’s approach to the NHS that bureaucratic control is favoured over
genuine professional-led care. Their dramatic changes NHS dentistry went ahead without
the use of adequate pilots or even proper engagement with dentists. The British Dental
Association, giving evidence to the Health Select Committee in Parliament, stated that it
had not been ‘involved in, or consulted on’ the use of Units of Dental Activity (the new
way dentists are made to perform activity – see below) before the contract was
introduced.3 The Committee’s subsequent report rightly called it ‘extraordinary’ that the

1
  Department of Health, NHS Dental Reforms: One Year On, August 2007
2
  Ibid.
3
  House of Commons Health Committee, Report on Dental Services, July 2008, p. 17, DS 19A


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Department of Health did not pilot the new payment system for dentists before it came
into force.4 More than one in ten dentists rejected the contract they had been offered by
their Primary Care Trust by April 2006.5


2.2. The results of failure

Three years on from Labour’s introduction of a new bureaucratic and target-driven
contract for NHS dentistry, the service is in a worse state than ever.

Firstly, patient access has fallen enormously since the Government abolished the system
of patient registration. This severely damaged the dentist-patient relationship6 meaning
people are no longer able to say they have an NHS dentist unless actively undergoing
treatment. More than a million people have lost their NHS dentist in just the last three
years7 as dentists’ activity shifted from managing the oral health of patients on their
books, to simply performing targeted units of dental activity – or ‘UDAs’.

Secondly, the UDA system directly disadvantages both patients and dentists because
there are just three UDA charging bands which dentists claim against for each course of
treatment provided, and which patients also pay set charges against (unless exempted).8
As a result, a dentist will receive the same amount of money to perform six fillings as
they would one filling, and are incentivised to undertake severe treatments because they
get paid more: official NHS reports show that, against the normal trend, there was a 14
per cent rise in tooth extractions in the year following the new dental contract, while
fillings and crowns declined.9 In fact, the number of complex treatments that involved
laboratory work fell by half during the contract’s first year.10

Thirdly, the contract does little to assist dentists in delivering the preventative work that
we need to secure our nation’s ongoing oral health, whilst managing costs. Routine
check-ups provide the only regular opportunity to undertake preventative care, but these
fall into the lowest income band and constitute the smallest contribution toward the target
dentists are required to meet by the Government’s contract. Dentists now have an
incentive to minimise the time taken for routine check-ups – there is evidence that
dentists can only afford to give around 15 minutes to provide a check-up, in which time
there is very little scope for preventive care and education. A study of London patients
found that a third had received no preventive advice when they last visited a dentist.11

Sound preventative work has been further undermined by Labour’s phasing out of NHS
dental screening in schools, which used to be organised through local Primary Care

4
  Ibid, p. 49
5
  Ibid, p. 18
6
  See House of Commons Health Committee, Report on Dental Services, July 2008, p. 5
7
  NHS Dental Statistics for England, Quarter 2: 30, NHS Information Centre September 2008
8
  Charges to patients for dental treatment have been in place since 1951. There are currently exemptions for
those under 18, in receipt of income support, and expectant mothers.
9
  Dental Treatment Band Analysis: England and Wales, 2007-08, NHS Information Centre, 2008
10
   House of Commons Health Committee, Report on Dental Services, July 2008, p. 33
11
   House of Commons Health Committee, Report on Dental Services, July 2008, pp. 30-31


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Trusts as a means of ensuring the good oral health of local populations.12 Requests made
under the Freedom of Information Act by Conservatives led to the admission that only
around a fifth of Trusts now have a screening programme that is widely available to
schoolchildren.13

The overall effect of Labour’s system of perverse incentives and top-down bureaucratic
control has been disastrous, raising the costs of NHS dentistry, while at the same time
pushing oral health into decline. This inevitably leads to extra pressure on the service,
making accessing an NHS dentist far more difficult under the new contract.


2.3. The need for a new approach

Labour have no strategy to deal with these systemic access problems beyond simply
throwing more money into the existing failed system, with budgetary increases that
outstrip other areas of funding across the NHS. The budget for dentistry increased by 11
per cent in 2008-09 and is planned for a further 8.5 per cent increase in 2009-10 to a total
budget of £2.25 billon, an increase of approximately £176 million next year.14 This
money will not fix the crisis in NHS dentistry unless used along with fundamental
reforms to undo the damage done by Labour’s failed system.




12
   Department of Health Guidance, Dental Screening (Inspection) in Schools, January 2007 pp. 1-4
13
   118 of 152 PCTs responded to the request – a response rate of 77.6 per cent. Of the 118 PCTs that
responded to the entire request (some did not make their position on screening clear) 75 (63.6 per cent) are
no longer screening children –of those, 6 PCTs reported continuing with some form of research or dental
surveying. 44 (37.3%) of PCTs responded positively to say that they were screening children, though 17
make it clear that the programme is only in operation is special needs schools. As such, 27 (22.9 per cent)
of PCTs disclose a screening policy that could be deemed widely available.
14
   Hansard 16 Dec 2008, Column 660W


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3. Transforming NHS dentistry
3.1. What we want to achieve

We believe that a patient should have an established relationship with their dentist, much
as they do with their GP. This is the best way to ensure that patients receive the care that
they need, and supports dentists in their desire to look after the long-term oral health of
their patients. It is also the best system for ensuring value for taxpayers’ money.

A move to a proper registration system is supported by the British Dental Association.
However, they caution against simply introducing registration without addressing, “either
the problems associated with capacity or the tensions between registration and the current
UDA system.” They rightly point out that: “The current dental capacity of the NHS,
based on the workforce and their levels of NHS commitment, would not be able to
support full registration of the population without generating excessive patient lists and
waiting times.”15

This is why we must look directly at building extra capacity and also at ways to ensure
enough NHS dentists are available. And it is why we are consulting on a series of
innovative measures to build essential preventative care and financial discipline into the
system. The result of the proposals we are consulting on, below, will be to at least free
enough capacity to restore access to dentists for the million people that have lost it due to
Labour’s reforms in 2006, and we hope that the total benefit will give up to two million
more patients access to an NHS dentist. This will then allow us to move to a proper
registration system to ensure value for money over the long term.


3.2. Our plan for reform

We have a clear vision of the NHS dental service we want to create for patients and
dental professions; one which patients can trust to meet their needs, and which empowers
dentists to provide the improvements in oral health and patient care that they came into
the profession to deliver. But the systemic problems and failures Labour have already
built into the service mean it cannot be fixed overnight. This is not just because to do so
would cost far more than is available to the NHS, it is because fundamental structural
reforms are needed for the spending increases that are already planned to deliver any real-
terms added value. So we will need to progress in two clear stages of reform.

3.2.1. Tackling the immediate crisis: stage one of our improvements

We will take immediate steps to reform the existing system so that dental professionals
are freed to give far better preventive care, thus improving oral health and reducing long-
term costs.




15
     Response to the Health Committee Report on Dental Services, BDA, September 2008, p.7


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a) Preventative care incentives

Prevention is better than cure in any area of healthcare. Preventive dental care activity,
such as oral hygiene treatment with a dentist, or oral health education and advice, is not
only far cheaper than restorative treatment such as crowns or bridges, it helps prevent
such serious treatments from having to be undertaken in the first place. In fact,
international evidence shows that for every £1 spent on preventative dental care, at
least £8 can be saved on curative treatments.16

The benefits are particularly strong for early intervention. Research from the US,
involving thousands of infants over a five year period, showed clearly that the earlier a
child had their first preventive dental visit, the more likely they were to establish a good
preventive health routine, and the less likely they were to need subsequent restorative or
emergency visits. The cost impact was huge: average dentally-related expenditure on
each child was less than half (48 per cent) where a child had their first visit at age one,
compared to age five.17

We propose to:

     •   Reward NHS dentists for preventative activity. We will eradicate the perverse
         incentives in the UDA charging system whereby dentists have to avoid proper
         preventative treatment because it is not financially advantageous. We will consult
         on how best to take immediate measures to include, within the same overall
         budgetary limits, specific incentives for preventative treatment and advice – while
         aiming in the long term to remove the current contract altogether. Preventative
         activity would be funded through the resulting decrease in dentists’ chargeable
         curative and restorative activities.

     •   Incentivise preventative help for children to embed good oral health. We will
         allow for far greater innovation in delivering oral health initiatives for young
         children. Screening and advice in schools has the most potential for long-term
         oral health improvements while delivering cost savings. So we will free £17
         million of already-planned spending to allow all children to be given an oral
         health check-up at age five. This will allow all schools to access support to give
         an oral health assessment and an initial engagement with a dental professional.
         We also want to look at innovative information or promotional strategies to target
         oral health education at parents of very young children, to maximise the benefits
         of early intervention.

         The cost of screening the 680,000 five year-olds in our schools in any given year
         would be around £17 million if we assumed a £25 per head cost (the comparable
         price charged by dentists for this kind of activity, which could be reduced if other
         health professionals were used to perform this). This cost represents less than 10

16
   Sharon Stull, C, Connolly, Irene M, Murphree, Kellie R., The Economic Impact of Preventative Dental
Hygiene Services, Journal of Dental Hygiene, January 2005
17
   Savage et al, (2004), Early Preventive Dental Visits: Effects on Subsequent Utilization and Costs,
Pediatrics: official journal of the American Academy of Pediatrics


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         per cent of the £176 million the Government has allocated for dentistry budget
         increases, mentioned above. Given the evidence, this strategy would pay for itself
         in a relatively short time and go on to make big improvements in oral health, as
         well as delivering value for money to taxpayers.

     •   Free NHS dentists from perverse incentives, restoring access to care for a
         million patients excluded under Labour’s system. By freeing dentists to deliver
         better preventative care we can tackle the perverse incentives created by Labour’s
         contract which are blocking access to care for many patients. NHS data shows
         that, despite the fact that the NHS guidance is that dentists should not recall
         healthy patients within three months if no problems are identified,18 dentists are
         recalling healthy patients for check-ups and charging the NHS for courses of
         treatment unnecessarily. This has already been publicly exposed by the
         Government’s chief dental officer as a potential means by which dentists were
         earning extra money.19 It is not our belief that this represents any widespread
         fraud, it is the effect of perverse incentives within the UDA system.

         Our calculations show that by removing these we could, at the very least, create
         enough extra capacity to treat a million more patients – enough to restore dentist
         access to all those who have lost it since Labour’s botched reforms. Our analysis
         of the most recent NHS data shows that enough capacity for treating 2.3m patients
         is being used up by early recalls20 and that figure does not count urgent cases
         where recall could be deemed clinically necessary. A small proportion of the 2.3m
         could be recalls for non-urgent but complex treatments, where follow-up may be
         necessary while a patient heals or work ‘settles’, but that would obviously account
         for only a minority of treatments. So while our proposal is to provide capacity for
         a million extra patients, our hope is that over time we can extend this to achieve
         capacity for up to two million.

     •   Give dentists the power to charge patients who repeatedly miss
         appointments. This was abolished by Labour and many NHS practices now face
         huge problems over missed appointments. Our consultations with the profession
         indicate that NHS patients currently miss an average of around five per cent of
         their appointments, though there are wide variations between practices. This
         wastes in the region of 1.8 million courses of treatment each year nationally.
         Charging is common in the private sector and has the effect of significantly
         reducing missed appointments. If NHS dentists were given back the freedom to
         charge a fixed financial penalty for a missed appointment, and assuming a prudent
         reduction in missed appointments of only 25 per cent as a result, the NHS could
         take in well over 100,000 additional patients each year.21

     •   Give dentists the freedom to have child-only contracts. We recognise that
         there are real attractions for dentists to leave the NHS for the private sector.

18
   http://www.nice.org.uk/nicemedia/pdf/word/cg019niceguideline.doc
19
   See BBC News Online, 13 October 2008
20
   http://www.parliament.uk/deposits/depositedpapers/2008/DEP2008-2756.xls
21
   See Appendix 1


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         Through no fault of their own, dentists’ loyalty to the NHS is being tested by
         unhelpful Government reforms. Thus, it is important that we remove barriers to
         those who wish to return to the NHS – for instance, if dentists only wish to
         provide dental care for children as part of their NHS case-mix. It is also
         important, given the Government’s failure on preventative dental screening in
         schools for children, that we do not force dentists into deciding if they wish to
         provide treatment completely within a private setting or completely within an
         NHS practice.

b) Supporting and trusting dentists and dental professionals

     •   Removing barriers to setting up and selling new practices. Labour’s short-
         term funding contracts mean dentists often cannot attract the investment they need
         to start up new practices, sell or maintain existing ones. Dentists occupy a
         different position within the NHS to other providers of primary care, and incur a
         considerable amount of financial risk themselves in caring for patients. We will
         look at longer-term deals, which will provide the certainty investors need to buy
         into NHS dentistry. We will also examine ways to eliminate Primary Care Trust
         interference in the sale of contracts with goodwill, subject to due diligence.

     •   Smarter commissioning. We will open up commissioning to allow a wider range
         of professionals, such as hygienists and oral health educators, to be used to
         support improvements in NHS dentistry. This will be especially useful for
         allowing innovative preventative advice strategies to emerge, for example.

     •   Five-year tie-ins to the NHS for taxpayer-trained dentists. It costs the NHS a
         huge amount to train new dentists – around £170,000 each22 and the NHS spends
         around £460 million a year on training bursaries.23 Our consultations with the
         dental profession show that up to five per cent of new dentists, with a training cost
         to the taxpayer of around £23 million a year, are being lost to the private sector.
         Some estimate the attrition to be even greater, and there are widespread concerns
         regarding the ongoing retention of dentists on the NHS given the recent expiry (in
         April 2009) of an income guarantee for practitioners, whether or not they reached
         their UDA allocations.24 We propose that new dentists who were trained at the
         taxpayers’ expense carry out five years’ work for the NHS in return for the
         support they have received.

         It is no surprise that many NHS-trained dentists take up work in the private sector
         when they qualify. Not only are they frustrated by the Government’s bureaucratic
         contract, but the rewards can be very attractive. Denplan (the largest provider of
         private dental care) has estimated that the private dental market is worth some £3
         billion, and represents up to half by volume of the total dental market.25 Our
         consultations reported actual poaching of newly qualified dentists working in the

22
   Hansard, 30 Mar 2009, Column 898W
23
   Dept of Health figures for show £462m in 2007-8
24
   House of Commons Health Committee, Report on Dental Services, July 2008, p. 50
25
   House of Commons Health Committee, Report on Dental Services, July 2008, p. 21, Ev. 66


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       NHS by private firms, so our proposals will ensure the system is fair. Tie-ins of
       five years are already being used successfully in Scotland and Wales.


3.2.2. Moving to patient registration: completing our reforms

As our reforms start to ease capacity, and as prevention allows more money to be fed into
increasing access, we will be able to move to a system where patients can register with a
dentist and have the certainty that they can access the care they need.

a) How the system will work

In essence, patient registration means that each NHS dentist would have a list of patients
for whom they are responsible. The number of patients on the list would form, at least
partially, the means by which dentists would be paid, replacing the current fixed
treatment quotas.

While in some areas it may be possible to quickly move to registration, we recognise that
others will need time to do so. So we will allow the two systems to exist in parallel for a
time. We are determined not to create unnecessary upheaval and will not repeat the
Government’s mistake of overhauling NHS dentistry without properly testing any
changes first. Sadly, it is a legacy of recent government mismanagement that we are not
in a position to restore patient registration everywhere instantly; we must first address the
fundamental problems that have been created.

But to ensure there are no barriers to moving as quickly as is practical, we intend to
replace the Government’s failed contract with a new negotiation based on registration
whenever a NHS dentist come to the end of their contracted period.

b) Ensuring rising standards

We do not simply want to create a patient registration system and expect standards to rise
from that reform alone. In line with our vision for improving the NHS more widely, we
want dentists to be paid according to the actual health outcomes they secure for patients,
not for meeting targets for the procedures they perform. We will build positive incentives
into the system to allow standards to rise through rewards, not bureaucratic targets.

But we also want patients to be empowered to help standards rise because they meet their
individual needs. So, in line with our wider NHS vision, we will give people access to
new forms of information about the results dentists achieve, empowering their choices
over which best meet their needs.

The result of these incentives will be a system where more effective rewards for dentists
and more empowered patient choices drive a virtuous cycle that increases access to care
while controlling costs and delivering value for money to taxpayers.




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3.3. Consultation

We believe that for a registration model to be workable, we must not repeat the mistake
the Government made in 2006 and implement a system without the full consultation of
the dental profession and patients. We are particularly interested in the following:

   •   whether a registration system will still need to incorporate measures to ensure
       output is maintained – without creating perverse incentives;

   •   how patients without a registered practice can gain ad-hoc treatment within a
       registration system;

   •   what the terms and obligations of registration might look like;

   •   how we might engage with the dental profession to better prevent fraud,
       particularly in the case of patients who should not qualify claiming exemption
       from the requirement to pay charges for treatment;

   •   in what ways dental care professionals might, within their professional
       competence, better assist dentists in the provision of oral care and preventative
       advice.

We are also keen to gain views on any other topic raised in this paper, and are opening all
its proposals to the public and the dental profession for consultation.




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