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Dental services in difficulty

Will new contracts have an effect upon NHS dental care?

NHS dental services face a number of well documented difficulties, including patients having problems gaining access to NHS dental care, the suggestion of rising costs and falling quality. In an attempt to address these issues, various changes to the NHS dental contract are being implemented across the UK. How will these contractual arrangements affect NHS dental care? Will they lead to changes in the amount of treatment provided by dentists?
The new dental care contracts vary in structure and will be implemented at different times across the UK. This presents researchers with an ideal opportunity to study a number of key questions relating to the impact of different contracts on health service delivery. Researchers will develop a new cross-national dataset which links data on dentists’ attitudes, confidence and beliefs with the treatment they provide. This will enable researchers to assess the impact of different contractual arrangements on the delivery of dental services in the UK.

What the research means for policy makers and the wider community

Research methods

Researchers will create and pilot a dataset which links questionnaire data on dentists’ attitudes and beliefs with data from the NHS on the levels of dental treatment provided. The study will specifically explore the treatment patterns of a group of recently qualified dentists who are currently working across the UK in Scotland, Wales, Northern Ireland and northern England. Researchers will take a multidisciplinary approach, incorporating clinical, psychological and economic aspects, to develop and evaluate the dataset.

Further Information: Project Posters

Updated Project Poster 2009

Below is a summary of this project’s provisional findings. It was originally presented as a dissemination poster, which is available here as a pdf document. All figures can be found at the bottom of this poster summary as thumbnails, which one should click to view full-size images. Alternatively, where figures are reffered to in the text, click the linked text for a full-size version.




For all professionals providing public services, the way formal incentives interact with individual attitudes and professional norms to shape behaviour is central to policy and institutional design. Dentists are a key example: would you rather your dentist was paid on a fee- per-item basis (meaning dentists are paid a fee for each treatment carried out, but there may be an incentive to over-treat), or paid a fixed monthly amount (meaning there may be an incentive to under-treat)? How best to pay dentists is central to NHS dentistry policy in the UK and indeed in 2006 England and Wales moved from a payment system like the first type to a payment system like the second.


We aimed to:

» put together, for the first time, data on treatment given by a cohort of dentists across the UK, who all graduated in the same year, with measures of those dentists’ attitudes and information about the various types of contracts those dentists worked under.

» Creating this unique database was intended both to help us to exploit the natural experiment resulting from the changeover in NHS dentist contracts and to explain the way dentists’ attitudes and contracts interact to influence the way they treat patients.

What We Did

» We had to put together a research team that combined expertise in dentistry with social science expertise (psychology and economics).

» We gathered  data on clinical treatment from routinely collected payment records (Figure 1) and data on dentist attitudes from questionnaire surveys. This involved a formidable obstacle course of negotiating approvals from national and local NHS R&D bodies across the UK (Figure 2).

» To test our predictions of how payment systems affect attitudes and treatment we use theoretical and empirical models, incorporating contract types, dentist attitudes and patient co-payments.

Provisional Findings

So far this project has revealed:

» the extent of the obstacles to clearing health research projects that go across the UK to make use of its potential as a site for a natural experiment;

» the extent of variation in dentists’ concern for patients’ ability to pay (Figure 3);

» the extent to which intensity of treatment depended on patients’ liability to pay part of the costs, known as co-payments, themselves (Figure 4).

» We are completing our analysis of the links between attitudes and treatment to determine the effect of attitudes within contracts, and how contracts affect attitudes and treatment.


Click on the figures to enlarge

clarksonfig1.jpg         clarksonfig2.jpg         clarksonfig3.jpg         clarksonfig4.jpg

Project Publications

Discussion Paper DP0807, Initial Estimates of the Impact of the New NHS Dental Contract on England and Wales, is available in the Library section of our website.

Article in JPART Special Issue on Incentives Martin Chalkley, Colin Tilley, Linda Young, Debbie Bonetti, and Jan Clarkson ‘Incentives for Dentists in Public Service: Evidence from a Natural Experiment ’, July 2010.

Research Team

Jan Clarkson

Jan Clarkson

Jan Clarkson is Director of the Effective Dental Practice research programme at the Dental Health Services Research Unit (DHRSU), University of Dundee. Her research interests include: the effect of remuneration and education on the implementation of research evidence to reduce inequalities in oral heath; and the effectiveness of evidence-based oral hygiene advice and instruction on patient oral hygiene.

Tel: 01382 420060 begin_of_the_skype_highlighting              01382 420060      end_of_the_skype_highlighting

Martin Chalkley

Martin Chalkley

Martin Chalkley is Professor of Economics at the University of Dundee. His research interests include: contracts for health services; information and incentives; and the economics of health. He is an academic consultant to the Department of Health.

Tel: 01382 344371

Colin Tilley

Colin Tilley

Colin Tilley’s main research interests are variations in healthcare provision. His recent publications include an analysis of how frequently NHS dental services are used by patients.

Tel: 01382 420070

Linda Young

Linda Young

Linda Young is a registered general nurse and a research fellow with the Scottish Dental Practice Based Research Network (Scottish Dental PBRN). Her main research interests include the development of effective interventions to encourage the implementation of evidence-based practice.


Debbie Bonetti

Debbie Bonetti

Debbie Bonetti is a research fellow at the DHRSU. She is particularly interested in developing more efficient trial methods in terms of intervention selection and evaluation.

Tel: 01382 420154 begin_of_the_skype_highlighting              01382 420154      end_of_the_skype_highlighting begin_of_the_skype_highlighting              01382 420154      end_of_the_skype_highlighting

Andrea Baker

Andrea Baker

Andrea is Research Fellow at the Dental Health Services Research Unit, University of Dundee.

Tel: 01382 420073
Fax: 01382 420051

Kim Stringer

Kim Stringer

Kim is administrator for the study Creating a Clinical, Economic, and Psychological Research Resource. Previously, she was secretary for the Scottish MALT Project a Wellcome Trust funded study examining the natural history of pathology-free wisdom teeth. This was a collaborative project between the departments of Public Health, DHSRUnit, and Dundee Dental School. Kim also offers secretarial support for DHSRU.