Does the English NHS Have a 'Health Benefit Basket'?

Does the English NHS Have a 'Health Benefit Basket'? Author(s): Anne Mason Source: The European Journal of Health Economics, Vol. 6, Supplement (Dec., 2005), pp. S18- S23 Published by: Springer Stable URL: http://www.jstor.org/stable/20069423 Accessed: 29/11/2009 14:51 Your use of the JSTOR archive indicates your acceptance of JSTOR's Terms and Conditions of Use, available at http://www.jstor.org/page/info/about/policies/terms.jsp. JSTOR's Terms and Conditions of Use provides, in part, that unless you have obtained prior permission, you may not download an entire issue of a journal or multiple copies of articles, and you may use content in the JSTOR archive only for your personal, non-commercial use. Please contact the publisher regarding any further use of this work. Publisher contact information may be obtained at http://www.jstor.org/action/showPublisher?publisherCode=springer. Each copy of any part of a JSTOR transmission must contain the same copyright notice that appears on the screen or printed page of such transmission. JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide range of content in a trusted digital archive. We use information technology and tools to increase productivity and facilitate new forms of scholarship. For more information about JSTOR, please contact support@jstor.org. Springer is collaborating with JSTOR to digitize, preserve and extend access to The European Journal of Health Economics. http://www.jstor.org
Eur J Health Econ 2005 [Suppl 1] 6:18-23 DO110.1007/sl 0198-005-0314-1 Published online: 5 November 2005 ? Springer Medizin Verlag 2005 Original Papers_ Anne Mason Centre for Health Economics, University of York, Heslington, York, UK Does the English NHS have a 'Health Benefit Basket7? I he English National Health Service (NHS) was established in 1948 to provide healthcare for all, free at the point of use and irrespective of ability to pay. Legis lation outlines the broad categories of healthcare service that should or could be provided within the NHS. However, the legal duties and powers of provision are not absolute, but tempered by powers of discretion as to what is a 'reasonable re quirement' and by the right to take into account NHS financial capacity. Strictly speaking, this means that patients have no entitlement to specific services; this part ly explains the existence of variation in lo cal provision known as the postcode lot tery' [1]. Furthermore, the courts have es tablished that NHS organisations may not operate a 'blanket ban on the provision of particular services [2]. Consequently the re are few services that are explicitly un available to all NHS patients. Within a health service with no specif ic entitlements but few explicit exclusions, internal quality control mechanisms are important to ensure that citizens' rights to health care, established under interna tional law, are honoured [3]. National stan dards, embodied in guidance from Nation al Service Frameworks (NSFs), the Nation al Institute for Health and Clinical Excel lence (NICE) and waiting time guarantees, are regulated by the Healthcare Commis sion, which monitors NHS organisations' compliance. The regulatory framework contributes to what may be considered as 'reasonable requirements' for health ca re provision and helps to specify entitle ment. Fixed charges or payments, whilst in no way guaranteeing provision, implic S18 I Eur J Health Econom Suppl 1-2005 itly brand services with an 'NHS' label and may therefore also serve to signal the ser vice is, or should, be in the health basket. Incentive payments for clinicians may be seen in a similar light. This paper describes the statutory and regulatory frameworks and discusses how these may impact upon patient enti tlement to NHS 'services of curative care', 'HO' of the International Classification for Health Accounts (ICHA) taxonomy [4]. An overview of the legal and regula tory framework defining benefits for Eng land is given in O Table 1. England's'Health Benefit Basket7: the case of services of curative ca re Services of curative care are defined as those where the principal medical intent of care is to relieve symptoms or reduce sever ity or protect against exacerbation or com plication of illness or injury. In addition to in-patient and day care, HCi includes but-patient care, defined as basic medical and diagnostic services, out-patient dental care and other specialist health care pro vided to outpatients by physicians or pa ramedics, including services provided at home [4]. The legal framework Primary legislation addresses the establish ment and promotion of'a comprehensive health service, requiring the Secretary of State for Health 'to provide or secure the ef fective provision of services'. However, dis cretion is at the heart of these duties and politicians are entitled to take into account the resources available to them. Under the 1977 National Health Ser vice Act (chap. 49), the Secretary of Sta te has a duty to provide 'to such extent as he considers necessary to meet all reason able requirements': (a) hospital accommo dation [s. 3 (i(a))], including high securi ty psychiatric services (s. 4); (b) other ac commodation necessary for the purpose of any other services required by the Act [s. 3 (i(b))]; (c) medical, dental and nurs ing services [s. 3 (i(c))] (N.B.: 'medical' in cludes 'surgical'); and (d) such other ser vices as are required for the treatment of illness [s. 3 (i(f))] (N.B.: 'illness' includes a mental disorder and any injury or dis ability requiring medical or dental treat ment or nursing). The Secretary of State for Health also has powers to provide 'as he considers appropriate facilities for the care of persons suffering from illness [s. 3 (i(e))]. The responsibility for providing these services has passed to local health authorities, which in the current organisa tional structure are known as Primary Ca re Trusts (PCTs). The 1977 NHS Act also places a duty on PCTs to provide general medical services (s. 29), general dental ser vices (s. 35), pharmaceutical services (s. 41) and general ophthalmic services (s. 38). In the law courts "R v NW Lancashire Health authority, ex p A, D and G" exam ined the case of three applicants suffering from gender identity dysphoria [2]. The Health Authority had identified this ill ness as amongst the bottom 10% in terms of need (together with cosmetic surgery, reversal of sterilisation, correction of myo pia and most 'alternative' medicines) and
Table 1 Documents defining the English Health Basket, 2005 Catalogue: type of document, actors and contents Type of document Legally Positive/nega- Degree of Updating binding tive definition explicitness* of benefits Criteria used for defining benefits N C E CE B Other Acts of Parliament Yes Irregular, amended by further legislation Political judgement 'necessary to meet all reasonable requirements' Statutory instruments Yes (SI) PorN 1-3 Irregular, amended by further legislation + Safety Directions Yes No National Service Frameworks No 2or3 Unclear NICE technology appraisals Yesb PorN Every 4 years + + + NICE clinical guidelines No 2or3 Every 4 to 6 years + + + NICE ?nterventional procedures No PorN Unclear Safety Contracts Yes 1-3 Infrequent-although small amendments more frequent + Waiting time guarantees0 No Irregular HRG tariffs No 2or3 Still evolving Devices tariff No Monthly + + Safety, quality, appropriateness Fee schedules No Annually (at least) N need, C costs, E effectiveness, CE cost-effectiveness, B budget (from [1,2,3], DH website (http://www.dh.gov.uk/home/fs/en), HMSO website (http://www.hmso.gov.uk/), expert advice (see Acknowledgements)) a "Explicit is subdivided as 1: all necessary"; 2: areas of care; 3: items. b The statutory duty is upon PCTs to ensure funding is available to facilitate implementation, not upon doctors to adopt the approved technology. c The dominant instrument for securing these are performance ratings prepared by the Healthcare Commission. therefore transsexual surgery would be provided only in cases of overriding clin ical need'. The court acknowledged the need for priority setting in which issues of effectiveness, the seriousness of the con dition and cost were taken into account. However, the court found that the Health Authority had in practice adopted a 'blan ket ban and recommended the authorities introduced a fair and consistent policy for decision making that adequately assessed exceptional cases by considering each re quest for treatment on its individual mer its. The case therefore made it illegal for health authorities to refuse to provide spe cific services, with the possible exception of a treatment where 'the clinical evidence of its inefficacy is overwhelming [2]. The case implies that costs and benefits should be evaluated on an individual patient ba sis, rather basing entitlement on the typi cal or average case. Primary legislation and case law have therefore not prescribed which services are to be included in or excluded from the English health basket. However, secondary legislation on professional contracts goes some way towards defining entitlement to specific services. For example, the 2004 National Health Service (General Medical Services Contracts) Regulations provide details of the terms of service for general practitioners (GPs) and state that essen tial services' must be provided, covering emergency treatment and treatment for patients with chronic, terminal and self limiting disease [National Health Service, General Medical Services Contracts, regu lation SI 2004/291, reg. 15 (3:5,6:8), 2004; see Q Table 2]. For dental practitioners the Nation al NHS (General Dental Services) Regu lations 1992 make provision for the Sec retary of State for Health to determine dentists' remuneration, including a 'sca le of fees' for providing particular ser vices [reg. 19 (1)]. Updated at least annu ally, the Statement of Dental Remunera tion describes over 400 services covered by the fees, including clinical examina tions and treatment planning, diagnostic procedures, such as radiographie examina tions, preventative, periodontal, conserva tion and surgical treatments and the sup Eur J Health Econom Suppl 1-2005 I Si 9
Abstract Eur J Health Econ 2005 [Suppl 1] 6:18-23 DOI 10.1007/S10198-005-0314-1 ? Springer Medizin Verlag 2005 Anne Mason Does the English NHS have a Health Benefit Basket? Abstract A'health benefit basket'is a range of pub licly entitled health-related goods and ser vices. Primary legislation ensures the provi sion of broad categories of healthcare, but this provision is subject to political discre tion. Case law has established that health care organisations may not operate a 'blan ket ban'for particular services. This means that the English health basket currently has very few specific services explicitly includ ed or excluded. Regulation may, however, be important in determining citizens'rights. With reference to'services of curative care', this paper explores whether the NHS is mov ing towards a more explicit definition of a health basket. Keywords Health Services National Health Programmes United Kingdom Health Benefit Plans Public Policy S20 I Eur J Health Econom Suppl 1-2005 ply of prostheses; patients pay 80% of the charge up to a stated maximum, although some exemptions apply (Department of Health, Statement of Dental Remunera tion, amendment no. 93, 2005). The Doc tors' and Dentists' Review Body reviews existing fee scales and makes recommen dations regarding uplift. The Department of Health then considers these recommen dations and the Chief Dental Officer for England notifies Strategic Health author ities, PCTs, NHS Trusts (groups of NHS hospitals, each operating as a single legal entity) and all general dental practitioners of the updated fee scales (ibid.). Similarly, the 1986 NHS (General Oph thalmic Services) Regulations make provi sion for opticians and ophthalmic medical practitioners to charge for sight tests and for optical appliances (National Health Service, General Ophthalmic Services, regulation SI 1986/975,1986). Charges are determined by the Secretary of State in consultation with professional bodies, updated at least annu ally and amended by secondary legislation. For certain patients vouchers are available that reduce or remove the charge incurred by patients. Eligibility for general ophthal mic services, outlined in section 13 of the Health and Medicines Act 1988, is deter mined by age, disease (or risk of disease) or income. Voucher values are updated at least annually by secondary legislation. Quasi-law In addition to legislation, NHS provision is shaped by a considerable amount of 'quasi-law'. Quasi-law is defined as 'ru les which are not usually legally binding, although they may have some legal force, but which will in practice determine the way in which people act' [3]. Amongst the regulation helping to define patient enti tlement to services are NSFs, NICE guid ance, waiting time guarantees, fee sched ules, and incentive schemes. The Health care Commission is the key regulator, as sessing the performance of NHS organisa tions against national standards in its 'an nual health check', a monitoring process that assesses both existing performance (core standards) and capacity to improve ('developmental'standards) [5]. The programme of NSFs, launched by I the Department of Health in April 1998, usually produces one new framework a year. NSFs set national standards, identify key interventions for a defined service or care group that should be available, estab lish strategies to support implementation and outline ways to ensure progress with in an agreed time scale [6]. Frameworks cover some services of curative care (O Ta ble 3). Each NSF is developed with the assistance of an external reference group (ERG), which seeks to engage a range of views from health professionals, service users and carers, health service managers, partner agencies and other advocates. However, the economic input into NSFs is sometimes weak. The Department of Health supports the ERGs and manages the overall process. It is unclear how NSFs are to be updated to reflect changes in the evidence base that underpins them. There is no statutory obligation on health care organisations to implement NSF standards. However, the Health And Social Care (Community Health And Stan dards) Act 2003 [Health and Social Care (Community Health and Standards) Act, Chap. 43, 2003) gave the Secretary of Sta te powers to publish standards for health care [s. 46 (1)] that NHS bodies are bound to take into account [s. 46 (4)]; NSFs could inform these standards. Furthermore, the Healthcare Commission reviews health care organisations' implementation of NS Fs as part of its annual health check [5], reinforcing the quasi-legislative nature of NSF guidance. NICE, the organisation responsible for assessing whether new or existing technologies should be available on the NHS, produces three types of guidance which help define the availability of NHS services of curative care. Firstly, technolo gy appraisals give guidance on the use of new and existing treatments within the NHS. Of the 91 technology appraisals pub lished to date (July 2005) some relate to in-patient care, such as Appraisal No. 11 (the use of implantable cardioverter de fibrillators for arrhythmias); to day ca re, such as Appraisal No. 48 (home com pared with hospital haemodialysis for pa tients with end-stage renal failure); and to out-patient care, such as Appraisal No. 24 (debriding agents for difficult to heal sur gical wounds). Secondly, NICE clinical guidelines offer guidance on the appropri
Table 2 Eligibility for primary care'essential services' under the 2004 General Medical Services Contract if rom II9]) Type of essential service Immediate and necessary emergency treatment Eligibility for treatment 'Any person to whom the contractor has been requested to provide treatment... at any place in its practice area' [reg.15 (6)] Management of terminal illness Registered patients and temporary residents Treatment of conditions from which recovery is generally expected Registered patients and temporary residents Treatment of chronic disease Registered patients and temporary residents Advice in connection with the patient's health, including relevant health promotion advice Registered patients and temporary residents Referral of the patient for other services under the 1977 Act Registered patients and temporary residents Home visits Where contractor considers it inappropriate, because of a patient's medical condition, for the patient to attend the practice premises Annual health checks Patients aged over 75 years Patients not seen within 3 years; newly registered patients Table 3 Services of curative care covered by selected National Service Frameworks; ICHA category HC.1 : services of curative Category Children Services Standard 7: Guidance on hospital-based services for children Standard 3: Guidance on community-based care Coronary heart disease Standard 7: NHS Trusts to provide appropriate investigations and treatments for patients with suspected or confirmed coronary heart disease Diabetes Standard 7: NHS to provide rapid and effective treatment for diabetic emergencies Mental health In-patient hospital beds for persons needing a short period of intensive intervention and observation Elderly Standard 4: Need for appropriate specialist care Standard 7: Effective diagnosis, treatment and support for those with mental health problems Renal disease Quality requirement 2: Timely, appropriate and effective investigation, treatment and follow-up for those with chronic kidney disease Standard 5: All likely to benefit from a kidney transplant to receive a high quality service which supports them in managing their transplant (from: DH website, hnp://www.dh.gov.uk/PolicyAnd6uidance/HealthAndSocialCareTopics/HealthAndSod ID=4070951&chk=W3ar/W, accessed 12 July 2005) ate treatment and care of people with spe cific diseases and conditions within the NHS. Clinical guidelines are based on the best available evidence and are intended to help health care professionals in their work but not to replace their knowledge and skills. Services of curative treatment are included amongst the 40 currently pub lished guidelines. For example, the dyspep sia guideline (Clinical Guideline, CG, 18) recommends life-style advice and appro priate medication as secondary preventa tive measures and the guideline on head in jury (CG4) specifies treatment pathways covering emergency, out-patient and in patient care. Thirdly, NICE produces guidance on whether interventional proce dures used for diagnosis or treatment are sufficiently safe and effective for routine use in the NHS. Of the 127 currently pub lished topics most relate to hospital-based care, such as radiotherapy for age-related macular degeneration (Interventional Pro cedure Guidance, IPG, 048) and auditory brainstem implants (IPG108). The three types of NICE guidance are developed and updated using distinct methodologies. Guidance on technology appraisals is formulated by the NICE Ap praisal Committee, an independent advi sory body with individuals from a range of professional backgrounds. Preliminary guidance is based on evidence from an aca demic assessment group and from compa ny submissions. Following consultation, the Final Appraisal Determination is de veloped, approved by the NICE Guidance Executive and put out again for consulta tion. An appeal process may ensue, after which the guidance is published. All guid ance is reviewed at regular intervals [7]. To develop a guideline, NICE commissions one of the National Collaborating Cen tres to establish a Guideline Development Group. The Group appraises clinical and cost-effectiveness evidence from systemat ic reviews of the research evidence. Views of clinicians, consumers and stakeholders Eur J Health Econom Suppl 1-2005 I S21
Original Papers also inform the guideline [8]. To produce guidance on interventional procedures, the Interventional Procedures Advisory Committee, an independent body of 24 members with a range of expertise, consid ers the safety and efficacy of procedures, but does not examine clinical or cost ef fectiveness [9]. The Committee produces a Consultation document and published guidance reflects comments received over the 4-week consultation period. NICE guidance generally acts as qua si-law, but one aspect of guidance on tech nology appraisals is supported by statu te. If NICE guidance is that a new technol ogy should be made available to certain NHS patients, the funding bodies (PCTs) are obliged by law to ensure there are ade quate resources to facilitate the implemen tation of NICE guidance (Secretary of Sta te for Health "National Health Service Act 1977: Directions to Health Authorities, Pri mary Care Trusts and NHS Trusts in Eng land", 2001). However, the guidance is not binding on individual clinicians, who must assess whether the technology is ap propriate for the patients they treat [10]. Another illustration of quality stan dards impacting upon patient rights is Public Service Agreements. Published an nually, these specify national goals within the public sector, including waiting time targets (or guarantees') for the NHS [11]: (a) By the end of 2005, patients will wait a maximum of 6 months for in-patient ad mission and no more than 13 weeks for an out-patient appointment, (b) By the end of 2008 the maximum wait from GP refer ral to hospital treatment will be 18 weeks. Targets that should already be achie ved, and henceforth maintained, include the 4-hour maximum wait for emergency care and the 24/48 target for accessing pri mary care. (The 24/48 target refers to pa tients being able to see a general practitio ner within 2 working days or another pri mary care professional within 1 working day, whilst the 4-hour wait target is that pa tients should spend no more than 4 hours in an accident and emergency hospital de partment from arrival to admission, trans fer or discharge.) Where fee schedules exist for NHS ca re, patient 'entitlement' to services might be inferred. For example, the new national tariff system of payments for hospital ser S22 I Eur J Health Econom Suppl 1 2005 vices, whilst in no way guaranteeing provi sion, 'suggests' services that should be ac cessible on the NHS. The national price schedule for patient services is classified by Health Care Resource Group (HRG) codes. A range of clinical procedures, treat ments and diagnoses is included in the cur rent list of 550 HRG tariffs for elective in patient care [12]. The Quality and Outcomes Frame work, part of the GP contract, is a volun tary mechanism for encouraging primary care provision of some services of curative care, such as antiplatelets for patients with coronary heart disease [13]. With total pay ments amounting to 15-20% of available total practice remuneration [14], there is a clear incentive for GPs to make these ser vices available to NHS patients. Discussion The NHS is a complex and heavily regu lated health care system in which the ro les of actors are in general clearly defined. As the primary emphasis has historically been upon local cost control rather than quality or access issues, geographical vari ations in quality and quantity of provision have emerged [1]. The lack of explicitness in the definition of the health basket has led to a great deal of uncertainty about en titlement. Even if there is a statutory duty gov erning provision, this does not necessari ly guarantee access to NHS services. For example, the 1977 NHS Act obliges PCTs to provide, or to arrange for the provi sion of, general dental services (National Health Service Act, Chap. 49,1977). How ever, a large proportion of the population is unable to access NHS dental services be cause of a shortage of dentists willing to provide these services for the NHS. The rapid growth of private practice since 1992 was apparently precipitated by a 7% cut in NHS fees, which was designed to redress perceived excessive income [15,16]. Access problems to NHS dentistry have triggered an urgent review of the regulations govern ing the dentists' terms of service with a re cent cash injection of over ?350 ( 504) million, aimed at increasing the number of dentists working for the NHS [17]. The British Dental Association in is negotia tions with the Department of Health to develop a new contract which is expect ed in April 2006. This example illustrates the general principle that private practice flourishes where there are access or quali ty problems within the NHS. The use of regulation to address quality and access issues has had mixed results. A national evaluation of compliance by NHS organisations with NICE guidance found variable implementation. Looking at ra tes of prescribing and use of procedures and medical devices, the time-series anal ysis found significantly increased prescrib ing of some taxanes for cancer and orlistat for obesity in line with guidance. However, prescribing practice frequently appeared to have little relation to detailed guidance [18]. NICE guidance specifies entitlement in terms of patient groups and PCTs are obliged to provide funding only for the se patients. Whether this practice is equiv alent to the PCT operating a 'blanket ban for patients whose condition lies outside the specified guidance is debatable and has not been tested in the courts. Over the past decade the growth in qua si-law' suggests that the English system is heading towards a more formal statement of benefits and entitlements. NICE guid ance on new and existing technologies is in effect establishing a 'positive list' of tech nologies that the NHS should fund; NS Fs describe interventions that should be implemented to achieve standards of care. The Payment by Results system will be ex panded to cover non-elective care and the Healthcare Commission will increasing ly encourage NICE and NSF implemen tation, reinforcing standards through the annual health check' [5]. These factors to gether will take the NHS forward in defin ing a more explicit health basket for Eng land. However, variations in local capacity to comply with national standards may re sult in a more explicit rationing of health care services at the local level. Corresponding author Anne Mason Centre for Health Economics, University of York, UK e-mail: arm10@york.ac.uk
Acknowledgements The results presented here are based on the pro jecf'Health Benefits and Service Costs in Eu rope-HealthBASKET" which is funded by the Eu ropean Commission within the Sixth Framework Research Programme (grant no. SP21-CT-2004 501588). I thank the following individuals for their helpful and pertinent comments on an ear lier draft: Norman Ballantyne (Public Private Part nerships Programme), Karen Bloor (University of York); Brian Ferguson (Yorkshire and Humber Pub lic Health Observatory); Caroline Glendinning (University of York); Maria Goddard (University of York); Nicky llliott (ABPI); James Mason (University of Durham); Adam Oliver (London School of Eco nomics); Phill O'Neill (ABPI); Mark Sculpher (Uni versity of York); Andrew Street (University of York); and Jon Sussex (Office of Health Economics). Pe ter Smith supervised the work and Mike Drum mond (University of York) provided supportive advice. All remaining inaccuracies and omissions are my own. Nachschlage werk! 2006. Etwa 1180 S. 60 Abb. Brosch. 34,95; sFr 59,50 ISBN 3-540-28368-4 In seiner j?hrlichen Bilanz analysiert der Arzneiverordnungs-Report kritisch und sachlich die kassen?rztlichen Arzneiverord nungen Exklusive Detail-Informationen ?ber Arznei mittel, Verordnungsverhalten, Kosten, neue Therapie-Trends, erfolgreiche Innovationen und Spar-Optionen Brandaktuelle, zuverl?ssige Daten und Fakten Jetzt in Ihrer Buchhandlung. Die -Preise f?r B?cher sind g?ltig in Deutschland und enthalten 7% MwSl Pretsanderungen und Irrt?mer vorbehalten. springer.de 4y Sprini References 1. Department of Health (2000) The NHS plan: a plan for investment, a plan for reform. Stationery Office Limited: London 2. Newdick C (2005) Who should we treat? Rights, ra tioning and resources in the NHS. Oxford Universi ty Press: Oxford 3. Montgomery J (2002) Health care law. Oxford Uni versity Press: Oxford 4. Organisation for Economic Cooperation and Devel opment (2000) A system of health accounts. OECD: Paris 5. Healthcare Commission (2005) Assessment for im provement: the annual health check - measuring what matters. Healthcare Commission: London 6. Department of Health (1997) The new NHS: mod ern, dependable. Cm 3807. HMSO: London 7. National Institute for Clinical Excellence (2004) Guide to the methods of technology appraisal. NICE: London 8. National Institute for Clinical Excellence (2004) The guideline development process: an overview for stakeholders, the public and the NHS. NICE: Lon don 9. National Institute for Clinical Excellence (2004) The interventional procedures programme. NICE: Lon don 10. Newdick C (2005) Evaluating new health technol ogy in the English National Health Service. In: Jost T5 (ed) Health care coverage: an international com parative study. Open University Press: Maidenhead 11. Treasury HM (2004) 2004 spending review: public service agreements 2005-2008. HMSO, London 12. Department of Health (2005) Implementing pay ment by results: technical guidance 2005/06. De partment of Health: London 13. Department of Health (2004) Quality and out comes framework: guidance (updated August 2004). Department of Health: London 14. Anonymous (2005) CCA calls for closer working be tween GPs and pharmacy. Pharm J 274:667 15. Oliver A (2002) Reforming public sector dentistry in the UK. BJHCM 8:212-216 16. Department of Health (2004) NSH dentistry: deliv ering change. Report b y the Chief Dental Officer. Department of Health: London 17. Department of Health (2004) Reforms with bite: 1000 more NHS dentists by October 2005: Reid un veils ?368m funding injection for NHS dentistry. Press release, 2004/0265. Department of Health: London 18. Sheldon TA, Cullum N, Dawson D, Lankshear A, Lowson K, Watt I, West P, Wright D, Wright J (2004) What's the evidence that NICE guidance has been implemented? Results from a national evaluation using time series analysis, audit of patients' notes, and interviews. BMJ 329: doi:10.1136/bmj.329.747 3.9992004;329;999 19. Department of Health (2003) Delivering Invest ment in general practice: implementing the new GMS contract. Department of Health: London