The CAB Service welcomes the opportunity to respond to the Department of Health’s consultation on the draft NHS (dental charges) regulations 2006.
The objective of the proposals is to make the charging system fairer, simpler and clearer by moving from the current system of over 400 individual items of dental treatment, with a maximum charge of £384, to a system of three Bands. Band 1 (at a proposed rate of £15 for 2005/6) would apply to diagnosis and maintenance such as check ups and x rays, Band 2 (£41) would apply to simple treatments such as extractions and fillings, and Band 3 (£183) to complex treatments and the provision of appliances such as crowns and dentures. In addition urgent treatment would be charged at the Band 1 rate.
The CAB Service has for some time been raising concerns about dental charges, notably in our evidence report Unhealthy Charges (2001). This report included a survey of CAB clients which found that 44% of people registered with an NHS dentist found the charges difficult to afford, rising to 75% among patients charged £200 or over. We therefore called for a fundamental review of all NHS charges including examining the case for abolition, as their continuation is arguably contrary to the fundamental principle of the NHS to provide a service on the basis of need and not ability to pay. We have also recommended that, whilst dental charges remain, there should be a significant reduction both in the maximum charge and in the percentage (currently 80% of the fee paid to dentists) which patients are required to pay.
In addition CAB evidence regularly shows how patients are confused by the complexity of the current charging regime, with the result that many find themselves paying for private treatment when they had thought they were being treated under the NHS.
Citizens Advice was therefore pleased to be able to take part in the Working Group established by the Department to review the existing system of charges and make recommendations for reform. Although we regretted that the scope for reform was restricted by the terms of reference which required that patient charges should raise the same level of funding as at present, we consider that the Working Group’s proposals made real progress towards reducing complexity, improving affordability and reducing the extent to which people with high dental health needs faced the highest charges.
We are therefore in broad agreement with the specific questions set out in the consultation, on which we are in a position to respond (i.e. questions 1 to 5).
We do however have a number of concerns regarding the projected level of charges as set out in the consultation paper.
Firstly the levels of Band 2 and 3 have been increased significantly above the Working Group's illustrative figures which were based on 2003/4 rates. Band 2 has been raised by 52% (from £27 to £41) and Band 3 by 41% (from £130 to £183). This is clearly well above the rate of inflation and essentially means a significant increase in the burden of fees which patients as a whole will have to bear. Indeed as the question and answer brief in the consultation paper concedes, the majority of courses of treatment will cost more under the new regime.
We understand that the reason for this significant increase is that revenue from charges in the PDS pilots has fallen without a corresponding fall in the cost of the service. This is because dentists are spending more time with patients on broader health related work to which charges do not apply, whilst the overall cost of the new contract is expected to rise. It appears to us that there has as a consequence been in a shift in the language - from requiring patient charges to raise the same level of income (£485 million at 2003/4 rates) as under the existing scheme (as was the remit of the working group) to requiring them to raise the same proportion (£645 million at 2006/7 rates) of the significantly increased funding which will be available under the new contract.
We regret that the opportunity has not been taken to reduce the very high percentage (80%) of treatment fees currently paid by patients, by ensuring that the income raised from charges did not increase by more than inflation as a result of the shift to the new contract. By not taking this approach, patient charges overall will have increased faster than patients’ incomes and will therefore become less affordable. People with poor dental health and with incomes only just above the level for help through the NHS low income scheme will be particularly affected.
In contrast, dentists have received undertakings regarding the protection of their incomes in the early years of the new contract.
It is of concern that people requiring dentures, who will mainly be older people on fixed incomes, appear to be among the losers under the reforms. Patients requiring replacement dentures due to loss, breakage or simply wear and tear, may find the charge more than doubles. Currently the cost for a replacement partial denture ranges from £61.85 to £97.50. Under the proposed new scheme the charge will be £183.
As older people are likely to be the main purchasers of dentures, they will therefore be significant losers under the reforms. Such large one off costs are likely to cause hardship for people living on fixed incomes and sit uneasily with the wider Government objective to tackle pensioner poverty.
A similar problem will arise for patients needing replacement orthodontic appliances (mostly children). Currently the patient charge for these replacements ranges from £47.08 for a simple removable spring appliance to £90.08 for a fixed multiband appliance. Again under the proposed new scheme all these charges will be £183, representing a significantly increased financial burden on parents.
These increases are unacceptable and threaten to undermine what is in other respects a welcome reform. We urge the Government to reconsider the level at which Band 3 in particular has been set. At a minimum, alternative arrangements must be made for replacement appliances – either providing them free of charge, or at a nominal charge only.
Our second concern is that, although the consultation paper states ( para 1.7) that “we have accepted the main recommendations of the report”, the Working Group’s Recommendation 2 has not in fact been accepted. This recommendation stated that “When deciding the exact level of payment in each Band, the relative weighting of the Bands outlined in this report should be maintained.” The Working Group was keen to reduce the extent to which people with higher treatment needs faced higher charges, in recognition of the Government’s broader objective to break the links between poverty and poor health. This objective has been compromised under the new figures, as the level of Band 1 has remained unchanged whilst Band 2 has been increased by 52% and Band 3 by 41%.
We recognise that the revised weightings link across to the proposed values of the Units of Dental Activity (UDAs) under the new dental contract. However part of the attraction of the reforms is that there is no direct relationship between dentists’ remuneration and patient charges, so that there is then the opportunity to design the charges scheme to deliver greater equity and affordability than has been the case under current arrangements. It is very regrettable that this opportunity appears to have been missed under these proposals.
This leads to our third concern, which relates to the rate at which charges may rise in future years. Inevitably there is uncertainty at present as to how the new contract will impact on dental activity and on the mix of exempt and non-exempt patients, and therefore the revenue raised through patient charges. It is crucial that patients, many of whom will be on fixed incomes, do not one again find themselves facing above inflation increases in charges in order that the Department is able to maintain the same proportion of revenue from charges in future years.
We would therefore urge the Department to:
- Review the proposed level of charges for 2005/6, with a view to reducing Bands 2 and 3, so that patients with more expensive dental needs receive greater protection.
- If Band 3 is not reduced, introduce alternative measures to ease the burden on pensioners who require replacement dentures, and on parents whose children require replacement orthodontic appliances. This would however reduce the simplicity of the new scheme unless replacement appliances were taken outside the scheme altogether by being supplied free of charge.
- Undertake that future increases in dental charges will be determined having regard to the levels at which patients’ incomes rise, and will therefore not exceed the level of general inflation.
Social Policy contact: Liz Phelps liz.phelps@citizensadvice.org.uk
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