Has capitation failed?

When capitation was introduced in 1990 I was an enthusiastic supporter. Intended to promote prevention rather than restoration, it seemed to be the obvious answer to the problems of the fee-per-item system of payment. Eight years later I now feel that capitation has partially failed. It has failed in three ways:

  1. 1

    It has not sufficiently encouraged general dental practitioners (GDPs) to provide effective prevention of decay, particularly in the primary dentition.

  2. 2

    It has failed to maintain a good level of restorative treatment for young children.

  3. 3

    It has proved unable to attract the very young and the most highly caries prone children from disadvantaged families into regular dental care.

The evidence for these conclusions lie in recent child dental health surveys.1 These reveal that the average dmft (decayed, missing and filled deciduous teeth) of 5 year olds has remained about the same since 1982 (i.e despite the introduction of capitation in 1990) at around 2.0. Meanwhile, the “care index” which measures the level of restorative care provided by practitioners has fallen from 32% to 19% over the last 10 years. In other words, since capitation came in not only has there has been no reduction in the level of decay but the number of teeth filled has dropped sharply.

The inability of capitation to deliver prevention to the most caries prone is again revealed in the figures. When we look at the children with the greatest numbers of decayed teeth, these are the ones least likely to be regular attenders.1 The failure of capitation to reach out to the youngest age groups is clear from the registration rates. Less than a fifth of all children under the age of 3 are in capitation.8

The situation is almost as worrying for permanent teeth with surveys also showing a reduction in the care index for 12 and 14 year olds. On a brighter note, while fewer fillings are being provided there seems to have been a corresponding and very welcome increase in the number of fissure sealants placed.2 In both dentitions the evidence of a slight increase in prevention provided6 does not seem to compensate for the drop in the number of fillings. This is an area where capitation has badly let down some of the most vulnerable members of our society whose dental health should be one of our highest priorities.

I believe this failure is the result of a combination of two factors: underfunding and a lack of clarity in the goals of capitation. The lack of clarity arose from the fact that in its original form, capitation payments were intended to foster a more preventive approach by GDPs. However, the same payments were also meant to cover such restorative work as was necessary. In reality the available funding was inadequate for either. GDPs rightly feeling that they were being asked to do two jobs for less than the price of one were reluctant to embark on the vigorous and expensive preventive programmes which would have made it a success. To make matters worse, many GDPs seem to have been less willing to carry out restorative work under capitation. It is hard to see much serious dental health gain from over one billion pounds which has been pumped into capitation over the last 8 years.

Some efforts have been made recently to address this dire state of affairs. Fees for fillings were reintroduced in 1996 to encourage more restorative care to be provided.

In effect this signalled the failure of the original capitation concept. This measure addressed the problem of restorative care, but the lack of prevention particularly for the primary dentition remains. It will continue to remain a problem despite the recent announcement of a small increase in capitation fees for practices in deprived areas. This will make little difference and a more radical reform is now badly needed.

Setting clear goals

Given that there is never likely to be enough public money to fund both top quality restorative care and effective prevention we must make a hard decision. Which should be our priority: prevention or restoration? I believe that given the many problems associated with restoring deciduous teeth, prevention must come first and take the lion's share of any available funding.

It might be argued that the unhappy experience of the original scheme means that capitation should be abandoned and we should return to a completely fee-per-item system.

I do not agree. Capitation is especially good for funding prevention which is a prolonged enterprise requiring long term regular funding and commitment from both dentist and patient. The original scheme was not a complete failure. One of its successes has been the large numbers of children who have become registered. It is also interesting to note the numerous fissure sealants which have been provided purely under capitation and without additional payment. This shows that where GDPs have confidence in a particular preventive measure they are prepared to provide it on a large scale under capitation.

Principles

So how are we to improve the capitation system in the light of experience? I believe that a successful reform must be based on the following principles:

We must ensure that children get off to the best possible start with their dental health

Capitation must be:

  1. 1

    For prevention only To avoid the confusion of the original system it is essential that capitation payments are seen to be there to pay for prevention alone. This will help practitioners to budget for the costs of preventive programmes out of regular income earmarked for just this purpose.

  2. 2

    Targeted on the very young and the caries prone There has been a huge drop in the decay rate of children in the last 30 years. The average dmft of five year olds has dropped from 5.1 in 1963 to 1.97 in 1993.1 This average figure disguises the fact that most decay is now concentrated in a small minority of children. This means that in many parts of the country the great majority of children are now completely caries and filling free. It is folly to pay for preventive programmes for all these children who are at very low risk of disease. Much of the decay which now occurs affects children from low income and deprived families. Any preventive scheme must be able to target its resources on these groups as well as on those who have already suffered from decay.

  3. 3

    We must ensure that children get off to the best possible start with their dental health

    The very young must also be a priority. Most parents do not realise the importance of registering children as soon as the teeth begin to erupt or even before. By the time most children are registered at 2-3 years, dietary patterns and brushing habits, or lack of them, are firmly established and hard to change. Early prevention will provide much greater cumulative benefits than that given later. We must ensure that children get off to the best possible start with their dental health.

  4. 4

    Linked to the provision of specific, evidence-based preventive measures Luckily, deciding which preventive measures are evidence-based has become a relatively simple matter recently. Kay and Locker's comprehensive review of oral health promotion methods3 came up with a very clear message; the only intervention which can be described as truly evidence-based can be summed up in a single word – 'fluoride'.

  5. 5

    Fluoride is effective in many forms but especially in toothpaste. There is now a remarkable consensus amongst cariologists that the extraordinary decline in the decay rates of children seen all over the developed world can be explained by the increased use of fluoride toothpaste.5 Brushing twice a day with a good fluoride dentifrice is a highly effective way to control caries and very acceptable to our patients. So much so in fact that we should be seriously thinking of ways to use this as a public health measure to reduce inequalities in dental health. It has been suggested that free fluoride toothpaste and toothbrushes should be provided to children from deprived families.7 Given that widespread water fluoridation is unlikely to take place, especially in the low caries areas, this might well be the best way to tackle inequalities in child dental health in these regions.

  6. 6

    Fissure sealing as a way to prevent decay in permanent molars has been shown to be a highly effective measure.9 It is also very popular amongst GDPs as is shown by the far greater numbers placed under capitation.

  7. 7

    Fissure sealants and fluoride, especially in toothpaste, should be the mainstays of any future preventive strategy in the General Dental Services (GDS).

  8. 8

    Funded at a level which will allow GDPs to provide the highest quality prevention The old capitation method failed largely because of underfunding. Not unreasonably GDPs felt that they were being underpaid for the job they were being asked to do and lost faith in the concept. To their great credit many continued to provide an excellent level of care, but it seems that some provided only a limited service for the children on their lists. The problems caused by underfunding must not be allowed to happen again. The dental health of our children is far too important.

  9. 9

    I believe that to fund prevention properly will not need a great deal of new money. If resources can be targeted on those who really need it a 'Rolls-Royce' quality service can be provided at a negligible extra cost to the taxpayer.

The reform of capitation

The present capitation system is costing around £200 million a year.8 This money is being wasted as there is precious little evidence of dental health gain resulting from this spending. I believe that the money could be used much more wisely. For little additional net cost we could have an excellent and highly effective preventive service provided by general practitioners.

How could this be done? Using the principles outlined above a reformed capitation system would look like this:

Capitation would be strictly for the funding of prevention only. Restorative care and examinations would be funded by fee-per-item payments. Instead of four age bands and levels of payment as now there would be two higher monthly payment levels. One for 0-5 year olds and the other for 6-18 year olds. These would relate to the needs of the primary and permanent dentitions. These monthly payments would be linked to the provision of a specified minimum level of evidence-based preventive care. This preventive care would be mandatory and subject to the normal monitoring procedures of the GDS.

0-5 year olds

This age group would become a much higher priority than before and accordingly would attract a significantly higher level of payments. This would encourage dentists to register young children in much greater numbers.

At the moment only 19% of the child population is registered in the 0-5 age band compared with 72% for the 6-9 age band.8 Registration levels would then match or rise above those now achieved for the older age groups. The most effective preventive measure for this age group is brushing twice daily with a good fluoride toothpaste. Accordingly the payments would be linked to the provision of toothpaste and toothbrushes free of charge to the families of young children. This would be supplemented with dietary advice and motivation to brush correctly and regularly. The free brushes and paste would be a real incentive for low income and deprived families to get their children registered.

All children in the age range would be eligible for registration and the free brushes and paste. This would be regardless of whether they are at high or low risk of decay. This will ensure that all children start off their lives with the best possible chance of maintaining perfectly healthy teeth.

When bought in bulk a brush and 100mls of paste would cost about 80p. This must surely be the bargain of the century for a dental public health measure.

The cost of providing toothbrushes and paste is remarkably low. It has been estimated that when bought in bulk a brush and 100mls of paste would cost about 80p.7 If dispensed twice a year this would add a mere 13p onto the monthly capitation fee for each child. This must surely be the bargain of the century for a dental public health measure.

6-18 year olds

From the age of 6, capitation would be limited only to those who have already experienced decay. In England and Wales the surveys record nearly 60% of children as completely decay and filling free1 (although we must remember that epidemiological studies only count carious lesions into dentine). Taking these low caries risk individuals out of capitation would therefore liberate large amounts of money which could be applied to the capitation rates for the more caries prone children. These children would continue to have free toothpaste and brushes and motivation provided. In addition the funding would be sufficient to allow the placement and maintenance of fissure sealants in the permanent molars and for the application of topical fluorides. If the children remain caries free for three years they would then come out of capitation.

The end of the epidemic

In the 22 years since I qualified I have seen stunning improvements in children's dental health. Like many practices in the SE of England, two thirds of my registered children are completely caries and filling free. This is great, but I now feel deep frustration that the remaining third continue to suffer the misery of decay. If so many ordinary families can practice effective prevention there is no reason why, with a little extra help, they could not all do so.

The great caries epidemic which has devastated children's teeth for the last 200 years may be near its end. I am convinced that modest reforms of the capitation system could enable us to make great strides in eliminating the remaining pockets of the disease. It is surely now realistic to imagine a time when child tooth decay has been all but wiped out. The pain and suffering it brought in its wake would be just a grim memory of the bad old days. Reforming capitation would bring us a step nearer this wonderful goal.