Patient registration

Published On: 01-09-2010

Is this what we all want, asks Apolline?

Everyone, it seems, wants patient registration in dentistry and some form of capitation payment. Everyone, that is, except the health department apparently. The Conservatives in opposition wanted registration, the health select committee wanted it and so did Prof Steele. We used to have registration for all and capitation for children, but they were omitted by the health department when it drew up the 2006 contract.

Patients want to be able to know there is a practice where they are registered, where the dentist will see them if they turn up every six months or every six years. They want it especially when they have pain or other trouble. Registration should guarantee access; it has done for doctors for more than 60 years. Capitation has also been the mainstay of the GP service since the start of the National Health Service. It means the GP can concentrate on your condition, not on how much money they will get from your visit.

From what I hear it may become the norm for NHS dentistry in the future. But I have also heard misgivings which can be summed up in one unflattering question: 'Can dentists be trusted with capitation?' No one is quite so blatant as to ask this question in public, but that is assuredly where those in authority have doubts. It all boils down to the pejorative phrase 'supervised neglect' and sometime the supervision is not that good.

It has to be admitted that the case against the profession is strong. The original PDS pilots operated a type of registration/capitation system. There was a lot of talk about being able to offer a prevention-based service, where the dentist spent as much or as little time that was needed to look after patients. To give us the benefit of the doubt there was probably more prevention being done, but as that increased so other activity fell. Fewer fillings and crowns meant less collected in patients' charges, leading to the plug being pulled on these pilots.

Registration (albeit initially for two years) came in with the 1990 contract. It may have guaranteed access for regular attenders, but not for all. By the end of that decade, Tony Blair was promising access for all, just by making a phone call; a target which even he acknowledged had not been fulfilled. So registration doesn't appear to guarantee access, especially not if the patients are removed after a defined time.

Capitation for children was introduced 20 years ago, so had an opportunity to demonstrate whether it was a useful method of payment from dentists' point of view and also for patients. You can notch up a few hours of non-verifiable CPD by researching the various papers that emerged from this system. At best they show little change in children's oral health. The proportion of decayed teeth that had been restored remained stubbornly low.

Supervised neglect was such a problem that after the system had been going for a few years payments for fillings and extractions were reintroduced. One can well understand why the powers-that-be are reluctant to bring back capitation. It works well for Denplan, but their fees are higher and we need to convince patients that they are getting good value for the money they pay us.

It also works for GPs, but their job is to diagnose, advise, prescribe or refer. They don't have to do the treatment themselves. Another difference is that once on a GP's list we stay there until we move or die. There is no question of being struck off after an arbitrary two years or even the 15 months it was before 2006. Given that we have around 20,000 dentists to deal with 60m people, that would mean 3,000 patients per dentist.

Some of these dentists are part-time so a full-time dentist might have a list of nearer 4,000. Just what sort of service could you offer them? Little more than a 'toothache service'. This brings me back to the original question about whether dentists can be trusted with capitation. The answer is if you set up a system that demands that dentists see the maximum number of patients and do the minimum amount of work on each, then expect some 'supervised neglect'.


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