Why you CAN’T get an NHS dentist
And even if you’re lucky enough to find one, it can cost a fortune
DENTISTS — we all love to hate them, and it isn’t hard to see why. For a start, practices willing to take on new NHS patients seem to have become as rare as hens’ teeth and the situation looks set to worsen.
Last week, the British Dental Association (BDA), the professional body that represents dentists in the UK, claimed 58 per cent of all NHS dentists intend to quit the health service in the next five years to do private work, move overseas, retire or leave dentistry altogether.
A dearth of dentists is frustrating for patients and costly for the NHS. in January this year, a joint study by the BDA and newcastle University concluded that every year more than 130,000 people with dental problems, unable to find a dentist, were seeking help from hospital A&e departments at an annual cost of £18 million.
Last month it was revealed that half of NHS dentists were no longer accepting new patients, with two fifths refusing any new child patients.
When someone finally does agree to see you, chances are your session in the dreaded reclining chair will involve some degree of pain — even if it’s only financial.
For, to add insult to injury, what you’ll be charged for treatment has risen for the second year running. NHS dental charges, divided into three treatment bands, rose by 5 per cent in April this year.
in england, it costs £20.60 for a basic examination, £56.30 for a filling or extraction and a whopping £244.30 for crowns, dentures or bridges (up from £189 in 2006). Charges for the same three treatment bands are less in Wales — £13.50, £43 and £185 — and much cheaper in scotland, where a basic examination is free, a filling £19 and a full set of dentures £150.
the BDA says rising charges are why more than 11,000 people a week in the UK — 600,000 a year — seek free help for tooth problems from their GP (according to a study by Cardiff University published in the British Journal of Dental Practice in May last year). this is costing the NHS at least £26 million a year, says the BDA.
not surprisingly, dentists have come in for some bad press over the past few years. in what was called ‘the great dental ripoff ’, an investigation in August 2016 claimed ‘ thousands of people are losing teeth needlessly because it is more lucrative for NHS dentists to take them out than try to save them’.
But Good Health can reveal that the real villain isn’t necessarily the dentist at all.
the true scandal, which is costing patients both teeth and money, is that a clumsy targets-based payment system, introduced in 2006 by tony Blair’s Labour government, has robbed dentists of the time and incentive to carry out complex, time-consuming procedures.
Furthermore, the rising fees you pay to your dentist are being used to offset a reduction in the amount the Government puts into dentistry.
NHS dentists are paid a fixed sum for every ‘unit of dental activity’, or UDA. the criticism is that this creates a perverse incentive, because it places the same UDA value on extractions as on root canal work, even though the latter often takes twice as long to carry out.
EACH dentist is contracted to deliver a set number of UDAs each year. A check-up is worth one, while extractions, fillings and root canal work all count for three. For each UDA dentists are paid about £25. this target-led system, says the BDA, is ‘ not fit for purpose’ because it ‘ wrongly puts the focus on meeting these targets rather than on patient care’.
And if they miss the target by more than 4 per cent — as spending time on too many lengthy procedures almost guarantees they will — a dentist will be penalised.
Do more work than the contract sets out and they don’t receive an extra penny from the NHS.
Are dentists extracting teeth rather than battling to save them? Almost certainly.
One dentist gave Good Health this example: a patient has two molars with large cavities in them. Fixing each one will probably involve removing the nerve and cleaning out the tooth (a root canal), filling it with so-called composite core and capping it with a crown. As a single course of treatment, this would count for 12 UDAs, worth up to £300 to the dentist.
From the £300 they are paid, the dentist has to take off laboratory charges for the manufacture of the crowns — typically about £50 each — then pay for the singleuse instruments for the root canal. that’s £100 just for those two. And in theory, if they have already hit their UDA target for the year, that means the dentist is effectively paying to do the treatment.
‘Dentists are on a treadmill to hit their targets every April 1st,’ says Henrik Overgaard-nielsen, chair of the BDA’s General Dental Practice Committee and an NHS dentist in south-West London. ‘Come March many dentists will find themselves working for nothing or having to turn patients away if they have met their quota.’
But the crucial factor is the time it will take: to treat the two molars will take ‘several hours over a number of visits’, for which the dentist has earned less than £200, with staff and rent still to pay (which take up to 70 per cent of their earnings, see below).
‘the alternative, created by the UDA system, is that they pull both teeth out, for which they claim three UDAs, and it has only taken 20 minutes,’ one dentist told Good Health. ‘Which would you do?’
even the most principled dentist is going to think twice about treatment that is going to leave them out of pocket.
the system also leaves patients in a financial dilemma. the cost to a patient in england for having those two rotten molars fixed would be £244.30 — per tooth, if the work was carried out as two separate courses of treatment. Having both teeth pulled out, on the other hand, would cost only £56.30 per tooth.
the UDA system is ‘an absolute farce’, says Anthony Kilcoyne, who in 2015 was one of 100 family dentists who signed an open letter to the Government claiming NHS dentistry was ‘unfit for purpose’. A new letter was sent this spring — this time signed by 2,000 dentists.
‘the system punishes you for doing higher quality treatment that takes longer,’ Dr Kilcoyne told Good Health. He is ‘firmly convinced that UDAs will go down in the history books as one of the worst things that ever happened to dental health in this country’.
Far from profiting from such apparent ‘gaming’ of the system, figures published last month by NHS Digital showed the average pre-tax income of NHS dentists in england and Wales has been steadily falling since the current dental contract was introduced in 2006.
income for ‘ associate’ dentists — those who don’t own a practice, who make up more than 80 per cent of the workforce — has fallen in real terms by 30 per cent over the past decade. in the same
period, practice - owning dentists’ pay has fallen by 34 per cent cent, to £116,000.
Of course, many people earn far less than this, but the point is that dentists are not making lots of money from the system. W hat’s more, ‘every penny of investment this service receives comes from dentists’ own pockets’, says the BDA, which claims dentists are subsidising NHS dentistry.
‘Unlike GPs, NHS dentists do not receive any capital investment from central Government.’
What this means is that a dentist’s pre-tax salary also has to cover ‘all improvements in equipment, training and facilities’, says Mr Over - gaard-Nielsen. In fact, last year’s NHS Digital earnings report showed 70 per cent of dentists’ earnings went on expenses such as premises, staff and lab costs.
And while patients are having to pay more and more, so the Government is paying less and less.
Since the new dental contracts, hated by the profession, were introduced a decade ago, the cost of treatments for patients set by the Government has risen by more than 30 per cent.
At the same time, the Govern - ment’s contribution has been steadily falling. The total NHS dental budget for 2017 is £2.8billion. Of this, the Government is providing about £2 billion and patient charges make up the balance. This year the total paid by patients topped £780 million, up by two thirds on a decade ago.
If the trend of rising charges compensating for falling funding continues, says the BDA, ‘a third of the dental budget will be coming from charges by 2020’.
By about 2031, patients will probably be paying more for the NHS dental service than the Government does. ‘NHS charges have ceased to be a mere “contribution” towards the cost of NHS dentistry,’ says Mr Overgaard-Nielsen. ‘They are a tax on health. At what point will NHS dentistry technically cease to be part of the NHS?’
ALTHOUGH dentistry was a central plank of the NHS when it was launched in 1948 with the pledge that all services should be ‘free at the point of delivery’, charges for dental work were introduced as early as 1951 and have been rising ever since.
And this is affecting people’s health. Increasingly , research suggests dental health has an impact on general health — for instance, gum disease is thought to be linked to raised risk of heart disease, diabetes and stroke.
The most recent Adult Dental Health Survey, published in 2009 — when patient charges were far lower than they are today — found that a quarter of adults had been influenced by cost when making decisions about which type of dental treatment to have.
The yawning chasm between the claim that NHS dentistry was accessible — and affordable — to all and the shameful reality has been highlighted by work in the UK by Dentaid, a Salisbury-based charity that usually works in Africa, Nepal and Cambodia.
In a pilot project in Dewsbury , West Yorkshire, in 2015, in a six - month period more than 150 people who either couldn ’t find a dentist to treat them or couldn ’t afford to pay for NHS treatment took advantage of emergency treatment being offered by volunteer dentists under the UK’s first ever ‘Pay If You Can’ scheme. The waiting list to register with an NHS dentist in Dewsbury is at least two years, the charity said.
Funded by Kirklees Council, Dentaid returned to Dewsbury last month and over two weeks treated 30 patients a day and extracted more than 100 teeth.
Dentaid has also offered free dental care in Salisbury, Winchester and Cornwall.
It is, says Dr Kilcoyne, ‘scandalous the system has been allowed to get so bad that we need a Third World charity to provide basic pain services the NHS can’t.’
There is, as yet, no official word on whether dental charges will rise again next year, but the BDA is not optimistic. ‘Ministers seem intent on asking patients to put in more, while they pay less,’ says Overgaard-Nielsen. ‘W e would expect further charge increases from next April.’
There is, supposedly, hope of a new deal ahead for both dentists and patients. The Department of Health told Good Health it is trialling a new type of dental contract with 75 practices ‘to help us find the best ways to maintain high standards in dentistry’.
But the DOH declined to comment on the BDA’s claim that half of NHS dentists were planning to quit, or to explain how the new contract differed from the old.