Student ID: 7301871

In 2008 the NHS had a total expenditure of about 102bn, which equates to 7.2% of GDP [1]. However figures for 2010 estimated that total expenditure rose to around 120bn [2]. Government spending must be distributed appropriately and GDP must increase, to maintain this high standard of living that we enjoy in the UK. If the increase in expenditure is in line with an increase in GDP this does not create too many problems. However when one service (such as health, education, state pensions etc.) demands a higher percentage of GDP, the opportunity cost must be calculated. An increase in pay out of state pensions, for example, may mean fewer textbooks are purchased for schools. When it comes to the health service, patients would not expect a substandard level of medical care. Therefore the NHS must juggle its budget to ensure that the opportunity cost of harming patients is not incurred.One of the most obvious points to make is that as the population of the UK rises so does the overall costs of the NHS. The estimated resident population of the UK was 61,792,000 in mid-2009, up by 394,000 on the previous year [3]. This increase in population is going to have an increase in pressure on the NHS. The health service must now provide health care for almost 400,000 more patients without compromising the standard of care. Therefore NHS resources must be increased.The table below shows the projected population for the UK: [4]

The UK population is projected to increase by 4.3 million by 2018. As this trend progresses it will put an increasing amount of pressure on the NHS. To keep expenditure under control cost per head of the NHS must be reduced without harming patients.In the period from 2007-2008 the cost per head on average was 1,626. It had risen for the previous 10 years and is still estimated to rise. [1] This could be coupled with the fact that as population increases, the UK faces an aging population.Over the last 25 years the percentage of the population aged 65 and over increased from 15 per cent in 1984 to 16 per cent in 2009, an increase of 1.7 million people. Over the same period, the percentage of the population aged under 16 decreased from 21 per cent to 19 per cent.[5] This change in ageing population puts a strain on NHS expenditure, as more pensioners are requiring expensive treatment and fewer children are requiring cheaper treatments. On average it is estimated that 1,416 per head is spent on the age group 65-74, compared with the age group 5-15 which is 210 per head. [6]This situation can only get worse for government expenditure if the trends continue. In 1984, there were around 660,000 people in the UK aged 85 and over. Since then the numbers have more than doubled reaching 1.4 million in 2009. By 2034 the number of people aged 85 and over is projected to be 2.5 times larger than in 2009, reaching 3.5 million and accounting for 5 per cent of the total population. [5] With age 85+, the NHS costs per head are estimated at 4077 [6], which is significantly more than any other age group. The UKs GDP would not be able to cope with this burden, as the majority of aged 85+ collect state pensions and run high costs with the NHS. This would put much more pressure on the taxpayer so that GDP can increase as the demand for the NHS increases. Therefore many savings need to be made in the Health service to avoid problems like this.The rise in NHS spending is not only from a rise in ageing population. A rise in alcoholism already costs the NHS more than 2.7bn a year. Experts believe that changing the way these services are delivered could save hospitals 1,000 bed days and PCTs up to 650,000 a year [7].

Smoking and obesity have also affected the budget in the same way. Around one in six NHS trusts have seen spending on obesity rise more than seven-fold in just three years [8]. These alarming statistics suggest that the NHS must rethink its distribution of expenditure if it is to cope with rising pressures and still preserve a high quality service.The government has stated In the five years from 2011, the predicted lower increases in budgets and the impact of the recession coupled with rising costs mean it is likely the NHS will face a real terms shortfall of 15bn. [9]. 20bn must be saved for this to be avoided.In order to tackle this, Health Secretary Andrew Lansley proposed a reform, which involves passing control of the bulk of the NHSs 105bn budget for England to consortia of GPs [10]. Andrew Lansley has the power to set government policies for the NHS as he represents the Department of health. Therefore he can influence change within the NHS.

Andrew Lansley has been heavy criticized about the reform both from medical journals and doctors alike. The worry is that such a radical change within the NHS at this delicate time could have negative implications for the NHS. It is estimated that the cost of implementing the changes is 1.4bn and at a loss of 24,000 jobs [11].However Andrew Lansley insists that Modernising the NHS is a necessity, not an option - in order to meet rising need in the future we need to make changes.[11] He also goes on to say that it will save the NHS more than 5bn by 2014/15 and 1.7bn every year thereafter.[11]This shows that in order for Andrew Lansley to influence the NHS he must win over his critics, as he needs the cooperation of people associated with NHS to execute his proposals.The Patients Association is an independent charity in a position to influence change. The Patients Associations aim is to reduce health inequalities by helping patients to be better informed and they can achieve this by involving patients in decision making.The Patients Association is able to communicate with all parties that are involved with Health care. We work with the people that affect care directly from the NHS itself to the companies that produce the medical devices it uses, as well as the pharmaceutical industry, the medical insurance companies and private healthcare provider [12]

The Patients Association has voice worries about the reform as it feels that it is not in the patients best interests. Patients tell us that the time they spend with their GP is already too short and they do not want their GP focusing on balancing the books instead of treating them.[11]. Clearly if budget cuts are trying not to harm the patient, then the Patients Association must first be happy with the proposed ideas. This therefore gives them a lot of influences as to what ideas actually materialize, as the NHS is providing a service for the patients.I also believe the BDA to be in a position to influence change. As opposed to the Patients Association, the BDA work for the best interests of the Dentist. The BDA acts as a collective representation of the profession when dealing with the government [13]. Therefore the government must make sure that it considers the requests of the BDA. Failure to do so could result in an uproar from its 23,000 members [13]Dr. Susie Sanderson, Chair of the BDAs Executive Board, stated, The indication of new contractual arrangements and the centralization of commissioning give an opportunity to improve NHS dental service for patients and dentists."[14]. The overall message of the press release exhibited the BDAs support for the reform. Yet, like the Patients association, the BDA expressed apprehensions about the cuts to the frontline services.The general consensus across the NHS seems to be that the money that is required for the cost of implementing this new reform should not come at the cost of frontline jobs. Thus there is a need for different implementation of budget cuts.This year, 2.2bn will spent on dentistry [15]. As this budget comes directly from the NHS, the proposed cuts directly affect the dentistry budget too.In order for the reform to follow through, Andrew Lansley must propose an ideal reform, which all parties are happy with. However it is extremely difficult to suggest a perfect reform that meets the desires of all parties. Therefore he must correctly balance at a compromise that satisfies the most influential parties and gets them on board.Since the Patients Association showed their concerns against the reform does the recent Health Bill offer real change for patients and will it deliver on its promise of making the NHS truly patient-centric? We are not convinced.[11]. Clearly there is a need to address the reform. The Patients Association claims that the need of the patients are being neglected and that the policy appears to conflict with providing them the best treatment[11].One of their major concerns are the cuts to the frontline services. We are already hearing on our helpline that patients are experiencing the withdrawal of a range of service and treatments including asthma medication, physiotherapy, counseling services and hernia operations. Perhaps tackling this issue and would restore the Patients Associations faith in the Reform policies.One possible alternative within the dental budget is to suggest salary capping on wages. 60% of the NHS budget is used to pay wages [16]. By targeting this portion of the budget it will have the biggest impact on savings, as spending on wages is well over the majority of the budget gone.Many of the dentists in this country operate as part of independent businesses that hold contracts with the NHS. They receive an agreed amount of money in return for delivering an agreed number of weighted courses of treatment each year. [15]. Hence the dentist is in control of their wages with what they have agreed with their PCT.

This has been done previously in 1990. Expenditure and earnings were higher than expected and the fees paid to dentists were cut by 7% to bring expenditure back into line. [15] However this did not sit well with the dentistry profession as dentists felt they were unfairly penalized[15]. To avoid this, cut can be made equally across the NHS not just with doctors and nurses but also with administration staff and so on.By capping wages or even cutting wages this will reduce the expenditure of the NHS over future years. This will allow more frontline jobs to be saved consequently improving the quality of treatment that patients are receiving. If redundancies were made then there would be many departments that would become understaffed or patients may not be able to receive certain treatments that they previously could [11]. Therefore redundancies across the NHS could make treatment a lot more inefficient thus increasing expenditure.

Unemployment would have negative implications on the budget as fewer people are working and therefore paying taxes and more people would be claiming unemployment benefits. Consequently reducing the governments overall expenditure and therefore the NHS budget.Hence it is very important for jobs to be kept secure, which can be done with the introduction of salary caps to assure that cuts are made.

Another big area in which massive savings could be made is prevention. The two common dental diseases, dental decay and gum disease, are chronic and the damage they cause is cumulative and costly. [15]. These diseases have been prevalent for over 50 years with little consideration for preventative dentistry, merely treatment [15]. As they are cumulative and costly there is a need to address these diseases early to reduce costs. In fact, there is a need to prevent the diseases from even developing in the first place! Currently treatment is charged in a band system, where by the treatment the patient is receiving, is ranked due to the complexity of the procedure [17]. If a more preventative approach is taken to dentistry, patients are more likely to be receiving less extensive and therefore cheaper treatment. Hence instead of paying 204 for a crown, which is band 3, they may only need fillings or a scale and polish (band 2 and 1 treatments respectively) [18]. This is a definite advantage for patients as the dentist, for financial reasons, puts many off. I have not seen a dentist for more than two years. I cant afford it. [15]

Regular treatment of low band procedures would have a massive cost benefit for General Dental Practitioners (GDPs) and the NHS. Patients that require Band 2 or 3 treatments such as root canal treatment or crown incur a larger cost on the dentist and therefore the NHS. Hence GDPs must be encouraged to use preventative measures on patients. As the cost inflicted on the NHS for preventing the disease are far smaller than treating the disease once it has advanced. The use of relatively cheap Band 1 procedures such as applying sealants or fluoride preparations to the surfaces of teeth[17] should be encouraged by perhaps offering a higher weighting of UDAs to the GDP. This increase in prevention will reduce the pressure that costly procedures inflict on the NHS budget.A review of the NHS by Jimmy Steel [15] talked about how preventative measures should be taken with emphasis on the quality of treatment rather than quantity. The Quality, Innovation, Productivity and Prevention (QIPP) programme is all about ensuring that each pound spent is used to bring maximum benefit and quality of care to patients. [19]. Hence the patients best interests are put first as all treatment received will be at a high standard and much more efficient therefore costs will decline.

Not only is there a need for preventative treatment to increase but there is also a need for education about prevention for patients. This is an important part of prevention because regardless of how many preventative procedures a dentist does to a patient, they are pointless if the patient does not know to brush his or her teeth.Nevertheless it is important to look at how these methods can be implemented cost effectively. Some reports show that a cost-effective method for reliably promoting such behavior has not yet been established. [20]. The need to change patients habits for the long run must be put in place rather than these methods fizzing out over a short period.Hence promoting good oral hygiene from a young age is vital. Several schemes have already been put in place to do so. Delivering better oral health is an evidence-based toolkit for prevention [21]. Giving guidelines for the clinician as to what preventative measures to take. To add to this, schemes designed for educating children, such as the brushing for life scheme, aims to reduce the inequalities in childrens oral health and encourage the formation of an early tooth brushing habit [22]. This was achieved by promoting regular brushing of childrens teeth using fluoride toothpaste by handing out packs containing toothpaste, a toothbrush and a health educational leaflet are distributed to the parents of infants at their 8, 18 and 36 month development checks [22]. This method was proven to have a 100% success rate by 36 months. It is clear that a national level scheme must be put in place if prevention if going to be seriously endorsed.To summarize the need for budget cuts is essential however the execution of these budget cuts must be thought about extensively and all options must be exhausted.The government should work with several influential groups, such as the BDA, to come up with a collective reform that satisfies the needs of all parties affected.

Catering dentistry towards a QUIPP [23][19] programme, implementation will ensure that necessary budget cuts can be made without patients being harmed.References: [1] House of Commons Health Committee. 2010. Public Expenditure on Health and Social services 2009. Available at: http://www.parliament.the-stationery-office.co.uk/pa/cm200910/cmselect/cmhealth/269/269i.pdf. [Accessed 01 May 2011].

[2] Health Care Spending Chart for United Kingdom 1985-2015 - Central Government Local Authorities Available at: http://www.ukpublicspending.co.uk/uk_health_care_chart_10.html. [Accessed 01 May 2011].

[3] National Statistics Online. 2010. Population Estimates. [ONLINE] Available at: http://www.statistics.gov.uk/cci/nugget.asp?id=6. [Accessed 01 May 2011].

[4] National Statistics Online. 2009. National Projections. Available at: http://www.statistics.gov.uk/cci/nugget.asp?id=1352. [Accessed 01 May 2011].

[5] National Statistics Online. 2010. Ageing. Available at: http://www.statistics.gov.uk/cci/nugget.asp?id=949. [Accessed 02 May 2011].

[6] House of Commons Health Committee. 2006. Public Expenditure on Health and Social services 2006. Available at: http://www.parliament.the-stationery-office.co.uk/pa/cm200910/cmselect/cmhealth/269/269i.pdf. [Accessed 02 May 2011].

[7] BBC News. 2011. Rising alcohol addiction costs 'could cripple the NHS'. Available at: http://news.bbc.co.uk/1/hi/health/8433935.stm. [Accessed 02 May 2010].

[8] Jon Land - 24dash.com. 2009. NHS trusts count rising cost of obesity. Available at: http://www.24dash.com/news/health/2009-04-09-nhs-trusts-count-rising-cost-of-obesity-treatment. [Accessed 02 May 2011].

[9] Rebecca Smith, Medical Editor - Telegraph. 2009. NHS will face 15bn budget shortfall due to effects of recession managers Available at: http://www.telegraph.co.uk/health/healthnews/5485814/NHS-will-face-15bn-budget-shortfall-due-to-effects-of-recession-managers-warn.html. [Accessed 03 May 2011].

[10] Jeremy Laurance - The Independent. 2010. NHS cuts attacked by leading medical. Available at: http://www.independent.co.uk/life-style/health-and-families/health-news/nhs-cuts-attacked-by-leading-medical-journals-2028443.html. [Accessed 03 May 2011].

[11] Channel 4 News. 2011. NHS: 'patient-centred' reform means 24,500 job losses. Available at: http://www.channel4.com/news/nhs-patient-centred-shake-up-means-24-500-job-losses. [Accessed 03 May 2011].

[12] The Patients Association. 2011. About. Available at: http://www.patients-association.com/About-Us. [Accessed 03 May 2011]. [13] BDA (British Dental Association). 2011. Overview. Available at: http://www.bda.org/about-the-bda/overview.aspx. [Accessed 03 May 2011].[14] BDA (British Dental Association) - Press Releases. 2011. Engagement must fill in White Paper gaps says BDA Available at: http://www.bda.org/news-centre/press-releases/29173-engagement-must-fill-in-white-paper-gaps-says-bda.aspx. [Accessed 03 May 2011].

[15] Professor Jimmy Steele. 2009. NHS dental services in England - An independent review led by Professor Jimmy Steele. Available at: http://www.dh.gov.uk/dr_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_101180.pdf [Accessed 04 May 2011].

[16] NHS. 2009. About the NHS. Available at: http://www.nhs.uk/NHSEngland/thenhs/about/Pages/overview.aspx. [Accessed 04 May 2011].[17] NHS. 2011. What is included in each NHS dental band charge?. [ONLINE] Available at: http://www.nhs.uk/chq/Pages/nhs-dental-band-charges.aspx. [Accessed 04 May 2011].

[18] NHS. 2011. How much will I pay for NHS dental treatment?. Available at: http://www.nhs.uk/chq/pages/1781.aspx?categoryid=74&subcategoryid=742. [Accessed 04 May 2011].

[19] Department of Health - Health care. 2010. Quality and Productivity. Available at: http://www.dh.gov.uk/en/Healthcare/Qualityandproductivity/index.htm. [Accessed 05 May 2011].[20] Kay E, Locker D. A systematic review of the effectiveness of health promotion aimed at improving oral health. Community Dent Health 1998; 15:132-44.[21] Department of Health and the British Association for the Study of Community Dentistry. 2009. Delivering Better Oral Health An evidence-based toolkit for prevention - second edition. Available at: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_102331 [Accessed 05 May 2011].[22] Brushing for life, Available from: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_085673.pdf [Accessed 05 May 2011].[23] Lord Darzi. 2008. High Quality Care For All - NHS Next Stage Review Final Report. Available from: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_085828.pdf [Accessed 05 May 2011].