The Big Question: Why are there so few NHS dentists, and is the service getting worse?

Why ask this now?

Tony Blair pledged at the Labour Party conference in 1999 that everyone would have access to an NHS dentist. Last week, more than seven years later, the Department of Health slipped out figures showing that 55.7 per cent of adults and 70.5 per cent children had been seen by an NHS dentist in the previous 24 months. Yesterday, a report from the National Association of Citizens Advice Bureaux revealed that 77 per cent of the 4,000 respondents to their survey said they could not find an NHS dentist prepared to accept them. There is still a very long way to go to meet Tony Blair's pledge.

Does this matter?

Not if you consider that all talk of "NHS dentistry" is a government confidence trick. Use of the term "NHS" implies a universal service that is free at the point of use. NHS dentistry is neither. Since 1951, when charges for dental treatment were first introduced, the cost to the patient has increased steadily. Overall, patients who pay contribute approximately 80 per cent of the cost of their treatment. (Treatment is free for children, pregnant women and those on benefits.) The choice for patients is not between private and NHS dentists but between expensive dentistry and slightly less expensive dentistry.

How can the same dentist provide both NHS and private treatment?

This is one of the anomalies of the system and a source of endless confusion for patients. The vast majority of the 20,887 dentists in England with an NHS contract also offer private treatment. (A few dentists are exclusively private.) But charges for private treatment may be two or three times higher (or more) than the NHS charge.

Why would anyone choose to pay £90 for having a filling done privately when they can have the same work performed by the same dentist for less than half as much on the NHS?

A spokesperson for the British Dental Association says: "When treating patients privately, dentists tend to offer longer appointments and take a longer time. There is not the same pressure to get patients in and out of the surgery. There may also be a choice of materials for fillings and other treatments."

What is required of NHS dentists?

The rules state that dentists who are treating patients on the NHS must provide "all clinically necessary treatment". However, some dentists ignore this rule, by saying, for example, that they will provide check-ups and fillings on the NHS but will only do crowns and root canal work privately. Many also provide NHS treatment to children but insist adults pay privately.

A health department spokesman says dentists are not permitted to pick and choose which treatments they provide on the NHS and that to do so was "misrepresenting the NHS dental contract". He says dentists were permitted to have "child-only" NHS lists in the past and this was now at the discretion of Primary Care Trusts. But the health department's preference is for the entire family to be treated on the NHS and the intention is to phase out child-only lists.

What do NHS dentists charge?

A new charging system was introduced a year ago, under which the previous 400 separate payments were simplified into three price bands. From 1 April, the charge for an examination with X-ray and scale and polish (if necessary) will be £15.90; for one to six fillings it will be £43.60, and the highest charge, for crowns, root fillings and the like, will be £194. The new system was designed to be simpler and fairer, but was criticised by dentists who said it left little time for preventative work. In fact, as preventative care does not count as a "unit of dental activity", dentists have little financial incentive to carry it out. Dentists with NHS contracts earn on average £80,000 a year from the NHS. Private earnings are on top.

What do dentists charge privately?

Charges vary widely, often without apparent justification, and some are extortionate. That was the view of the Office of Fair Trading which investigated dentistry in 2003. Its report said there were no checks on private dentistry, no universal complaints procedure and that private dentists routinely flouted guidance from their regulatory body and failed to disclose treatment they proposed or what it would cost in advance - problems which still apply.

The OFT says private charges at the time ranged from £9.50 to £40 for an examination and from £85 to £327 for a large filling in a back tooth. Such differences were difficult to justify and the report concluded that "the market is not working well for consumers".

Are dentists leaving the NHS?

Not according to the Department of Health. "Contrary to popular belief," it says, "dentists are not deserting the NHS." There were 1,260 more dentists working in the NHS at 31 December 2006, a 6 per cent increase on the numbers in March 2005.

This small rise in the past couple of years cannot disguise the huge swing to private dentistry over the past two decades. The rot set in in 1984, when a sharp rise in NHS dental charges led to a collapse in the number of courses of treatment provided on the NHS, which still has not recovered to its previous level more than 20 years later, as the graph shows.

The exodus accelerated in 1991, when the last new dental contract was introduced along with a fee cut for dentists. Although most dentists still have NHS contracts, they have progressively reduced their NHS work and increased their private work - the private market grew 60 per cent between 1997 and 2001. The £1.8bn spent on NHS dentistry in England in 2006-07 is now matched by a the amount spent on private dentistry, according to the BDA.

Has the new dental contract made the situation better or worse?

The previous system was driven by market forces. NHS dentists could set up shop wherever in the country they chose and wait for patients to turn up - or not. The new system was designed to end the drill-and-fill approach by removing individual payments for separate treatments and replacing them with the three price bands. , the budget for NHS dentistry has been passed to Primary Care Trusts who can plan provision, replacing NHS dentists who leave or go private.

But the Primary Care Trusts' dental budgets are capped, as for the National Health Service as a whole, and based on historic activity. This has led to some practices running out of cash before the year end and having to send their dentists on holiday.

Once the teething problems are sorted out, the new contract, with its simpler payment system, should be better for patients. But nothing is likely to stem the exodus of dentists and patients to the private sector.

Is the NHS dental service improving for patients?

Yes...

* The number of NHS dentists has increased by 6 per cent in the past 21 months to almost 21,000

* NHS charges have been simplified into three price bands and the maximum charge halved to £194

* Primary Care Trusts hold the budget for NHS dentistry and can allocate new dentists where they are needed

No...

* Over the past 20 years NHS dentists have reduced their NHS work and increased their private work

* The market for private dentistry grew by 60 per cent between 1997 and 2001 and now matches that spent by the NHS

* The Citizens Advice Bureaux survey found two million patients are unable to find an NHS dentist

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