THE PRODUCTION OF DENTAL CARE ION THE BRITISH NATIONAL HEALTH SERVICE
| Published date | 01 February 1982 |
| Date | 01 February 1982 |
| Author | Alastair M. Gray |
| DOI | http://doi.org/10.1111/j.1467-9485.1982.tb00436.x |
Scoftish
JournalofPolirical Economy.
Vol.
29,
No.
1.
February
1982
0
1982
Scottish
Economic
Society
0036
9292/82/00040000
$02.00
THE PRODUCTION
OF
DENTAL CARE
IN
THE BRITISH NATIONAL HEALTH SERVICE
ALASTAIR
M.
GRAY*
Health Economics Research Unit, University
of
Aberdeen
I
INTRODUCTION
The scant attention which economists have hitherto given to the provision of
dental treatment within the National Health Service (NHS) not only contrasts
sharply with the volume of research work by North American economists but
also is peculiarly at odds with the possibilities this health care sector presents
for economic analysis. These possibilities are only loosely related to the size of
the sector, for at an annual cost of some
€350
million the General Dental
Service consumes less than
4
per cent
of
NHS expenditure.
Rather, they stem first from the fact that the fourteen thousand General
Dental Practitioners working within the
NHS
operate under a contractual
arrangement and remuneration system which has few parallels, and secondly
from the increasing feeling that dental care is “probably one of the few areas in
the Health Service which is ready for a root and branch investigation which
could result in
a
great improvement in public health” (Bramley,
1980)
and that
the remuneration system is implicated in some of the problems currently
besetting it.
The remuneration system is an object of attention in its own right, but it is
also the vehicle for research into more specific aspects of dental care. The
payment mechanisms underpinning the system yield information which may
be interpreted as aggregate levels
of
production. Thus, using data from the
remuneration system and from a sample of dental practitioners, this paper
examines the techniques of production and the input combinations employed
by dentists, and estimates the influence of these factors on productivity. It is
hoped that estimates such as these will play a part in policy decisions
on,
for
instance, task substitution and the training of ancillary personnel
;
the
promotion of new technology and techniques through education, in-service
training and financial inducements
;
or indeed the continued existence of the
present remuneration system.
*
An earlier version
of
this paper was presented at the World Congress on Health Economics,
Leiden, The Netherlands, in September 1980.
I
was greatly assisted
by
Gavin Mooney and other
colleagues in the Health Economics Research Unit and Department
of
Political Economy,
University
of
Aberdeen
;
to Dr
R.
J.
Elderton
of
the University
of
Dundee Dental Health Services
Research Group; and
to
the many dentists and
NHS
personnel who unstintingly co-operated in
furnishing data.
Date
of
receipt offinal manuscript: 28 May 1981.
59
60
A.
M.
GRAY
Section
I1
sketches an outline of the principal features of the operation of the
General Dental Service. This is followed
by
a summary of previous research
into the supply of dental treatment and productivity in dental practice. In
Sections
IV
and
V
the data used in the study are described and analysed and
the main findings presented, and the paper ends with a short summary and
conclusions.
I1
DENTAL
CARE
WITHIN
THE
NATIONAL
HEALTH
SERVICE-A
BACKGROUND
This section relates the study to the more general context within which
dentistry is provided in the
NHS
by giving
a
brief outline of the formal
organisation of NHS dental services, the remuneration system, and the role in
which the dental practitioner
is
cast as an economic agent.
The provision of dental care within the
NHS
reflects the tripartite
organisational structure of the
NHS
as a whole
:
hospital services, community
services and family practitioner services. The hospital service (mainly provid-
ing out-patient treatment and oral surgery) and the community service (school
dental health, domiciliary care, etc.) are small measured by the number of
dentists working within them and the range of services provided, and it is
through the General Dental Service (GDS)-the family practitioner wing-
that the great bulk of routine dental treatment is supplied. The GDS is
operated by around
14,000
General Dental Practitioners (GDPs), that is, some
80
per cent of all dentists working within the
NHS,
and this part of the service
is the subject
of
this paper.
During negotiations on terms under which they would be incorporated in
the
NHS
in 1944, dental practitioners asked for and obtained the following
conditions of employment
:
“.
.
. freedom from medical control, no salaried
service of local or central government, and the maintenance of private
practice” (Teviot Committee, 1946). Thus the GDP has fewer contractual
obligations either to the
NHS
or to his patients than his medical counter-
parts. He retains the right
to
accept or refuse patients for
NHS
work, and to
undertake as much private work as he wishes. In accepting a patient for
NHS
treatment the GDP must, however, provide that course
of
treatment
necessary to render the patient dentally fit, without resort
to
private charges.
On completion of treatment the contract is terminated
;
that is, unlike the
medical practitioner, no patient ‘‘list’’
is
maintained.
A
key factor in the functioning of the service is the remuneration system.
Payments for
NHS
work are made on a fee for item of service basis, these fees
being set by the Dental Rates Study Group (DRSG). The basic function
of
the
DRSG is
‘I.
. .
to set general dental service fees at such a level that dentists in the
service earn, on average, the target net income accepted by the government”
(Scarrott, 1979). The procedure adopted is, first, to obtain data on the volume
and pattern
of
dental treatment the “average” dentist provides
;
secondly, to
estimate the practice expenses the average dentist incurs; and thirdly, to set a
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