Open consultation

Evidence note

Published 8 July 2025

Applies to England

Introduction

Access to routine NHS dental care is challenging for patients. Evidence from the GP Patient Survey demonstrates that patients without a regular dental practice had a 35% success rate in accessing care compared with an 85% success rate where patients were known to a practice. Access to the full range of unscheduled care interventions is also challenging. This is in part due to under-remuneration of many urgent care interventions under the current contract, alongside the lack of contractual levers to require dental contractors to direct a portion of their contract activity to unscheduled care. Together, these issues result in many integrated care boards (ICBs) having to buy additional urgent care capacity on both a systematic and an ad hoc basis to meet the needs of their populations. This approach is subject to instability and the value for money secured is variable.

Poor oral health is experienced most acutely by adults and children in lower socio-economic groups, who have an increased requirement for care. However, they struggle to access care and frequently cycle between repeated unscheduled care episodes, rather than a holistic care approach which integrates prevention and treatment, supporting patient self-care.

NHS care is increasingly focused on those with the lowest care needs, with a gradual but persistent shift away from more complex care to band 1 check-ups.^{[footnote 1]} Band 1 check-ups now account for 59% of all courses of treatment compared with 55% in 2008, despite guidelines from the National Institute for Health and Care Excellence (NICE) (Dental checks: intervals between oral health reviews) that adults with good oral health only need a check-up once every 2 years, and children once every year.

Dental contract delivery rates continue to be lower than pre-pandemic, with improvements slowing since then, resulting in unused dental capacity and ultimately a loss of patient care. This is compounded by clinicians’ concerns about adequate payment to enable appropriate care delivery to those people with more complex needs.

Modelling by The Economist Group (2024) on caries (tooth decay) and periodontal (gum) disease prevention suggests that the UK currently experiences an overall lifetime per-person cost of $22,910 as a result of these diseases. Effective action to address caries and periodontal progression, as targeted through these reforms, could result in a per person reduction of $17,728, with these savings being over 3 times higher in the most deprived groups.

The changes being proposed in the 2026 quality and payment dental contract reforms build upon the 2022 reforms, seeking to:

• rebalance activity to those with complex care needs
• integrate prevention into revised care pathways
• further utilise skill mix
• introduce specific funding for quality improvement
• put in place a comprehensive unscheduled care offer that incorporates delivery of the manifesto commitment of 700,000 additional urgent appointments

This will be achieved through aligning payments and incentives to a revised clinical model in which evidenced-based, quality care is valued and monitored as much as contract delivery.

These reforms represent the next steps in addressing both payment inadequacies and refocusing on quality care. Given that oral diseases are the most prevalent non-communicable disease, they will support wider government ambitions to improve health outcomes and help get people back to work. The intention is that these changes will result in clinicians feeling more confident and supported to treat those with complex care needs and address the persisting inequalities in oral health. An important aim is to make the dental contract overall more attractive and rewarding for dentists and dental teams, improving the recruitment and retention of professionals within the NHS.

Objectives and anticipated impacts of the reforms

These reforms have been developed following stakeholder engagement and are designed to deliver benefits for patients and providers of NHS dental services.

For patients, these changes are intended to deliver the following benefits:

• making it easier for those with poor oral health, unscheduled and ongoing care needs to find a dentist willing to provide them with care
• improvements in the diagnosis and management of grade C periodontal disease (severe form of gum disease), supporting people to retain healthy teeth for as long as possible
• improvements in the management of caries, using modern, evidence-based, minimally invasive techniques within an integrated treatment and prevention support pathway
• easier access to unscheduled (urgent) care, due to all providers being required to deliver an agreed amount, irrespective of whether they have been to the practice before
• for those with good oral health, a reduction in the number of unnecessary check-ups and their associated cost

For providers of dental services these changes are intended to:

• enable dental teams to focus a greater share of time and resource on those with the greatest clinical need, including those with unscheduled (urgent) care needs
• provide fairer remuneration for the treatment of patients with higher clinical needs, supported by clinical guidance which describe holistic new care pathways which integrate prevention and treatment
• address contractual payments for denture modifications which currently result in financial losses at a practice and clinician level
• support providers to deliver their contracts, leading to improved financial stability and reduced financial recovery
• incentivise a reduction in the amount of time and resource dedicated to those with good oral health as a result of recalling patients more frequently than clinically necessary
• further encourage and expand the utilisation of skill mix in NHS dentistry and release dentists’ time to enable them to operate at the top of their license
• drive up care quality through introduction of quality improvement and structured audit activities
• support dental teams to feel part of the NHS

As a result of these reforms, we expect to see the following changes over the coming 3 years:

• an increase in the numbers of patients with more complex care needs and clinically higher oral health risk being able to access NHS dental care
• a decrease in unnecessary check-ups for patients with clinically low risk oral health
• consistent delivery of evidence-based, holistic care with integrated prevention and treatment to patients with complex treatment needs - we estimate that this will apply to around 370,000 people per year based upon estimates of people presenting with the most complex needs at present who are being inadequately managed in the current system due to lack of appropriate funded treatment pathways
• consistent delivery of evidence-based, holistic care to patients with a new diagnosis of grade C periodontal disease - epidemiological evidence suggests that this would be around 320,000 people per year. Our evidence to date and engagement has suggested that in the current system this high-risk population are routinely unable to receive the care they need, due to the restrictions of the current payment mechanisms
• an increase in unscheduled care provision from 3.5 million to 4.2 million courses of treatment, incorporating 700,000 additional appointments
• an increase in chairside preventative actions (fluoride varnish and fissure sealant application) in children through increased use of dental team skill mix
• an overarching ambition and anticipated changes to care delivery

We have developed proposals to address the overarching challenges described above which aim to:

• deliver the manifesto commitment to provide an additional 700,000 urgent care appointments and ensure a safety net is in place to allow any patient with an unscheduled (urgent) need to get rapid support on the NHS
• improve access, provide fairer remuneration and support implementation of evidence-based care pathways for the treatment of patients with more complex care needs
• support increased use of cost-effective, evidence-based prevention interventions in children
• improve quality and provide support to the profession, helping them to feel part of the wider NHS

While each change is described separately below, these proposals are designed to act in synergy to address the barriers to access for those with poor oral health and unscheduled care needs. Taking this explicit approach to address poor oral health and associated health inequalities will result in a greater proportion of our current budget being spent on these groups of patients.

To do this within a constrained budget, we will need to both make the contract more attractive overall and reduce the current over-provision of clinically unnecessary treatment to people with good oral health in the form of too frequent, clinically unnecessary check-ups. Reduction in clinically unnecessary care will be driven both by improved incentives for patients with complex treatment needs, and through specific actions to reduce check-ups at intervals more frequent than clinically indicated (in NICE guidelines Dental checks: intervals between oral health reviews). This includes learning from the dental prototype practices and behavioural change insights, along with a realignment of incentives and payment structures, to address the current under-remuneration of those with complex care needs.

These changes have the potential to improve contract delivery from around 88% to close to 100% and for patients to be prioritised differently relative to their level of care need.

Detail of the proposals

Unscheduled care

In dentistry, ‘unscheduled care’ generally refers to dental care provided outside of routine or elective pre-booked appointments (known as ‘scheduled care’) and is for patients who present for immediate treatment, often due to a dental emergency or urgent condition. The manifesto commitment to deliver 700,000 additional urgent appointments is therefore interpreted in this evidence note as unscheduled care and includes both care that is required within 24 hours or 7 days.

Two key challenges have been identified with the provision of unscheduled care which have led to ICBs needing to buy additional unscheduled capacity on both a systematic and an ad hoc basis. These challenges are that within current general dental service (GDS) and personal dental service (PDS) arrangements:

• there is no contractual lever to require practices to prioritise patients with an unscheduled need
• the current remuneration is considered insufficient by the profession, leading to the alleviation of symptoms and an increased use of antibiotics and analgesia rather than definitive treatment to resolve the presentation and provide initial disease management

Proposal to improve unscheduled care

We propose to introduce a contractual requirement to provide an agreed amount of contracted activity as unscheduled care, covering care that is required within 24 hours or 7 days, with care quality supported by a revised clinical standard and local clinical leadership. The minimum number of appointments secured in this way will be 4.2 million, which incorporates the current annually provided unscheduled care courses of treatment (around 3.5 million) plus the 700,000 urgent additional appointments committed to through the government’s manifesto. While access routes will be for ICB determination, we will set out an expectation that this will be via a single route of access.

We are proposing that all unscheduled care receives an activity-based payment of £70 for each course of treatment provided, rather than the current 1.2 units of dental activity (UDAs), which equates to an average of £41. Additionally, providers will receive a further fixed payment to account for the organisational demands of ensuring unscheduled care provision in this way and the risk of patients failing to attend. A fixed payment of £5 will be paid for each course of treatment required to deliver the agreed unscheduled care capacity, irrespective of whether a course of treatment is delivered. This will be supported by improved quality metrics, still to be developed, to ensure that care delivered is high quality and change can be assessed as described above.

These proposals will provide an unscheduled care safety net which will act as an entry point to NHS dentistry for those with an acute problem, such as pain and broken teeth. We anticipate that most of these patients, and especially the additional capacity committed to in the government’s manifesto, will be new to practices. These proposals will improve payment for unscheduled care and we will monitor activity to ensure that this results in improvements in care quality defined as all of the following:

• patients receiving definitive treatment for their presenting complaint
• a reduction in antibiotic and analgesia prescribing
• an increase in those with ongoing care needs being identified and streamed into routine care or one of the new care pathways for those with more complex needs

Patients with complex care needs

Engagement with clinicians has highlighted the ongoing under-remuneration within the current banded courses of treatment for patients with complex treatment needs, characterised by:

• extensive caries, with and without concurrent unstable periodontal disease
• severe and progressive periodontal disease

This under-remuneration is leading to clinicians demonstrating a reluctance to see new patients as they are concerned that the care they require will not be adequately funded by the NHS. There is published evidence to support these concerns.^{[footnote 2][footnote 3]} In turn, these patients are currently both under-diagnosed and under-treated in the current payment system and likely to experience oral health inequalities.

Proposal to improve care for patients with complex care needs

We propose to introduce 3 new care pathways for patients who meet the following criteria:

• at least 5 teeth with caries into dentine with no periodontal disease paid at set fee of £272 (pathway 1)
• at least 5 teeth with caries into dentine with currently unstable periodontal disease paid at set fee of £680 (pathway 2)
• a new diagnosis of grade C periodontal disease paid at a set fee of £238 (pathway 3)

These care pathways are primarily aimed at adults, although some children who experience decay into dentine may be eligible for pathway 1. Once a patient completes the relevant new care pathway, they would enter routine care and be recalled on a risk-assessed basis.

These new pathways will underpin an evidence-based approach to care and will be supported by new payment values which will be expressed as a cash value rather than in UDAs. Taking this approach will address the variation in remuneration arising from the variation in indicative UDA value at a practice level.

Where patients are on this pathway due to experiencing at least 5 teeth with caries into dentine and where they require laboratory produced restorations such as crowns or bridges, the pathway remuneration may be supplemented with a band 3 course of treatment to provide this aspect of their care.

Skill mix and evidence-based clinical interventions

There is evidence to suggest that 2 of the most cost-effective and evidence-based prevention activities in children are currently under-utilised:

• the regular application of fluoride varnish as a primary and secondary prevention measure
• the application of fissure sealants as a primary and secondary prevention measure

While the reasons for this are multi-factorial, we have identified 2 which are amenable to contract reform:

• barriers to the utilisation of the wider dental team to apply fluoride varnish without a full dental examination
• the under-remuneration of fissure sealants as a primary prevention intervention

Proposal for fluoride varnish application by EDDNs

To support practices to deliver regular fluoride varnish in a cost-effective way, we propose to introduce a new course of treatment, paid at 0.5 UDAs, which will allow extended duty dental nurses (EDDNs) to apply fluoride varnish without requiring a dental examination.

Evidence-based guidance recommends that clinically low risk children should receive a dental check-up on an annual basis with fluoride varnish applied every 6 months and clinically high risk children should receive fluoride varnish every 3 months. Currently, these children, if they attend a dental practice regularly, will be having a band 1 check-up, delivered by dentists, every 6 months or 3 months to support this.

Allowing EDDNs to provide fluoride varnish would enable practices to set up specific clinics to deliver this at times convenient for children and their parents and release dentist time to undertake more complex work, while supporting implementation of evidence-based and cost-effective preventative care.

Proposal for resin-based fissure sealants

We propose to amend the current description of fissure sealant application for primary prevention from band 1 to band 2 care to bring this in line with the banding of fissure sealants when used alongside tooth restoration. This will address the perverse incentive to delay fissure sealant application until the child has experienced decay to a permanent tooth.

It also recognises that remuneration at 1 UDA as a band 1 does not acknowledge that the complexity of fissure sealant application is not impacted by whether it is intended as a primary or secondary preventative activity. This will result in either 3 or 5 UDAs depending upon the number of teeth being treated.

Proposal on denture modifications, repairs and relining

Engagement has suggested that many of these patients may require modification of existing dentures rather than a full denture replacement. At present this care is included within wider band 2 care, which fails to provide dental practices with sufficient funding to cover their costs. We are therefore proposing to introduce a new sub-band within band 2 which can be claimed where any patient requires a denture modification. This would be claimable if the patient is receiving care under the new complex care pathways or existing band 2 courses of treatment.

Quality improvement, funded support for annual appraisals and supporting the workforce to feel part of the NHS

Engagement with the sector has exposed that some dental care professionals do not feel part of the NHS, leading to:

• perceptions of not being valued
• retention issues
• lowered job satisfaction

This perception can be exacerbated by:

• the behaviours of some contract holders
• the self-employed status of most dental associates
• the ways in which NHS resources flow within the internal market in most dental practices

When disillusioned with the NHS, for whatever reason, dental care professionals can easily move into the private sector, further reducing the supply of NHS care.

The lack of focus on care quality also contrasts negatively with other primary and secondary care contracts where quality improvement and measurement are integrated activities.

Proposal for quality improvement

We propose to introduce funded quality improvement activities with a focus on participation in audit and peer review on a defined national topic or area of concern which will be determined annually. This will be supported by local clinical leadership and will lead to improved data on care quality in dentistry and evidence of change.

We are proposing that this will be funded for 3 years in the first instance with a parallel evaluation.

The initial topic is likely to focus on reducing unnecessary check-ups in those who are orally fit to align with our wider reform goals as set out here to refocus available capacity to those with oral disease and the greatest potential to benefit from care and treatment. We are proposing that this is funded at £3,400 per practice per year.

Proposal for funded support for annual appraisals

We propose to enable dentists, therapists and hygienists who are delivering NHS care to be funded to participate in an annual contractor-led appraisal. This will bring the dental contract into alignment with other contracts and professional groups where annual appraisal is the norm. We are proposing that this will be funded at 6 UDAs per eligible staff member.

Proposal on minimum terms of engagement and an NHS model contract for dental associates

We will consult on the potential for an NHS model contract for dental associates, which could ensure minimum engagement terms for self-employed associate dentists and address disparities such as whether the Review Body on Doctors’ and Dentists’ Remuneration (DDRB) uplifts are passed on to associate dentists.

Proposal on extending the minimum requirements for recognition of NHS service

We propose to prospectively enable all continuous NHS service irrespective of primary or secondary setting, rather than just time on the Performers List, to contribute to the calculation of 2 years’ service to be eligible for discretionary support payments such as long-term sickness and maternity support.

Proposal to publish an NHS handbook for associate dentists and the wider dental team

We will publish an NHS handbook for dental teams, which will clarify the support available to them from the NHS, how the contract works and signpost to other helpful sources of information.

Implications if the proposals are not implemented

Failure to deliver the proposals is expected to result in a continued slowdown and eventual reversal in the recovery of contractual delivery and will mean accepting an ongoing and gradual shift of dentists towards the private sector. We have no evidence to suggest that contract delivery will improve further without us taking action to address the issues identified.

Continued contract under-delivery will likely lead to deterioration in access over time, particularly for the most vulnerable and deprived patients, as retention of NHS staff becomes even harder.

It will also lead to greater underspend against dental budgets and increasingly poor value for money on local initiatives, as ICBs struggle to address the deficiencies in the core contract through separate commissioning.

As a result:

• unscheduled care: there will remain no contractual lever to direct capacity towards the provision of unscheduled care, and systems will need to rely on commissioning of additional capacity, potentially at higher costs, and put at risk delivery of the 700,000 manifesto commitment
• complex care needs: patients with these needs will continue to find it difficult to receive the care they require, continuing to exacerbate health inequalities; providers will continue to see band 1 courses of treatment as the most profitable source of income and thus perpetuate the over-provision of clinically unnecessary care to orally fit patients
• skills mix and evidence-based interventions: optimised use of skill mix will remain limited under the current course of treatment definitions and providers will remain disincentivised to provide resin-based fissure sealants, resulting in the continued low provision of preventative interventions and contribute to high rates of preventable decayed teeth in childhood with lifetime consequences
• feeling part of the NHS and embedding quality into the contract: should no change be made to better facilitate an NHS-team culture within dentistry, trends in the move of providers to private care will continue and challenges around recruitment will perpetuate; in addition, without supporting quality improvement and audit into the contract, NHS dental teams will continue to focus on quantity rather than quality of delivery

This therefore could lead to substantial issues in NHS dentistry remaining unresolved for longer, exacerbating the existing access, inequalities and care problems.

Description of options considered

Option 1: do nothing (business as usual)

For this option we assume that there are no reforms implemented, and the current dental contract continues unchanged. A baseline of 2023 to 2024 contractual performance of 73 million UDAs (34 million courses of treatment) delivered is assumed over the period of assessment. However, we might expect this to reduce if dentist motivation and morale decrease and there is a wider shift to private practice. More importantly:

• orally fit patients will continue to be prioritised
• oral health inequalities will widen further
• the potential return on investment of NHS dentistry remains diminished

Option 2: implementation of full reform package

For this option we would implement all the reform changes listed above in one package.

This will address multiple problems, with the aim of:

• improving access to NHS dental services for patients with complex care needs
• tackling health inequalities
• mandating extra appointments for unscheduled dental care
• supporting changes to the skill mix
• making staff feel more part of the NHS for dental professionals

This option will not increase overall the total population coverage affordable under current NHS dental resources, but will ensure the funding that is available to commissioners is spent in an evidence-based way, targeted at the highest priority patient groups and reducing inequality. This is the preferred option.

Option 3: implementation of a more limited or staggered reform package

There is the potential for modification of proposals in the light of feedback following the consultation. There is also the potential for some proposals to be delivered more rapidly than others depending upon the degree of legislative change required. The modelled outputs presented in annex D show that reducing the number of policies implemented reduces the patient benefit. Therefore, this is not a preferred option.

Modelling overview

The modelling undertaken has focused on understanding the impact of these proposals on:

• numbers of patients and changes in case mix
• patient charge revenue
• the relative proportion of spend on higher versus lower value care within a cash constrained envelope

Likely spend on the other policies has been estimated and this value top-sliced from the available budget. This is described in the section ‘Policies costed outside the main model’ below.

There are several limitations to the data utilised. Data is not currently collected on diagnosis or treatment in the way required to understand quality of care or to accurately estimate the numbers of patients eligible for the new care pathways. Where possible, we have estimated these numbers using available data supplemented by epidemiological estimates of population prevalence.

Estimating the impact and likelihood of behaviour change has also been limited by available data. Information from the prototype evaluation has been used to inform behaviour change estimates for recall intervals, supplemented with clinical opinion from the Chief Dental Officer’s team. In the absence of data, assumptions have been made about potential levels of change based on clinical opinion and expertise from the Chief Dental Officer’s team and leading academics with expertise in caries and periodontal disease management.

The expected impact of these proposals is outlined below. Where possible, impacts have been provided based on scenario modelling. However, it should be noted that changes in costs and patients seen will depend on current access, utilisation or quality of care, as well as the behaviour change of dentists within a complex contractual framework, so is subject to high levels of uncertainty. We have attempted to account for this uncertainty with the scenario modelling and sensitivity analysis.

Throughout the modelling we have taken the most recent full year of data - 2023 to 2024 - as the baseline year, inflated costs to 2026 to 2027 prices and used this as the ‘do nothing’ scenario.

Critically, overall spend will always be constrained - contractors cannot earn more than the value of the contract they hold without agreement from the ICB. The modelling is therefore designed to estimate:

• how overall performance of contractors and associated contractual spend will change over time
• changes to the case mix and care quality resulting from the altered incentives set out in this package
• changes to patient charge revenue associated with these proposals

The modelling illustrates the impact of the following contractual changes:

• the mandating of unscheduled care, including the additional 700,000 courses of treatment
• new care pathway for patients with grade C periodontal disease
• new care pathways for patients with 5 or more teeth with caries into dentine with or without unstable periodontal disease and the need for laboratory restorations

The model also considers the impact on numbers of patients receiving clinically unnecessary check-ups.

The reform package contains several elements that will have a smaller impact on costs and benefits and so have not been included explicitly in the modelling. Instead, we have allocated £88 million, 2% of the dental budget, to cover these costs. This allocation is based on estimates of the total cost of these proposals in year 1. These are covered in the ‘Policies costed outside the main model’ section below

While the detail of the model outputs are described below, the model suggests that if the reforms are fully implemented, we could expect by year 3 to see:

• an increase in spend on unscheduled care and patients with more complex needs, with an additional 700,000 people receiving unscheduled care courses of treatment
• a decrease in spend on clinically unnecessary check-ups, with around 3.3 million unnecessary courses of treatment avoided
• an overall increase in people being able to access NHS dental care of around 460,000 within the current budget, and with a reduction in patient charge revenue of around £59 million in year 3

The modelling, by necessity, includes a number of assumptions which are detailed in annex A. It is based on the most up to date data available when it was created. We expect activity data for 2024 to 2025 to be published before an impact analysis for these proposals is finalised. In the modelling for that impact analysis, we will update the data used and also reflect any amendments to the proposals as a result of the consultation. Therefore, the numbers included in the final impact analysis will likely differ from these, but we do not expect this to result in substantially different conclusions.

Details of the main model

The model segments courses of treatment into ‘types’ and assesses the impact of the policy and case mix changes on the number and costs associated with each of these segments. This allows us to understand how the policy changes impact the total delivery of NHS dentistry, not just the specific area changed by these policies. The model applies the constraints on delivery of dental care imposed by the fixed financial value of contracts.

Impact on patient segments and potential distributional impact of the reforms between these segments

The patient segments used within the modelling are outlined under ‘Patient segments’ below.

These segments are mutually exclusive and exhaustive for courses of treatment but are not mutually exclusive for patients. Some patients will be seen in multiple segments at different points in a year where they receive multiple courses of treatment of differing bands.

Modelling steps

The following steps are applied in modelling:

1. The model first estimates the courses of treatment delivered to patients in each of the patient segments who are current and seen at all by an NHS dentist, the level of care, and the cost of this care these patients receive now.
2. The model then calculates the cost of this care once the policies are implemented.
3. Where behaviour change is assumed, the spend on each patient care segment is adjusted. This is used to calculate the change in the number of courses of treatment delivered to these patients.
4. The change in the courses of treatment delivered to each segment is used to calculate the change in the case mix and benefits of improved care.
5. The results are then aggregated.

We have assumed that over time dentists will respond to the fairer remuneration for patients with more complex needs and those requiring unscheduled care and prioritise these patients over patients without a need for treatment. This will lead to a decrease in unnecessary band 1 recalls, given the vast majority of low-risk patients are assigned 6-monthly recall intervals (with 95% of practices bringing more than 50% of their low-risk patients back within a year), with behavioural change based on findings from the prototype evaluation.

Patient segments

The patient segments used within the modelling are described below, along with which policies affect each segment. Throughout this section, all values are in 2026 to 2027 prices. This is a cautious approach and assumes that the values being considered may be adjusted for inflation. We are not certain this will happen but if we did not model this and it did happen, we may conclude the changes are unaffordable when in fact they are not.

The model calculates year-zero impact without any behaviour change on each of these segments. It then applies behaviour change relating to change in case mix over 10 years to the segments where behaviour change has an impact. These are:

• band 1 adults
• ‘normal’ band 2 and 3 adults
• high-needs patients

The segments are:

1. New adult patients receiving a Band 1 course of treatment (new defined as not being seen in the past 2 years)

This patient cohort is not impacted by the policies. We estimate 1.27 million of these patients are seen each year. Average remuneration to dentists for this patient cohort is £35.48. Average patient charges paid by patients is £23.98. This average takes non-fee payers into account.

2. New adult patients receiving an existing band 2 or 3 course of treatment

By this we mean an existing course of treatment with fewer than 5 carious teeth and without a new diagnosis of grade C periodontal disease. 

We estimate around 790,000 of these patients are seen before behaviour change.

Average remuneration to dentists for this patient cohort is £175.07. Average patient charges paid by patients is £70.22. This average takes non-fee payers into account.

3. New adult patients with 5 or more carious teeth with and without severe periodontal disease

Average renumeration to dentists for this patient cohort across all pathways increases from £356.83 to £550.53. Average patient charges paid by patients increases from £70.51 to £71.34.

We estimate around 370,000 of these patients are seen pre-policy changes.

4. Returning adult patients receiving an existing band 2 or 3 course of treatment as defined above

We estimate around 6.25 million of these courses of treatment are delivered each year, and average renumeration and patients charges are not impacted by the reforms. Average renumeration to dentists for this patient cohort is £175.07. Average patient charges paid by patients is £70.22. This average takes non-fee payers into account

5. Adult patients with a new diagnoses of grade C periodontal disease with fewer than 5 carious teeth

Average renumeration to dentists for this patient cohort increases from £106.43 to £248.34. Average patient charges do not change.

We estimate around 320,000 of these patients are seen pre-policy changes.

6. Returning adult patients receiving a band 1 course of treatment

We estimate around 10.69 million of these courses of treatment are delivered pre-policy changes. Average renumeration to dentists for this patient cohort is £35.48. Average patient charges paid by patients is £23.98. This average takes non fee payers into account.

Fewer of these courses of treatment are delivered when unnecessary band 1s are reduced.

7. Children receiving non-unscheduled care

We estimate around 8.04 million of these courses of treatment are delivered each year. For band 2 or 3 care, average renumeration is £135.52 and for band 1 care it is £35.48. Children do not pay patient charges.

8. Adults and children receiving unscheduled care

Average renumeration to dentists for this patient cohort increases from £42.57 to £78.26. Average patient charges do not change.

For the purpose of the model, we estimate around 3.35 million of these patients are seen pre-policy changes and these increase to 4.05 million when urgent care is mandated.

Model outputs 

Benefits have been modelled in terms of number of courses of treatment delivered that are:

• non-evidence-based care, either under or over-treated
• evidence-based care

We also present number of patients receiving ‘types’ of care that are impacted by the policies. These types are:

• adult band 1 care - which corresponds to segments 1 and 6 (above)
• adults receiving treatment - which corresponds to segments 2, 3 and 4
• adults and children receiving unscheduled care - segment 8

We have detailed a full list of assumptions in annex A but the most important assumptions are as follows.

Initially, spend on adult care requiring treatment including new pathways will increase due to fairer renumeration and additional care provided to these patients, leading to better health outcomes. In later years, dental practices will further reduce unnecessary band 1 courses of treatment and switch to treating more of these patients. We assume a 15% drop in band 1 care in year 1, a 20% drop in year 2 and a 28% drop in year 3 onwards, all compared with the baseline year. These assumptions are informed by the behaviour change seen in the prototype evaluation.

Spend and activity on returning band 1 patients will decrease due to improved incentives to provide other forms of care. We assume that this reduction in over-treatment is predominately encouraged when the proposed new care pathways are implemented.

Spend and activity on unscheduled care will increase in year 1 and then remain stable. This is based on the assumption that mandating unscheduled care within the core contract will lead to increased delivery in year 1.

Currently, all patients receiving an unnecessary band 1 check-up are over-treated. Over-treatment is defined as care which a patient does not require - that is, clinically unnecessary check-ups where the recommended recall interval does not align with the patient’s oral health risk as described in NICE guidelines (Dental checks: intervals between oral health reviews).

Currently, all patients with high treatment needs for caries and grade C periodontal disease are undertreated.

Anecdotally, dentists have told us that the current unscheduled care remuneration is insufficient to provide optimal care to patients and that consequently, some patients may not have their definitive unscheduled care needs addressed. There is no clear evidence on the total volume of unscheduled care for which this could apply. However, a review of FP17 form data indicates the range of patients receiving unscheduled care where limited interventions are carried out. Accepting a degree of uncertainty in this data, we have assumed a placeholder of 25% of existing unscheduled care courses of treatment are not clinically optimal.

The overall spend on each dental contract will always be constrained by the contract value agreed by commissioners.

Behaviours are assumed to take 3 years to fully change. Therefore, costs and benefits for later years are the same as for year 3.

Changes in spend allocation, care quality, case mix and patient charge revenue when implementing all proposals - preferred option

The value of the dental contracts expected to be impacted by these reforms is £2,888 million in 2026 to 2027 prices, the year we expect the reforms to start. Therefore, each percentage point change in spend represents approximately £29 million. For the purposes of modelling, we have assumed that there is no change in current commissioning, only a change in how these resources are used at contract level.

Tables 1 to 4 show the change in:

• the proportion of spend on the various cohort groups modelled
• quality of care
• case mix
• patient charge revenue

Change in proportion of spend

This is illustrated in table 1 and shows that implementing all the proposals results in:

• reduced spending on unnecessary band 1 care
• increased spending on unscheduled care
• a reduction in monies lost to under-delivery of contracts

The proportion of spend associated with adult treatment, including the new care pathways, remains constant but this masks changes in the quality of care being delivered and that these will be different patients each year.

Table 1: impact on spend allocation, assuming all policies are implemented

	Baseline year	Year 1	Year 2	Year 3 onwards
Proportion of budget spent on adult band 1 care	14%	13%	12%	11%
Proportion of budget spent on adult care requiring treatment including new pathways	47%	51%	52%	53%
Proportion of budget spent on child non-unscheduled care	22%	22%	22%	22%
Proportion of budget spent on unscheduled care	5%	11%	11%	11%
Proportion of budget allocated to non-modelled expenditure	0%	3%	3%	3%
Proportion of budget either spent on other dental commissioning or underperformance returned to commissioners	12%	1%	1%	1%

Changes in care quality

Changes in care quality have been considered as a change in the number of courses of treatment where the care delivered aligns with evidence-based care, with associated changes to the numbers of courses of treatment that reflect both under and over-treatment.

Over-treatment is defined as care which a patient does not require - for example, clinically unnecessary check-ups where the recommended recall interval does not align with the patient’s oral health risk as described in NICE guidelines (‘Dental checks: intervals between oral health reviews’, linked above). Under-treatment is defined as a scenario in which important elements of care, usually preventative advice and support, are foregone.

Clinicians have described to us that the current payment systems do not adequately fund them to deliver all elements in the time available and so there is a tendency to focus on treatment - for example, completing restorations rather than prevention (such as supportive self-care actions) - in those with complex needs. This has been referenced in relation to both the need for frequent reviews during the initial periodontal disease management phase and care of people with significant caries. In relation to urgent care, this may manifest as a focus on short-term alleviation of symptoms - for example, antibiotics and analgesia - rather than definitive treatment.

We have not included a baseline of numbers of patients in each of these categories because we are not certain on the level of care provided to existing patients in courses of treatment not impacted by these policies.

The impact of implementing all proposals on care quality is illustrated in table 2. The model output suggests that there are improvements in care quality for all patient cohorts of interest:

• a reduction in inappropriate under-treatment (unscheduled care with potential for better management)
• a reduction in over-treatment (unnecessary band 1 recalls)
• an increase in courses of treatment aligned to evidence-based care (improved unscheduled care management and patients on the new care pathways)

Table 2: changes in courses of treatment (millions), assuming all policies are implemented

Impact on courses of treatment	Year 1 (m)	Year 2 (m)	Year 3 onwards (m)
Annual change in courses of treatment who are under-treated	–1.53	–1.53	–1.53
Annual change in courses of treatment receiving evidence-based care	3.84	4.38	5.25
Annual change in courses of treatment being over treated	–1.60	–2.14	–2.99

Changes in case mix

Table 3 illustrates the change in case mix when implementing all proposals, described as numbers of patients seen in the cohorts of interest. This is different to the impact on numbers of courses of treatment considered in table 2, as a single patient may have multiple courses of treatment in a given time period.

This suggests an overall increase in numbers of patients being seen of around 570,000 in year 1, falling to 460,000 in year 3 and beyond, as practices increasingly prioritise patients with unscheduled and more complex clinical needs over those who only require check-ups. This results in a fall in the numbers of patients receiving band 1 care. Those patients who are receiving unnecessary band 1 recalls will have good oral health who, according to NICE guidance, can be seen every 2 years with no expected risk to their oral health. Unnecessary care is a cost to these patients and so reducing their contact is beneficial to them, as well as to the NHS.

Table 3: impact on annual patient numbers (millions) receiving appropriate care, assuming all policies are implemented

	Year 1 (m)	Year 2 (m)	Year 3 onwards (m)
Annual change in adult patients receiving band 1 care	–0.14	–0.18	–0.26
Annual change in adult patients receiving treatment including new pathways	0.00	0.01	0.02
Annual change in patients receiving unscheduled care (adults and children)	0.70	0.70	0.70
Total change in patients seen	0.57	0.53	0.46

Changes to patient charge revenue

Patient charge revenue is dependent on:

• the number of patients seen
• the band of care they receive
• their exemption status

Currently, a higher proportion of band 1 patients pay patient charges than band 2 or 3, and the data suggests that the proportion of fee payers receiving the new care pathways will be low.

The model estimates a decrease in patient charge revenue of £28 million in year 1 rising to £59 million in year 3, as illustrated in table 4. This occurs due to the decrease in unnecessary band 1 care, as these patients are more likely to be fee paying.

Consideration will need to be given as to how to mitigate this before any implementation.

Table 4: estimated patient charge revenue collected (£ million) at 2026 to 2027 prices

	Baseline year (£m)	Year 1 (£m)	Year 2 (£m)	Year 3 onwards (£m)
PCR all policies	835	808	796	777
Difference	Not applicable	–28	–40	–59

In summary, the model outputs suggest that implementing all proposals could result in not only an increase in the numbers of people securing NHS care but also a shift in resources being targeted to those with the greatest need, defined as those with an urgent or unscheduled care need or more complex care needs within current resources.

Implementation of all the proposals secures a better outcome profile for patients than implementing the urgent care proposals only or the new care pathways for patients with more complex needs only. The model outputs for these options are detailed in annex D.

Policies costed outside the main model

Table 5 shows the estimated costs of the policies not included in the main model due to increased uncertainty about behaviour change and patients currently seen. The policies not included in the main model are:

• fluoride varnish
• fissure sealants
• quality improvement and funded appraisal

As noted above, £88 million has been ‘top sliced’ from the dental budget to account for the potential spend on these proposals. This is less than the total potential spend on these proposals given the uncertainty around fissure sealant application in particular. This is due to the nuanced clinical decision-making around this intervention.

Fluoride varnish

Dental nurses may feel more valued through new fluoride varnish treatments, and children and parents may benefit from more available appointments. As fluoride varnish reduces tooth decay, it could lead to:

• fewer extractions
• fewer missed school days
• less time off work for parents

There are estimated savings resulting from the value of time freed up for dentists by allowing dental nurses to apply fluoride varnish. This is estimated to be between 3 and 9 hours per NHS dentist per year. The time savings are based on the assumptions that:

• uptake of fluoride varnish among children stays at current levels
• between 40% and 60% of fluoride varnish treatments are in line with the better oral health guidance bi-annual application for low-risk children and once a quarter for high-risk children
• high-risk children are classified as those with visually obvious decay (enamel or dentinal)
• dental nurses only deliver one appointment for low-risk children, and 3 for high-risk children
• fluoride varnish application takes on average 10 minutes for both dentists and dental nurses
• population levels of children remain stable

Fissure sealants

Re-banding fissure sealants will give dentists fairer pay for this treatment, which should encourage dentists to provide more preventative treatment for primary prevention. Greater availability will:

• reduce tooth decay
• improve oral health
• reduce the number of children referred to hospital due to tooth decay

Indicative estimates suggest that around 215,000 children could be eligible for fissure sealants annually.

There is a range of evidence available to show that fissure sealants are highly effective in preventive dentistry, particularly for children and adolescents. They have been shown to reduce the risk of decay by 80% in molars. Applying sealants is also more cost-effective than treating cavities and the associated complications, with £1 spent on sealants saving £5 to £10 in cavity treatment costs.

There is also an interdependence with fluoride varnish, making both treatments easier to access, improving quality and the delivery of preventative care and therefore oral health of children.^{[footnote 4][footnote 5]}

Quality improvement and funded appraisal

These proposals support improvement in the quality and consistency of NHS dental care, and potential reduction in errors. An estimated cost of £28 million per year is associated with these proposals.

As discussed above, there are a further range of interventions to be taken on under the overall aim of ‘Feeling part of the NHS’, including:

• an NHS handbook
• minimum terms of engagement
• extending minimum requirements of discretionary payments

This evidence note does not attempt to quantify the impact of these proposals, as they will have a minimal effect on dentistry access, but are likely to improve conditions for dental professionals and quality of care for patients.

For the minimum terms of engagement, this gives associate dentists a higher floor to negotiate terms with providing performer dentists. Alongside the time for funded appraisals, this should help to improve the morale of the workforce.

Extending the minimum requirements of discretionary support payments in NHS dentistry makes the benefits package appear more competitive in the labour market. This should improve the working conditions of existing staff, helping with staff turnover rates, as well as making NHS dentistry more attractive in the labour market.

Table 5: summary of costs and benefits of non-modelled changes

Proposal	Description	Impact	Rationale for not including in the modelling and rough estimate of spend
Skill mix and clinical interventions	New course of treatment to support provision of fluoride varnish	- Improved fluoride varnish application rates for both low and high-risk children - Improved job satisfaction for EDDNs - Improved health outcomes - Dentist time released to deliver more complex care	This policy will not cost more money. It is making better use of skill mix, therefore reducing cost to the NHS. This cost has not been quantified.
Skill mix and clinical interventions	Re-banding of resin-based fissure sealants	- Improved fissure sealant application rates, especially for primary prevention - Improved health outcomes and reduction in childhood decay	The behaviour change resulting from this policy is difficult to model. An estimate of cost if a fissure sealant is applied to all high-risk children on eruption of permanent molar teeth is approximately £77 million in 2026 to 2027 prices. This is unlikely to be realised given the nuanced clinical considerations which underpin the decision to apply a fissure sealant.
Feeling part of the NHS	Introduce quality improvement (including structured audit and peer review)	- Improved care quality in areas of focus - Improved motivation and morale	An approximate cost for quality improvement and appraisals is £28 million per year.
Feeling part of the NHS	The development of an NHS handbook for associate dentists and the wider dental team	Improved awareness and information for the profession	No cost is associated with the development of the handbook.
Feeling part of the NHS	The development of minimum terms of engagement and an NHS modal contract for dental associates	Improved motivation and morale	No cost is associated with the development of the model contract.
Feeling part of the NHS	Funded support for annual appraisal	Improved motivation and morale	An approximate cost for quality improvement and appraisals is £28 million per year.
Feeling part of the NHS	Extending minimum requirements of NHS service for discretionary support payments to include all NHS service	- Improved motivation and morale - Bringing NHS dentistry in line with other parts of primary care or the NHS.	Costs for extending minimum requirements of NHS service are unknown but anticipated to be minimal.

Risks

The biggest risk to delivery of these proposals is that they rely on behavioural change from dentists to deliver the impact and health benefits. Due to the complexities in measuring these impacts, it has not been possible to be fully confident in the anticipated changes. Instead, the modelling assumes a certain behaviour change (detailed in annex A) and therefore the results are subject to a high level of uncertainty. The results provide an indication of the benefits that could be seen if these proposals were implemented but should not be taken as predictive of what will happen.

The changes made to band 2 in 2022 were adopted rapidly by the profession - that is, within months of implementation and quickly stabilised. Band 2b claims (filling or extraction to 3 or more teeth) now account for around 25% of all band 2 claims and have remained stable at this rate since February 2023. As of March 2025, dental therapists are now leading on around 5% of all courses of treatment from a baseline of near zero in July 2022. This represents significant progress towards the NHS Long Term Workforce Plan ambition of 15% dental therapist and hygienist participation in the delivery of NHS dental care, which has been supported by amendments to the Human Medicines Regulations, although there is more to do.

Other changes introduced through the dental recovery plan, and specifically the new patient premium, were not so impactful in terms of numbers of patients seen. However, qualitative evidence suggests that these payments were welcomed by the profession as an acknowledgment of the additional costs of new patients, particularly where they have more significant oral health needs. Focus group participants noted that:

• while welcome, these payments did not address the underlying under-remuneration of patients with complex care needs
• substantive reform was required

The proposals in this package are intended to deliver this more substantive reform to payment for those with more complex needs.

Given the lack of available data, several assumptions have had to be made regarding potential patient numbers and current care. These are detailed in annex A.

The modelling is at a national level and the impact on different ICBs has not been modelled. Currently there are differing levels of contract delivery between ICBs. We will seek to further understand these impacts during the consultation period.

Monitoring and evaluation

The aim of these reforms is to:

• improve the access to dental care among those in most need
• improve the patient experience of access
• fund training in quality improvement methodologies to drive improved professional standards

The evaluation plan for dentistry will focus on understanding the impact of payment changes on the care provided, and the types and numbers of patients accessing care. It will seek to:

• compare actual care delivery against forecasted care delivery (preventative care and unscheduled care) and examine variation at regional and ICB-level
• understand impact of changes on the characteristics of patients accessing care (clinical, demographic, protected characteristics) and examine variation at regional and ICB-level using data recorded on FP17 forms
• compare staff skill mix within the longitudinal care pathway against policy assumptions and forecast
• compare longitudinal care pathway activity against forecast to assess whether new arrangements lead to practices meeting patient needs

A further mixed-methods evaluation would also seek to:

• understand the uptake of the quality improvement support and motivations and barriers to engaging
• impact and implementation of quality improvement methodologies in practice as the result of the support provided
• understand the process of how changes were implemented and their effectiveness (process evaluation)

Most of the data to support monitoring and evaluation is currently captured on the FP17 form; the exception is diagnosis of periodontal disease. Another aspect where data needs to be improved is the identification of unique patients to help track longitudinal care given.

Where data items need to be added to the FP17 form, this will be taken forward. The standardised identification of unique patients will also be considered and a single methodology determined that gives the highest number of correctly identified patients and minimises incorrectly identified patients.

NHS England is also working on a new Secretary of State direction to collect patient-level FP17 data from the NHS Business Services Authority (NHSBSA). This will allow linkage with other data sets such as A&E data and help to understand patient outcomes and impact on the wider NHS.

Annex A: full list of assumptions

Assumptions are grouped into 4 areas:

• oral health and estimates of need
• clinical care delivery
• changes in clinician behaviour
• assumptions around commissioning and patient charges

These are detailed in the tables below, along with an assessment of the quality of the evidence to support these assumptions and their importance to the outputs of the model.

Table 6: population oral health and need assumptions

	Assumption description	Size of impact or importance of assumption	Quality of evidence	Areas of impact
1	The Global Burden of Disease (GBD) 2021 study estimates that the incidence of severe periodontal disease in 2021 in the UK is 360,000 people, while prevalence is 5.53 million (10%). We have assumed that people develop new incidence of periodontal disease multiple times in their life and have modelled an average of once, 3 times and 4 times to understand the impact of this assumption. We have assumed a base case of people who ever develop severe periodontal disease develop it an average of 3 times in their life.	Large - this assumption underpins the assessment of costs and impacts of improving periodontal care	Good - GBD epidemiological study	Cost estimates, number of patients impacted
2	The proportion of patients with 5 or more carious teeth into dentine within each of the different complex care pathways is the same as in the pre-2006 data detailed below.	Small	Medium - it is based on old data, care patterns may have changed and it relies on an estimation of unique patients	Cost of high-needs caries
3	The overall oral health of the population does not change over the next 10 years. Any change will be slow and due to the disruption to the adult oral health survey we do not have recent data to understand changes in population oral health since 2009. Therefore, in the absence of evidence we assume no change, which is a conservative estimate given the general trend of improving oral health.	Small	Poor	Overall level of dental need and case mix

Table 7: clinical care delivery assumptions

	Assumption description	Size of impact or importance of assumption	Quality of evidence	Areas of impact
4	Dentists will provide access to their existing patients before providing care to patients not known to their practice	Medium - underpins the choice to model impact on existing patients before impact on new patients	Good - we are repeatedly told this by dentists in focus groups and other discussions	Cost estimates, number of patients impacted
5	Dentists will provide the new intensive periodontitis course of treatment to their existing patients with a new diagnosis of grade C disease before taking on additional patients	Small - similar to above	Good - we are repeatedly told this by dentists in focus groups and other discussions	Cost estimates, number of patients impacted
6	Patients with severe periodontal disease is an adequate proxy for patients with grade C periodontal disease	Small - the exact clinical definitions have changed but the size of the population will be similar	Medium - the grading of periodontal disease relates to the rapidity of progression, but there is a likely large overlap between severity and rate of progression	Cost estimates, number of patients impacted, benefits in terms of case mix
7	All patients with 5 or more carious teeth into dentine are ‘new’ in that they have not been seen in the past 2 years.	Very small	Poor - it is unlikely that patients with a high level of decay have been seen in the past 2 years but there is no firm evidence	Case mix of additional patients seen
8	The care provided to patients is influenced by the available resources on the NHS, leading to under treatment of particular patient groups, including those newly diagnosed with grade C periodontal disease and those with high levels of dental decay.	Large - this underpins our estimates of case mix of patients seen	Good - there is anecdotal and published evidence to support this[footnote 2][footnote 3]	Case mix changes in terms of patients moving from evidence-based care to over treatment
9	Placeholder assumption that 25% of existing unscheduled care courses of treatment are not clinically optimal. These patients are those where the current remuneration does not match the level of care patients require. We assume that patients with a need for a filling or extraction are currently undertreated (18%), and that some of these patients do not receive this treatment when they need it	Medium	Poor - it is likely that more than the 18% of patients receiving fillings or extractions are undertreated, but we do not know how many.	Estimate of benefits in terms of number of people moving from under-treatment to evidence-based care in unscheduled care
10	Where dentists are appropriately remunerated for clinical treatment, this will lead to a higher incidence of evidence-based care being provided	Large	Medium - based upon the inverse of the published evidence of changes when remuneration is insufficient and feedback from the profession. There is a wealth of wider evidence on the impact of misaligned incentives.	Estimate of benefits in terms of number of people moving from under-treatment to evidence-based care

Table 8: behaviour change assumptions

	Assumption description	Size of impact or importance of assumption	Quality of evidence	Areas of impact
11	Over time, dentists will respond to the fairer remuneration for patients with complex care needs and see more of these patients. This will lead to a decrease in unnecessary band 1 recalls and an increase in new patients with an acute need gaining access to a practice. This will gradually change the case mix within NHS dental practices. Currently NHS management information suggests the vast majority of low-risk patients are assigned 6-monthly recall intervals, with 95% of practices bringing more than 50% of their low-risk patients back within a year. We assume all patients with an unnecessary band 1 course of treatment are over-treated. We assume a 15% drop in band 1 care in year 1, a 20% drop in year 2 and a 28% drop in year 3 onwards, all compared with the baseline year	Large - this underpins our estimates of case mix of patients seen	Good - estimates are drawn from the findings of the prototype evaluation where participating practices were selected to be representative of what might occur in wider rollout[footnote 6]	Estimate of benefit in terms of numbers of people moving from over-treatment to evidence-based care
12	ICBs will carry out contract management to ensure full delivery of UDAs. This will include: - delivery of contracts by most dentists - unilateral re-basing of underperforming contracts and subsequent re-commissioning of UDAs - non-recurrent in-year commissioning of UDAs to account for underperformance in certain contracts	Large	Medium - this activity can be seen in the regular reporting data we obtain from NHSBSA; however, this is more effective in some ICBs than others	Estimates of costs and benefits

Table 9: other commissioning and patient charge revenue assumptions

	Assumption description	Size of impact or importance of assumption	Quality of evidence	Areas of impact
13	These policy changes will only apply to ‘normal’ contracts. We use contracts with more than 100 contracted UDAs as a proxy for normal contracts due to a lack of transparency in the commissioning data	Large	Medium to high - most other contracts are for out of scope service lines. However, uncertainty in commissioning data and flexible commissioning spend means we cannot be certain that the contracts included are correct.	Overall costs of proposals
14	Patient charges - the proportion of patients receiving different bands of course of treatment will be the same as for existing courses of treatment and based on 2023 to 2024 data. The exception is for patients with complex care needs where we will use the proportion in the data set provided by NHSBSA	Medium	Medium to high - patient charges are relatively stable	Impact on patient charge revenue
15	Patients would only pay the revenue charge for the highest band of treatment they receive.	Small	High - this needs to be included in the specification of the new pathways	Impact on patient charge revenue
16	Dental care commissioned remains constant over the duration of the model.	Large	Medium - the dental budget has been largely unchanged in recent years	Patient numbers, patient charge revenue

Annex B: data sources used

NHS dental statistics annual publication 2023 to 2024 

This is the annual national statistics publication on NHS dental activity and patient charges. Within the model, it is used in estimating:

• pre-contract changes costs
• patient charge revenue
• patients seen

It is also used to understand current care delivered within an unscheduled course of treatment.

UK Data Service longitudinal dental treatment files (study number 7024) 

This is an approximately 5% sample of dental patients seen between 1990 and 2006. This is used to estimate the case mix of patients with high needs for both caries and periodontitis. It is possible a small number of these patients will be duplicates, but because we only use this data to estimate the proportion of patients falling into each pathway, it will have a negligible impact.

Table 10 contains the proportion of patients within the dataset with 5 or more fillings, extractions or crown restorations with or without laboratory restoration and with or without currently unstable periodontal disease.

Table 10: percentage of patients with 5 or more carious teeth with or without receiving laboratory restorations and treatment for unstable periodontal disease

	Without currently unstable periodontal disease	With currently unstable periodontal disease
Without laboratory restorations	50%	16%
With laboratory restorations	22%	12%

Summary of adults with 5 or more teeth filled, extracted or crowned 

This is a bespoke extract from NHSBSA of all patients identified as having 5 or more teeth filled, extracted or crowned in 2023 to 2024. This gives UDAs received and patient charges paid and is used to estimate the number of patients with complex treatment needs who are currently treated.

Dental data pack

We receive a monthly extract of dental claims data at contractor level from NHSBSA. We have used this data to understand current delivery for 2024 to 2025 using data for contractors with more than 100 commissioned UDAs, as we take these to be ‘normal’ contracts. This includes new patient premium activity data for all eligible contracts.

Population data 

We use ONS population statistics to estimate the proportion of the adult population with severe periodontal disease using epidemiological estimates in the GBD study.

Annex C: distributional and wider impacts

The elements of the proposed reforms that should have a positive effect on inequalities are the mandating of unscheduled care within the dental contract and those relating to evidence-based clinical interventions.

Robust evidence is available that shows there is a correlation between deprivation and access to dental care, with a disproportionate number of deprived people needing intensive dental care.^{[footnote 7]}

The change to mandate unscheduled care and reimburse dentists more fairly for evidence-based clinical interventions should incentivise dentists to provide this care. This should therefore benefit deprived populations and reduce inequality, though data is not available to directly test this assumption.

The issue of poor oral health in more deprived populations is illustrated in Figure 1. This shows that the mean number of decayed teeth is around 4 times higher for adult males in the most deprived areas, compared with the least deprived.

Figure 1: mean number of decayed teeth among male adults aged 16 to 65 years in England, Wales and Northern Ireland

Text description: figure 1 shows the mean number of decayed teeth among adult males aged 16 to 65 years against 4 categories in England, Wales and Northern Ireland. These categories cover occupation, income, long-term illness or disability and homelessness.

The graph shows that the mean number of decayed teeth increases in males aged 16 to 65 years where they experience higher levels of deprivation, have a long-term illness or disability or are homeless.

Poorer oral health also impacts the time taken for dentists to provide treatment. Using CACI’s Acorn consumer classifications,^{[footnote 8]} we know that people in financial hardship are less likely to visit an NHS dentist and more likely to need more intervention when they do.

Using a random sample of 2.6 million band 2 FP17 forms submitted between 2019 to 2022, we calculated the proportion of courses of treatment delivered to patients in each population segment that were estimated to take over 110 minutes of treatment time using the Heathrow timings study - the top 5% of time taken.

The results are shown in table 11. This demonstrates that younger adults and people in financial hardship are more likely to need a high level of intervention within a single course of treatment than older, richer adults and children. This finding allows us to be confident that contract changes to improve care for patients with complex needs will improve care for more deprived patients.

Table 11: odds ratio of being in the top 5% of band 2 courses of treatment in terms of duration for different age and Acorn categories (ACs)

Age group	AC 1: affluent achievers	AC 2: rising prosperity	AC 3: comfortable communities	AC 4: financially stretched	AC 5: urban adversity
0 to 5	0.56	0.74	0.80	1.08	1.22
6 to 17	0.50	0.58	0.66	0.88	0.94
18 to 24	1.44	1.68	1.86	2.34	2.40
25 to 44	1.16	1.16	1.36	1.60	1.68
45 to 64	0.78	0.78	0.88	1.00	1.04
65 or over	0.68	0.66	0.74	0.78	0.82

With the aim of these reforms being to provide better access to patients with complex clinical care needs, the modelling shows that other patients, particularly those requiring routine care including clinically unnecessary check-ups, may experience longer waits or reduced access to NHS dental appointments. While this presents a potential trade-off, the overall intent of the package is to raise the quality and effectiveness of care delivered through NHS dentistry, prioritising those with the greatest need.

Experience of dentinal decay is entrenched in more deprived areas from a young age. In 2024, 5 year old children living in the most deprived areas were 3.4 times more likely to experience dentinal decay than those living in the least deprived areas (see figure 2).

Figure 2: the slope of index inequality in the prevalence of experience of dentinal decay in 5 year old schoolchildren, 2024 ^{[footnote 9]}

Text description: figure 2 shows the prevalence of experience of dentinal decay in 5 year old children against deprivation using the 2019 national index of multiple deprivation (IMD).

The IMD is on a scale of 1 to 10, where 1 represents the most deprived and 10 represents the least deprived. The graph shows that 5 year old children living in the most deprived areas were 3.4 times more likely to experience dentinal decay compared with those living in the least deprived areas.

Note: error bars represent 95% confidence intervals.

The proposals around fluoride varnish will support dental providers to go further on skill mix and enable them to adapt practice to a cost-effective, nurse- led model, releasing dentist clinical time to deliver more complex treatment. This could include provision of nurse-led clinics at times which are more convenient for patients, including outside of school and working hours which may increase accessibility for income deprived groups who often must choose between healthcare and securing work-related income.

The re-banding of fissure sealants to provide fairer remuneration when this intervention is provided for primary prevention could incentivise greater use of this evidence-based treatment before a child has experienced decay in their permanent dentition. In 2023 to 2024, only 22% of FP17 form submissions which indicated that fissure sealants had been placed claimed this as a band 1, and therefore a primary prevention activity. Given the strong correlation between deprivation and child oral health, an increase in this percentage because of fairer remuneration is likely to be of benefit to children in income deprived families.

The other proposals in this package of reforms around ‘Feeling part of the NHS’ are likely to be neutral in terms of the impact on reducing inequalities. These elements are mainly targeted at improving quality and workforce morale, which should benefit all patients.

The impact of these reforms will also vary regionally and locally. While the unscheduled care proposals will include a mandated delivery level, several of the proposals above will depend on how much additional and existing capacity can be either delivered or redirected to those with complex care needs.

This is a decision for contractors and will also impact ICB areas in aggregate. For example, contractors in London ICBs are on average delivering close to their targeted UDA activity levels, so opportunities for extra spend will be limited and will rely more on shifts in the case mix to deliver more care to patients with complex needs, including periodontic care. On the other hand, lower performing ICBs (such as Somerset, Devon and Norfolk) will have capacity in contractual terms to deliver more of their UDAs through treatments for patients with more complex care needs. However, there may be other structural issues in these areas that explain why contract delivery is currently low (lack of dentists, vacancies or competition with private market), which mean that increasing delivery could be difficult.

Due to the complexity in modelling behaviour change in the dental contract, there has been no attempt to model these potential impacts, so the extent to which different areas will shift behaviour is not known.

Annex D: model outputs for partial implementation

As noted in the main body of this evidence note, the preferred option is to implement all proposals, as this results in a more optimal distribution of benefits across all cohorts of patients.

However, we have also considered the potential impacts of only implementing:

• the urgent or unscheduled care proposal
• the care pathways for patients with more complex needs

We have considered these impacts in terms of changes in:

• the allocation of spend
• quality of care
• case mix
• patient charge revenue

Model outputs for only implementing the unscheduled care proposal

These are illustrated in tables 12 to 15. These suggest that when the unscheduled care proposal only is implemented, there is an increase in spend on unscheduled care and an associated increase in numbers of patients receiving unscheduled care. Patient charge revenue also increases.

However, there is a reduced impact on addressing under and over-treatment when compared with implementing all the proposals, which represents a lost opportunity to address known issues and tacking the associated clinical and value for money issues.

Table 12: impact on spend allocation assuming only unscheduled care is implemented

	Baseline year	Year 1	Year 2	Year 3 onwards
Proportion of budget spent on adult band 1 care	14%	14%	14%	14%
Proportion of budget spent on adult care requiring treatment including new pathways	47%	47%	47%	47%
Proportion of budget spent on child non-unscheduled care	22%	22%	22%	22%
Proportion of budget spent on unscheduled care	5%	11%	11%	11%
Proportion of budget allocated to non-modelled expenditure	0%	0%	0%	0%
Proportion of budget either spent on other dental commissioning or returned the NHS England	12%	6%	6%	6%

Table 13: changes in courses of treatment (millions) assuming only unscheduled care is implemented

Impact on courses of treatment	Year 1 (m)	Year 2 (m)	Year 3 onwards (m)
Annual change in courses of treatment who are under treated	–0.84	–0.84	–0.84
Annual change in courses of treatment receiving evidence-based care	1.91	1.91	1.91
Annual change in courses of treatment being over treated	0.00	0.00	0.00

Table 14: impact on annual patient numbers (millions) receiving appropriate care assuming only unscheduled care is implemented

	Year 1 (m)	Year 2 (m)	Year 3 onwards (m)
Annual change in adult patients receiving band 1 care	0.00	0.00	0.00
Annual change in adult patients receiving treatment including new pathways	0.00	0.00	0.00
Annual change in patients receiving unscheduled care (adults and children)	0.70	0.70	0.70
Total change in patients seen	0.70	0.70	0.70

Table 15: estimated patient charge revenue collected (£ million) 2026 to 2027 prices

	Baseline year (£m)	Year 1 (£m)	Year 2 (£m)	Year 3 onwards (£m)
PCR-only unscheduled care	835	846	846	846

Model outputs for only implementing the complex care needs proposals

The model outputs for this option are illustrated in tables 16 to 19. As expected, proportion of spend increases on this cohort with an associated reduction in proportion of spend on adult Band 1 care. There is a decrease in the overall number in patients seen and a decrease in patient charge revenue as those with complex needs are more likely to be charge exempt. There is no increase in unscheduled care spend and importantly, this approach does not support delivery of the additional 700,000 unscheduled care appointments.

Table 16: impact on spend allocation assuming only complex care needs pathways are implemented

	Baseline year	Year 1	Year 2	Year 3 onwards
Proportion of budget spent on adult band 1 care	14%	13%	12%	11%
Proportion of budget spent on adult care requiring treatment including new pathways	47%	60%	60%	61%
Proportion of budget spent on child non-unscheduled care	22%	22%	22%	22%
Proportion of budget spent on unscheduled care	5%	5%	5%	5%
Proportion of budget allocated to non-modelled expenditure	0%	0%	0%	0%
Proportion of budget either spent on other dental commissioning or returned the NHS England	12%	1%	1%	1%

Table 17: changes in courses of treatment (millions) assuming only new care pathways for those with complex care needs are implemented

Impact on courses of treatment	Year 1 (m)	Year 2 (m)	Year 3 onwards (m)
Annual change in courses of treatment who are under treated	–0.69	–0.69	–0.69
Annual change in courses of treatment receiving evidence-based care	2.40	2.94	3.81
Annual change in courses of treatment being over treated	–1.60	–2.14	–2.99

Table 18: impact on annual patient numbers (millions) receiving appropriate care assuming only new care pathways for those with complex care needs are implemented

	Year 1 (m)	Year 2 (m)	Year 3 onwards (m)
Annual change in adult patients receiving band 1 care	–0.14	–0.18	–0.26
Annual change in adult patients receiving treatment including new pathways	0.10	0.11	0.12
Annual change in patients receiving unscheduled care (adults and children)	0.00	0.00	0.00
Total change in patients seen	–0.04	–0.08	–0.14

Table 19: changes in patient charge revenue (£ million)

	Baseline year (£m)	Year 1 (£m)	Year 2 (£m)	Year 3 onwards (£m)
PCR only complex care pathways	835	804	799	789

1. Dental treatments are split into 3 bands, based on the complexity or amount of treatment required (ranging from band 1 for the lowest cost to band 3 for the highest cost). The band determines the number of units of dental activity (UDAs) a practice receives for delivering a treatment and the cost charged to patients who pay for NHS dental treatment.  ↩

2. Tickle M and others. Paying for the wrong kind of performance? Financial incentives and behaviour changes in National Health Service dentistry 1992–2009. Community Dentistry and Oral Epidemiology 2011: volume 39, pages 465 to 473. ↩ ↩²

3. Mcdonald R and others. Changes to financial incentives in English dentistry 2006–2009: a qualitative study. Community Dentistry and Oral Epidemiology 2012: volume 40, pages 468 to 473. ↩ ↩²

4. Ahovuo-Saloranta A and others. Pit and fissure sealants for preventing dental decay in permanent teeth. Cochrane Database of Systematic Reviews 2017: issue 7, article CD001830. ↩

5. Marinho VCC and others. Fluoride varnishes for preventing dental caries in children and adolescents. Cochrane Database of Systematic Reviews 2013: issue 7, article CD002279. ↩

6. Harris RV and others. The impact of changes in incentives and governance on the motivation of dental practitioners. The International Journal of Health Planning and Management 2011: volume 26, pages 70 to 88. ↩

7. See page 28 of Dale V and others. ‘NHS dental charges and the effect of increases on access: an exploration’ (2021), available to download on the University of York’s PREPARE reports page. ↩

8. ONS. Estimates of the population for the UK, England, Wales, Scotland, and Northern Ireland. ↩

9. Office for Health Improvement and Disparities. ‘National Dental Epidemiology Programme (NDEP) for England: oral health survey of 5 year old schoolchildren 2024’, available on Oral health survey of 5 year old schoolchildren 2024. ↩