Summary
NHS dentistry ( NHSD), as it exists today ,is based on deception. In theory, it is available to all . The reality is that access to specific treatments and often to the system itself is restricted. Radical change is needed to improve access to basic care by sharply limiting the treatments offered.
Solution
The remuneration system of the private contractors who provide the bulk of NHS dentistry has always been plagued by a binary choice between fee per item and fee per capita. Both methods have their drawbacks. Fee per item led to unnecessary treatment by under-employed dentists and an inability to cap the dental budget allocation. Per capita fee, though functional for NHS medical practitioners, led to cherry -picking of patients who needed little work , rejection of complex patients and neglect. This is in no way to question the altruism of the majority of Dentists, but policy impacts on professional decisions. Furthermore, a wide grey area blurring the lines between NHSD and private work has developed. There has been a mutuality of interest between Dentists, trying to maintain an economically viable business and their political masters who wish to maintain the fiction of a service providing the full range of dental treatments. Though strict rules are in place to prevent mixing of NHS and private work, I believe it is fair to say that this abuse is widespread. The predictable result is that NHSD is essentially a deceit. Officially a patient has unfettered access to the entire range of treatments for their dental needs. Unlimited crowns, bridges, complex root filling etc. should be available but in practice no Dentist could afford to accept unlimited numbers of patients with complex lengthy courses of treatments,when there is a low fixed fee. It is not just the Dentists time but also expensive laboratory fees for crowns which easily can surpass the remuneration fee for that patient. An altruistic dentist would swiftly go bankrupt. The political weaponisation of the NHS has meant in practice that no government of either hue is willing to address this issue , so they turn a blind eye to the situation. This undermines the professional standing of Dentists and enriches those who game the system. How can this situation of offering unlimited treatment on the one hand and restricting it on the other be improved? The solution can only be to be honest about what is available. The two main dental diseases, decay and gum disease are not fatal. Though theoretically a patent can die from dental infection…this is a rarity which like oral cancer and fractures of the jaws is anyway dealt with by secondary or tertiary care. The founders of the NHS in 1948 were concerned with healthcare not aesthetics . Treatment then was primarily extractions , dentures and simple fillings. Once the patient had been rendered edentulous and provided with dentures, their subsequent maintenance treatment was occasional and economic. The concept did not take into account the inevitable scientific advances and changing patient expectations .Improved local anaesthetic and sedation diminished the fear factor which had also restrained uptake, The result has been that along with mental health and geriatric care, Dentistry has become one of the most significant parts of the total NHS budget. The restricted treatments available cause those who can afford it to move to the private sector. How long before the voter political support for NHSD drains away as an increasing number of people see no point in subsidising a system from which they draw no benefit. As a Dentist who has worked in all arms of the service, General Dentistry, Community and Hospital Dentistry for nearly fifty years, I see a structure with fragile foundations . I believe that the NHS , in concept, is ideal and there is truth in the quip that the NHS is the nearest the British nation have to a religion. The changes that I advocate are not an attempt to dismantle the NHSD but rational changes to preserve it. Let me first address the remuneration of Dentists. Increases in productivity have not served Dentists well. The profession has compared the situation to a treadmill. As Dentists have increased the units of work they produce, the fee per item has been cut. To maintain their income, Dentists become more productive and a vicious cycle results . I therefore suggest increasing the basic fee to dentists whether on a per capita or fee per item basis. In order to pay for this and to cap the state Dental budget, a drastic reduction of available treatments is necessary. I propose that the provision of dental services be limited to the following: plastic denture provision fillings root filling only on anterior teeth Crowns, molar root filling, metal dentures, bridges would not be offered. This would at a stroke, sharply limit the expense and complexity of dental treatment. Extractions under anaesthesia of children’s teeth comes under hospital treatment and budgets. Orthodontic treatment is aesthetic and would only be offered in community under strict selection criteria. Abolition of fees. This would take the political heat out of the restriction of services and give the employed a political stake in preserving NHSD. The increase in the remuneration to dentists would halt the exodus of Dentists into the private sector . The simplification of treatments available would lead to an improvement of access. There would be clarification as to what was and was not available. The state dental budget allocation would be reduced. The per capita method of remuneration would become sustainable. In parallel, light touch regulation , and a return to self-government would lead to a cut in needless practice expenses. Also a financial cap to malpractice claims against the NHS by making the acceptance of NHS treatment conditional on the patient signing a suitable waiver would reduce the steeply rising cost of malpractice insurance which blights the business model. In conclusion, the radical changes indicated , would improve access, control the budget and clarify the available treatment .
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