Community Dent Oral Epidemiol 2012; 40: 7079 All rights reserved

2011 John Wiley & Sons A/S

An analysis examining socio-economic variations in the provision of NHS general dental practitioner care under a fee for service contract among adolescents: Northern Ireland Longitudinal Study
Telford C, Murray L, Donaldson M, ONeill C. An analysis examining socioeconomic variations in the provision of NHS general dental practitioner care under a fee for service contract among adolescents: Northern Ireland Longitudinal Study. Community Dent Oral Epidemiol 2012; 40: 7079. 2011 John Wiley & Sons A S Abstract Objectives: To examine socio-economic variations in the use of publicly funded general dental practitioner care by adolescents under a fee for service arrangement. Method: Publicly funded general practitioner reimbursement data were linked to census and vital statistics data within the Northern Ireland Longitudinal Study. Data relate to 12 846 adolescents aged 11 or 12 in April 2003 included within the Northern Ireland Longitudinal Study (28% of the population). The main outcome measure was consumption of dental care between 2003 2004 and 2007 2008 by socio-economic status (as measured by National Statistics Socio-economic Classication of occupation and highest educational attainment of household reference person). Results: In multivariate analysis, socio-economic status was a signicant determinant of dental care consumed. Those of the lowest socio-economic status, according to both occupation and highest educational attainment of household reference person, were less likely to have consumed orthodontics OR 0.76 (0.62, 0.95) and OR 0.79 (0.69, 0.91), respectively. Those of lower socio-economic status were, however, more likely to have undergone an extraction and restorative treatment and also consumed on average more treatment than those of higher socio-economic status. Conclusion: A demand-led service, in which practitioners are reimbursed in part on a fee for service basis, may create incentives that contribute to different patterns of utilization between social groups. Such a system may not be providing equal access for equal need and may widen existing socioeconomic disparities in oral health among adolescents.

Claire Telford1, Liam Murray2, Michael Donaldson3 and Ciaran ONeill4

Peninsula School of Medicine and Dentistry, University of Exeter, Salmon Pool lane, Exeter, 2Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queens University Belfast, Belfast, UK, 3Regional Health and Social Care Board, County Hall, Ballymena, UK, 4Cairns School of Business and Economics, National University of Ireland Galway, Galway, Ireland
1

Key words: dental services research; disparities; economics Claire Telford, Peninsula School of Medicine and Dentistry, University of Exeter, Salmon Pool lane, Exeter EX2 4SG, UK Tel: + 1 392 726 094 Fax: + 1 392 421 009 e-mail: claire.telford@pcmd.ac.uk Submitted 30 January 2011; accepted 16 September 2011

The NHS was founded on the principle of equal access for equal need, and ongoing commitment to this principle has been reected in the NHS White Paper, Equity and Excellence: Liberating the NHS.

However, within the NHS, an important difference between the provision of dental care and the provision of other types of health care is that dental care is free of charge only to certain groups
doi: 10.1111/j.1600-0528.2011.00649.x

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Socio-economic variations in NHS dental care provision

including, for example, children and adolescents <18 years of age. Disparities in treatment provision according to ability to pay among those not entitled to free dental care can be expected and have been observed. People from lower socio-economic groups attend dentists less frequently, have a smaller number of healthy teeth and a greater number of extractions and restorations than those from higher socio-economic groups (1). While, among those eligible for free dental care, equal access for equal need should be achievable, previous studies suggest that this is not achieved in practice. The 2003 UK Childrens Dental Health Survey identied greater orthodontic need among 15-year-olds of poorer socio-economic background compared with those of higher socio-economic background (2). Similarly, a cohort study among children frequently attending a dentist in England indicated a greater number of extractions were prescribed to poorer children for reasons other than pain or sepsis (3), again indicative of differential care when needs are controlled for. These studies highlight the potential deciency of the prevailing arrangements for dental health care provision, which rewarded treatment activity but did not provide incentives for prevention of dental disease, that might reduce socio-economic inequalities in dental health. The way in which UK dentists are reimbursed for the treatment of NHS patients has recently been subject to substantial change. Prior to 2006, most dentists in England and Wales were reimbursed substantially on a fee for service basis, under which dentists received payment for work performed and this is still the case in Northern Ireland and Scotland. At present, within England and Wales, general dental practitioners are paid an annual sum in return for an agreed number of courses of treatment (weighted by complexity), but proposals have been laid out for a new dental contract in England and Wales that will focus on prevention and quality rather than treatment (4). Northern Ireland dental services are under review, and a new dental contract is expected to be rolled out in 2013. Ideally, arrangements for a new dental health service should be informed by robust evidence on the impact of existing services on dental health and inequalities in health and health care provision. This study examined differences in dental treatment consumption among adolescents differentiated by the socio-economic status of their parents. We hypothesize that different patterns of utiliza-

tion will be evident that reect differences in the needs and preferences of users as well as the potential for income generation among providers. We assume a greater relative need among those in lower social groups for restorative care and would expect this to result in greater relative consumption of such care compared with those from more afuent backgrounds. We assume a superior knowledge of and ability to access orthodontic care among those from more afuent backgrounds, as well as a greater value for aesthetic appearance than among those from less advantaged backgrounds and would expect this to result in higher relative consumption of orthodontic treatment. No previous study has looked at such cumulative use across the adolescent years.

Methods
Data from the Northern Ireland Longitudinal Study (NILS) were linked to dental registration and reimbursement data for publicly funded care delivered by general dental practitioners in Northern Ireland. NILS links data from the census (demographics including socio-demographics) and vital statistics (births, deaths and marriages) on 28% of the population in Northern Ireland. To ensure a representative sample, NILS sample members are chosen upon having one of 104 predesignated birth dates. The NILS is described in greater detail elsewhere (5). Individuals in the NILS aged 11 or 12 in April 2003 were included in this study. Registration and utilization by this cohort from April 2003 to March 2008 were examined. Individuals for whom data were missing or who were not resident within Northern Ireland throughout the entire study period were excluded from the analysis. In accordance with arrangements under which access to data in NILS is permitted, all data were anonymized and only made available within a safe setting at the headquarters of the Northern Ireland Statistics and Research Agency (NISRA). Dental reimbursement included information on all care provided by general dental practitioners during the study period as well as monthly dental registration status with a general dental practitioner (whether or not the individual remained registered with a publicly funded dentist). NILS data extracted from the census related to the 2001 census. National Statistics Socio-economic Classication (NS-SEC) of occupation and highest educa-

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Telford et al.

tional attainment of household reference person (head of household) were used to measure the socio-economic status of the household in which the adolescent resided. Occupation of the principal household earner and parental education are frequently used to indicate socio-economic status (SES) of the children (6, 7) and occupation is thought to more accurately reect long-term SES than income at a single point in time (6). Other variables included the gender of the adolescent (male versus female), parental marital status and the number of siblings. These were used to provide a richer socio-demographic characterization of the adolescent and the context in which they resided that might impact on service use than would otherwise be possible. For example, higher rates of caries have been found in females and among children from single-parent or reconstituted households that may indicate different oral needs among these groups and a need to control for these (8, 9). While there is a paucity of research on the relationship between family size and oral health needs, oral health behaviours such as tooth brushing have been found to have a negative association with family size that may again give rise to differences in oral health needs among adolescents from larger families that need to be controlled for (10). Dental care was specied both as a continuous variable (using cumulative reimbursement of care provided on a fee for service basis over the study period relating to the individual) and a dichotomous variable (whether care was received or not). Total care consumed and the following sub-categories of care consumed were examined: orthodontics, extractions, restorative (including separate analyses of llings and endodontics) and other types of care. Other types of care involved treatments not commonly delivered to adolescents such as periodontal treatment and prostheses. Preventive care (which would include at this time such items as ssure sealants) was also included in other types of care as minimal provisions are made for this within publicly funded care. Consumption of publicly funded general dental practitioner care is predicated on registration with a publicly funded dentist, and over time such registration can lapse and be renewed. Variations in registration will likely reect differences in exposure to dental care as well as potentially differences in the type of care sought. Those with more sporadic patterns of registration may, for example, use dentists in response to particular care

needs as they arise rather than in a more sustained and planned manner. Dental registration was examined using two specications: a count of the number of months registered during the study period and a count of the breaks in registration during the study period. This therefore allowed for investigation of inequalities in receipt of care after controlling for dental registration patterns. Within the UK, orthodontic treatment is often accompanied by extractions. Within multivariate analyses, orthodontic treatment, as a binary variable, was controlled for, so that disparities in extractions for reasons other than orthodontics could be investigated.

Statistical methods
Data analyses were performed using statistical software (Microsoft Excel and stata 11.0; StataCorp, College Station, TX, USA). Multivariate logistic regression was used to examine differences in care when these were specied as binary variables. Ordinary least squares multivariate regression was used to examine differences in cumulative expenditure in total and in separate analyses of categories of care. In multivariate analyses, all demographics (as discussed earlier) were specied as covariates, within which dummy variables were created to allow comparison to the reference category. In ordinary least squares regression, it was necessary to test for heteroscedasticity using Whites test, and in those regressions where it was signicant, they were re-run to report on robust standard errors. While expenditure data often does not follow a normal distribution, under the central limit theorem, with large samples it is appropriate to deploy parametric tests (11). For completeness, regressions were run on log transformations of the data, and this made no difference to the outcomes reported here. Kakwani concentration indices were used to estimate the degree to which pro-poor or pro-rich patterns of utilization were present in the data. These are based on a comparison of the cumulative distribution of expenditure by socio-economic group relative to its representation in the population. A similar approach has been used by others to quantify the degree of socio-economic inequality in health (12) and health care utilization (13). A requirement of concentration indices is that it must be possible to rank from lowest social status to highest, and this was achieved using a modied version of the NS-SEC scale in which intermediate and self-employed categories were combined as

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Socio-economic variations in NHS dental care provision

were semi-routine and routine, which has been documented to involve a hierarchy (14). Multivariate regression analyses were run for total cumulative expenditures, adjusting for demographics described previously. These were then used together with data on sample proportions of socioeconomic groups to estimate concentration indices in Excel. Each concentration index described how care expenditures were distributed across social classes on a scale ranging from )1 (indicating total concentration among the lowest social class) to +1 (indicating total concentration among the highest social class). An index value of zero indicates perfect equality.

Ethical considerations
Northern Ireland Statistics and Research Agency obtained ethical approval for the creation of the NILS on 3 October 2007. For the purposes of this study, it was necessary to submit a notice of substantial amendment to the Ofce for Research Ethics Committees Northern Ireland (ORECNI) to allow the merging of NILS and dental data. This project obtained clearance from ORECNI on 17 December 2008.

Results
From the NILS sample of 15 276 adolescents, 1108 had missing data (no census form had been lled in) and were removed from the analysis. Adolescents who did not remain in Northern Ireland throughout the study period were also removed (604). A further 700 adolescents were then removed as they did not register with a dentist or make use of general dental practitioner services at all during this time leaving a nal sample size of 12 864. Across the study period, 67% of total expenditure related to orthodontic treatments. Of the remaining expenditure, 22% related to restorative treatments (19% on llings, 2% on endodontics and 1% on other restorative treatment), 8% to other care and 3% was to extractions. Table 1 shows the results of logistic regression for each of the categories of care according to socioeconomic status as measured by NS-SEC of occupation and highest educational attainment of household reference person. Analysis of orthodontic treatments revealed, as hypothesized, those at the bottom of the social scale, according to both household reference person occupation and educational attainment, were less likely than those at

the top of the social scale to have received treatment. A partial social gradient emerged with respect to extractions, as social status decreased, likelihood of extractions increased, and this was seen according to both household occupation and education. Those with lower socio-economic status according to household reference person education were more likely to have received restorative treatment and llings, a component of restorative treatment, and this was as expected in our hypothesis. The analysis also showed that those of lower socio-economic status according to both household occupation and education were more likely to have received endodontic treatment. Use of care according to gender, parents marital status and siblings is also shown but are not the focus of this paper and in the interests of brevity are not discussed further. Table 2 shows the results of OLS regression analyses of cumulative expenditure for each category of care according to socio-economic status. For each reference category, average cost along with robust standard error is presented. For all other categories within each variable, average cost, robust standard error and difference in means when compared with the reference category along with 95% condence intervals and P values are presented. In respect of total expenditure, it reveals that, relative to those who were classed as professional, those who never worked were long-term unemployed had signicantly less cumulative total expenditure, everything else being equal. Similarly, it reveals that relative to those whose highest educational qualication was degree or above, those with no qualications had signicantly less cumulative total expenditure. In respect of individual categories of care, adolescents whose household reference person had never worked had signicantly lower cumulative expenditure on orthodontics relative to those whose household reference person was a professional. Similarly, relative to those whose household reference person had a degree or above, adolescents whose household reference person had no qualications or GCSEs only, had signicantly lower cumulative expenditure on orthodontics. Those adolescents with a household reference person who had never worked was long-term unemployed or an occupation classied as semiroutine had higher average expenditures on extractions compared with professional occupations. These differences were also evident in respect of educational attainment; those adolescents with a household reference person qualied to GCSE level

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Telford et al.

74
Extractions (95% CI) 1.00 (0.89, (0.89, (0.89, (0.84, (0.62, 1.21) 1.16) 1.13) 1.11) 0.95) P = 0.64 P = 0.81 P = 0.98 P = 0.61 P = 0.01 1.16 1.14 1.14 1.17 1.34 (0.99, (1.00, (1.01, (1.02, (1.11, 1.36) 1.30) 1.28) 1.34) 1.62) 1.01 1.05 1.12 1.12 1.13 (0.84, (0.91, (0.98, (0.96, (0.90, 1.20) 1.23) 1.29) 1.32) 1.42) = = = = = 0.95 0.50 0.10 0.16 0.30 1.01 1.06 1.12 1.14 1.12 (0.85, (0.91, (0.98, (0.97, (0.89, 1.21) 1.24) 1.29) 1.34) 1.40) = = = = = 0.89 0.42 0.10 0.11 0.34 P = 0.07 P = 0.05 P = 0.04 P = 0.03 P < 0.001 P P P P P P P P P P 1.23 1.13 1.16 1.48 1.44 1.00 1.00 1.00 (0.95, (0.92, (0.96, (1.20, (1.10, 1.58) 1.40) 1.42) 1.82) 1.88) Restorative (95% CI) Fillings (95% CI) 1.00 1.00 1.00 1.00 1.20 (0.99, 1.44) P = 0.06 1.26 (1.11, 1.43) P < 0.001 1.29 (1.12, 1.48) P < 0.001 1.00 1.06 (0.98, 1.14) P = 0.15 1.00 1.25 (1.01, 1.55) P = 0.04 1.17 (1.06, 1.30) P = 0.002 1.00 (0.87, (0.84, (0.75, (0.45, 1.18) 1.15) 1.05) 0.95) P = 0.89 P = 0.84 P = 0.15 P = 0.03 0.92 0.96 0.93 1.25 (0.79, (0.83, (0.79, (0.93, 1.07) 1.12) 1.09) 1.68) P P P P = = = = 0.26 0.64 0.37 0.14 1.00 0.97 (0.89, 1.06) P = 0.46 1.00 1.07 (0.84, 1.38) P = 0.58 1.35 (1.19, 1.53) P < 0.001 1.00 1.07 1.27 1.30 1.53 (0.90, (1.07, (1.09, (1.04, 1.27) 1.51) 1.57) 2.26) P = 0.48 P = 0.006 P = 0.004 P = 0.03 1.13 (0.93, 1.38) P = 0.21 1.53 (1.34, 1.76) P < 0.001 1.76 (1.52, 2.05) P < 0.001 1.11 (0.91, 1.35) P = 0.30 1.53 (1.33, 1.75) P < 0.001 1.75 (1.50, 2.03) P < 0.001 1.00 0.97 (0.89, 1.05) P = 0.44 1.00 1.08 (0.84, 1.38) P = 0.56 1.34 (1.18, 1.52) P < 0.001 1.00 1.06 1.27 1.30 1.48 (0.89, (1.07, (1.08, (1.01, 1.25) 1.51) 1.56) 2.17) P = 0.51 P = 0.007 P = 0.005 P = 0.05 1.00 1.00 1.00 0.93 1.22 1.23 1.68 (0.74, (0.96, (0.96, (1.14, 1.18) 1.54) 1.57) 2.48)

Table 1. Logistic regression for dental care as provided by a General Dental Practitioner for 12 846 adolescents in the Northern Ireland Longitudinal Study Endodontics (95% CI)

No. (%)

Orthodontic (95% CI)

1.00

1.03 1.02 1.00 0.96 0.76

P = 0.11 P = 0.25 P = 0.13 P < 0.001 P = 0.009

1.00

1.00 (0.83, 1.19) P = 0.97

1.06 (0.77, 1.47) P = 0.71 1.25 (1.01, 1.56) P = 0.04 1.42 (1.13, 1.79) P = 0.003

0.91 (0.80, 1.02) P = 0.10 0.79 (0.69, 0.91) P < 0.001

1.00

1.47 (1.36, 1.59) P < 0.001

0.92 (0.82, 1.04) P = 0.178

1.00

0.81 (0.64, 1.02) P = 0.07 0.80 (0.72, 0.89) P < 0.001

1.37 (1.01, 1.87) P = 0.04 1.28 (1.10, 1.49) P < 0.001

1.00

Socio-economic classication 3826 (29.8) Professional (reference category) Intermediate 1027 (8.0) Self-employed 2069 (16.1) Semi-routine 3048 (23.7) Routine 2079 (16.2) 797 (6.2) Never worked long-term unemployed Education 2241 (17.4) Degree and above (reference category) Two or more 769 (6.0) a-levels GCSEs 4859 (37.8) No 4977 (38.7) qualications Gender Male (reference 6584 (51.3) category) Female 6262 (48.7) Parents marital status 9602 (74.7) Married (reference category) Co-habiting 414 (3.2) Lone parent 2830 (22.0) No. of siblings 0 (reference 1041 (8.1) category) 1 4365 (34.0) 2 4298 (33.5) 3 2880 (22.4) 4 262 (2.0)

1.01 0.98 0.89 0.65

P = 0.57 P = 0.10 P = 0.10 P = 0.009

Bold indicates signicance (5% or less).

Table 2. OLS regression for dental care as provided by a General Dental Practitioner for 12 846 adolescents in the Northern Ireland Longitudinal Study mean cost and difference in means Orthodonticb 0.05 Mean cost (SE) 241.71 (18.40) 232.31 )9.40 ()35.81, 6.42 0.97 ()0.18, 50.59 (13.47) 17.01) P = 0.49 (0.59) 2.11) P = 0.10 (3.52) 226.96 )14.75 ()36.83, 5.90 0.45 ()0.46, 51.51 (11.27) 7.34) P = 0.19 (0.47) 1.37) P = 0.33 (2.72) 226.09 )15.62 ()35.58, 6.41 0.96 (0.08, 56.09 (10.19) 4.35) P = 0.13 (0.45) 1.83) P = 0.03 (2.51) 44.86 (2.55) 47.01 (2.11) 49.27 (1.86) 5.45 (0.81) 48.48 (4.38) 44.61 (3.43) Difference in mean (95% CI) Mean cost (SE) Difference in mean (95% CI) Mean cost (SE) Difference in mean (95% CI) Mean cost (SE) Difference in mean (95% CI) Mean cost (SE) 1.69 (1.26) 3.12 (0.91) 2.28 (0.76) 2.48 (0.69) 4.06 (0.79) 2.78 (1.10) 44.61 (3.43) 1.69 (1.26) 1.43 ()0.35, 3.22) P = 0.11 0.59 ()0.77, 1.94) P = 0.40 0.79 ()0.46, 2.04) P = 0.21 2.37 (0.80, 3.94) P = 0.003 1.09 ()1.09, 3.26) P = 0.33 0.12 0.04 0.05 0.01 Difference in mean (95% CI) Extractionsb Restorativeb,c Fillingsb Endodonticsb

Total carea,b

R2

0.06

Mean cost (SE)

Difference in mean (95% CI)

Socio-economic classication 321.79 Professional (19.32) (reference category) Intermediate 315.55 )6.24 ()34.09, (14.21) 21.60) P = 0.66 Self-employed 311.92 )9.87 ()33.19, (11.90) 13.45) P = 0.41 Semi-routine 316.59 )5.20 ()26.25, (10.74) 15.86) P = 0.63

Routine 182.65 )59.06 ()85.51, (13.49) )32.61) P < 0.001 241.71 (18.40) 5.45 (0.81)

321.23 (12.10)

)0.56 ()24.27, 228.47 )13.24 ()35.74, 23.16) P = 0.96 (11.48) 9.25) P = 0.25

277.07 )44.72 ()73.18, (14.52) )16.26) P = 0.002

2.11 ()4.79, 9.03) P = 0.55 3.03 ()2.31, 8.37) P = 0.27 7.61 (2.68, 12.53) P = 0.002 5.99 0.54 ()0.43, 58.17 9.69 (3.99, (0.50) 1.52) P = 0.28 (2.91) 15.39) P < 0.001 7.39 60.98 12.50 (3.66, 1.94 (0.72) (0.52, 3.36) (4.51) 21.35) P = 0.006 P = 0.007 48.48 (4.38)

0.25 ()4.75, 5.26) P = 0.92 2.40 ()1.74, 6.53) P = 0.26 4.66 (1.01, 8.30) P = 0.01 52.16 7.55 (3.27, (2.19) 11.84) P < 0.001 54.87 10.26 (3.17) (4.05, 16.47) P < 0.001

Never worked long-term unemployed Education Degree and above (reference category) Two or more a-levels GCSEs

321.79 (19.32)

No qualications 241.71 (18.40)

308.80 )12.99 ()46.28, 225.34 )16.37 ()48.13, 6.08 0.63 ()0.69, 50.83 2.35 ()4.20, 47.63 3.02 ()2.33, 1.25 )0.44 ()2.05, (16.99) 20.31) P = 0.45 (16.20) 15.39) P = 0.31 (0.67) 1.95) P = 0.35 (3.34) 8.91) P = 0.48 (2.73) 8.36) P = 0.27 (1.06) 1.17) P = 0.59 2.63 0.94 ()0.28, 57.31 12.70 62.81 14.33 (9.67, 312.61 )9.18 ()31.88, 214.30 )27.41 ()49.11, 6.73 1.28 (0.72) 2.15) P = 0.13 (1.84) (9.10, 16.31) (2.38) 18.99) (11.58) 13.52) P = 0.43 (11.07) )5.70) P = 0.01 (0.45) (0.41, 2.16) P < 0.001 P < 0.001 P = 0.004 68.87 20.39 (15.15, 1.42 (0.45, 298.18 )23.61 ()48.05, 196.02 )45.69 ()69.07, 6.87 3.52 1.83 61.74 17.13 (2.67) 25.63) (0.49) 2.39) (12.47) 0.83) P = 0.06 (11.93) )22.30) (0.78) (0.45, 3.21) (2.05) (13.12, 21.14) P < 0.001 P = 0.004 P < 0.001 P = 0.009 P < 0.001 5.45 (0.81) 48.48 (4.38) 44.61 (3.43) 1.69 (1.26)

Socio-economic variations in NHS dental care provision

Gender Male (reference 321.79 category) (19.32)

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Telford et al.

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Orthodonticb 0.05 Mean cost (SE) 302.48 (6.35) 5.45 (0.81) 7.04 (0.84) 6.25 (0.39) 48.48 (4.38) 44.61 (3.43) 60.77 (48.33, 73.21) P < 0.001 6.07 (0.28) 0.62 (0.06, 1.17) P = 0.03 46.21 )2.27 ()5.53, 43.45 )1.16 ()3.56, (1.66) 0.99) P = 0.17 (1.23) 1.24) P = 0.34 Difference in mean (95% CI) Mean cost (SE) Difference in mean (95% CI) Mean cost (SE) Difference in mean (95% CI) Mean cost (SE) Difference in mean (95% CI) 0.12 0.04 0.05 0.01 Mean cost (SE) Difference in mean (95% CI) 1.55 )0.14 ()1.00, (0.44) 0.72) P = 0.76 1.69 (1.26) 3.86 ()2.69, 1.62 )0.07 ()2.07, 10.41) P = 0.25 (1.26) 1.93) P = 0.94 3.92 2.23 8.03 (0.60) (0.88, 3.57) (4.75, 11.31) P < 0.001 P < 0.001 1.69 (1.26) 1.75 (0.87) 3.12 (0.88) 3.56 (0.93) 6.88 (1.76) Extractionsb Restorativeb,c Fillingsb Endodonticsb 1.59 ()0.07, 50.11 1.63 ()6.24, 48.47 3.24) P = 0.06 (4.01) 9.49) P = 0.69 (3.34) 0.80 (0.04, 52.64 60.67 12.19 (1.67) 1.56) P = 0.04 (2.43) (7.43, 16.96) P < 0.001 44.61 (3.43) 46.12 (2.37) 51.96 (2.40) 0.06 ()1.52, 1.63) P = 0.94 1.43 ()0.19, 3.05) P = 0.08 5.45 48.48 (0.81) (4.38) 5.05 )0.40 ()1.53, 50.85 2.37 ()3.73, (0.58) 0.73) P = 0.49 (3.11) 8.48) P = 0.45 5.06 )0.39 ()1.53, 58.75 10.27 (0.58) 0.75) P = 0.50 (3.16) (4.08, 16.45) P < 0.001 5.15 )0.30 ()1.52, 62.91 14.43 (0.62) 0.92) P = 0.63 (3.39) (7.79, 21.08) P < 0.001 5.78 0.33 ()1.76, 81.15 32.67 (1.06) 2.42) P = 0.76 (9.69) (13.69, 51.66) P < 0.001 1.51 ()3.13, 6.15) P = 0.53 7.35 (2.66, 12.05) P = 0.002 56.66 12.05 (2.60) (6.95, 17.16) P < 0.001 60.50 15.89 (5.16) (5.77, 26.01) P = 0.002 1.87 (0.12, 3.63) P = 0.04 5.19 (0.51, 9.87) P = 0.03

Table 2. (Continued).

Total carea,b

R2

0.06

Mean cost (SE)

Difference in mean (95% CI)

Female

385.50 (6.72)

63.71 (50.54, 76.88) P < 0.001

Parents marital status 321.79 Married 241.71 (19.32) (reference (18.40) category) Co-habiting 287.14 )34.65 ()68.41, 204.86 )36.85 ()68.73, (17.22) )0.89 P = 0.04 (16.27) )4.97) P = 0.02 Lone parent 306.72 )15.07 ()32.06, 212.96 )28.75 ()44.66, (8.67) 1.92) P = 0.08 (8.11) )12.85) P < 0.001 No. of siblings 0 (reference 321.79 241.71 category) (19.32) (18.40) 1 232.66 1.87 ()23.77, 242.88 1.17 ()23.31, (13.08) 27.51) P = 0.89 (12.49) 25.66) P = 0.93 2 327.93 6.14 ()19.62, 239.01 )2.70 ()27.34, (13.14) 31.89) P = 0.64 (12.57) 21.95) P = 0.83

315.73 (13.74)

)6.06 ()33.00, 223.20 )18.51 ()44.22, 20.87) P = 0.66 (13.11) 7.19) P = 0.16

306.88 )14.91 ()57.89, 193.93 )47.78 ()85.47, (21.93) 28.07) P = 0.50 (19.22) )10.10) P = 0.01

Total care does not sum to orthodontics, extractions and restorative because there exists another category, other. Condence intervals based on robust standard errors corrected for heteroscedasticity. c Restorative does not sum to llings and endodontics as within restorative, a few miscellaneous treatments exist. Bold indicates signicance(5% or less).

Socio-economic variations in NHS dental care provision

or with no qualications had higher average expenditures on extractions compared with adolescents whose household reference person had a degree or above. Analysis of restorative treatment and llings echoed this relationship; those in the lower socio-economic categories according to both household occupation and education had higher cumulative expenditures on restorative care. Differences in relation to endodontic treatment were the most stark. Those from routine backgrounds had more than twice the average expenditure on endodontics than those from professional backgrounds. This was similarly the case with respect to educational attainment; those with a household reference person with no qualications had more than twice the average expenditure on endodontics than did those with a household reference person with degree and above. Figure 1 shows the concentration indices for each of the care categories after adjusting for other variables (as discussed in the Methods section). Socio-economic status is measured by NS-SEC of occupation of the household reference person. Indices greater than zero indicate greater concentration of this type of dental care in the higher social classes while indices falling below zero indicate greater concentration in the lower social

classes. Orthodontic treatment was more concentrated in higher socio-economic groups. Extractions and restorative treatment (including individual components llings and endodontics) were more concentrated within lower social classes. While the concentration of total expenditure was signicant, the gure was very close to zero, demonstrating expenditure was only slightly more concentrated among higher socio-economic groups. The total expenditure gure is heavily inuenced by expenditure on orthodontics as within this study 67% of all expenditure on dental care was on orthodontics.

Discussion
The purpose of this study was to examine socioeconomic variations in the use of publicly funded general dental practitioner care by adolescents under a fee for service arrangement using longitudinal data. Within this study, a majority of all expenditure on dental care (67%) was on orthodontic treatment. This likely reects the fact that most orthodontic work is carried out during the years of early adolescence with children likely to commence treatment at 11 12 years old (15.). The study highlights signicant differences in the provision of dental care by socio-economic grouping. After adjusting for other factors, total dental care was more concentrated among those in higher socio-economic groups. However, the aggregate picture concealed important differences in respect of particular elements of care. The provision of orthodontic treatments was highly concentrated among those from higher socioeconomic groups while all restorative treatments and extractions, after adjusting for all other factors, were more concentrated among lower socioeconomic groups. Figures presented adjust for differences in registration. Within this study, lower social classes had lower levels of registration (results not reported) therefore, unadjusted gures would likely show larger differences in care provision, demonstrating a greater level of clinical as well as statistical signicance to those presented. Whether this pattern of service best serves the needs of the population of Northern Ireland is a matter of debate and warrants further investigation. Data on need, as assessed by a dentist, were not available in our study. Differences in the patterns of use observed may therefore be explicable in terms of differences in need and or the priority

0.05 0 Concentration index 0.05 0.1 0.15 0.2

Orthodontics Extractions All restorative

Orthodo ntics Total expendit ure Concentration Index 0.02 P<0.001 0 Lower 95% CI Upper 95% CI 0.03 0.01 -0.01 -0.03 0.01 0.00 -0.06 -0.04 0.00 P=0.02 -0.03 P<0.001 -0.03

Total expenditure Fillings Endodontics

All restorative Endodontics

Extractions Fillings

-0.04 P<0.001

-0.12 P<0.001

P=0.001

-0.05

-0.22

-0.03

-0.03

Fig. 1. Concentration indices according to SES (as measured by household reference person NS-SEC) for dental care adjusted for other factors (12 846 adolescents in Northern Ireland Longitudinal Study).

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Telford et al.

attached to different types of need by the individual consuming care. In respect of orthodontic treatment, it is worth noting that while the 2003 UK Childrens Dental Health Survey identied similar percentages of 15-year-olds across socioeconomic groups did not require treatment, a higher proportion of those requiring treatment from higher social classes had received it (2). Therefore, assuming equal orthodontic need across socio-economic groups in our sample would indicate differences in patterns of utilization are not needs related, and hence, the NHS may not be providing horizontal equity (16), equal access for equal need, with respect to orthodontic treatment. While orthodontic treatment has aesthetic benets, it also has clinical benets (17, 18). This suggests that differences in patterns of utilization should not be viewed simply as a matter of personal preference, especially if constrained budgets result in orthodontic care being rationed. Differences in caries related treatment need may well be evident between social groups given differences in, for example, sugar consumption and oral hygiene with those in lower socio-economic groups having greater risk exposure (19, 20). One might therefore legitimately expect greater consumption of such treatments among adolescents of lower socio-economic status, this is known as vertical equity (16) where different needs are met by providing different levels of treatment. In the absence of individual level data on needs, however, this conclusion must be treated as speculative. As orthodontic treatments have been shown to increase the risk of developing caries (21, 22), it could be argued that increased risk exposure to caries among those of lower socioeconomic status may make dentists more reluctant to prescribe orthodontic treatment to such groups. In the absence of evidence, however, this too is speculative. Although within Northern Ireland, the vast majority of publicly funded dental work among adolescents is carried out by general dental practitioners, a small amount of work is carried out by the Community Dental Service. The Community Dental Service exists to provide to those with special needs including those with social needs and those who have difculty accessing general dental services (23). Therefore, those of lower socioeconomic status are more likely than those of higher socio-economic status to have contact with the Community Dental Service. While no denite conclusions can be drawn about the use of these

additional services, as data are not readily available, it would seem unlikely that the patterns of care use evidenced here would alter signicantly were treatments from the Community Dental service to be included in the data.

Limitations of the study

This dataset does not contain information on need for dental care. Need for dental treatment would allow for a fuller characterization of demand and the exploration of, for example, the role of supplier induced demand in dental treatment provision. Also, although dental data used within this study were longitudinal, demographics socio-demographics used were cross sectional (taken from 2001 census) and may have been subject to change across the 2003 20042007 2008 study period.

Conclusions
A demand-led service in which practitioners are reimbursed in part on a fee for service basis may create incentives that accentuate patterns of utilization that reect preferences rather than the needs of users and that favour the more afuent. The concentration of orthodontic treatment among those in higher socio-economic groups together with the higher concentration of extractions and radical restorative treatment, such as endodontics, among those in lower socio-economic groups indicates very different patterns of utilization. While this pattern of utilization may reect users preferences, whether it best meets their needs or the priorities of society with respect to a publicly funded service is debatable. As health budgets come under increasing pressure whether the current demand-led system best serves users or society is an issue that warrants further consideration. Validated measures of orthodontic treatment need exist (24) and versions of these are used to determine access to treatment in, for example, the Republic of Ireland. In Northern Ireland debate is currently ongoing regarding the use of such measures as part of the basis upon which access to publicly funded care will be permitted. In a context of increasing pressure upon health care resources, linking access more explicitly to need in the interests of equity and transparency, as well as ensuring resources are used to best effect, does seem worthy of consideration given the evidence presented.

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Socio-economic variations in NHS dental care provision

Contributions
CT designed the study and data collection, wrote the statistical analysis plan, carried out the statistical analyses, wrote the rst draft of the paper and revised the manuscript. LM helped with the analysis and interpretation of the data and critically reviewed the manuscript. MD helped with the interpretation of the data and critically reviewed the manuscript. CON helped with the design of the study, collection of the data and critically reviewed the manuscript. All authors approved the nal version of the manuscript.

Funding
This work was carried out as part of a PhD funded by Queens University Belfast.

Competing interests
MD is head of Dental Services at the Regional Health and Social care Board. The help provided by the staff of the NILS and NILS Research Support Unit is acknowledged. The NILS is funded by the Health and Social Care Research and Development Division of the Public Health Agency (HSC R&D Division) and NISRA. The NILS-RSU is funded by the ESRC and the Northern Ireland Government. The authors alone are responsible for the interpretation of the data.

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