February 06, 2016
One in four of NHS patients is unhappy with dental care, and for good reason. Patients expect an NHS dentist to provide clinically necessary dental treatments to help maintain good oral health, at a reasonable price. Unfortunately, it doesn’t always happen that way. The NHS dental contract puts dentists in a difficult position, and is vulnerable to abuse. The pursuit of money has quickly become priority, and dentists are tempted to manipulate the system in an effort to maximize income. As a result, patients’ dental health is suffering, and what started out as minor fraud is quickly becoming a massive problem.
How Does NHS Dentistry Work?
With a focus on stabilizing dental health, patients in the United Kingdom have access to low-cost services and treatments provided by the NHS. Necessary treatments fall into three cost bands at a set price. Whether a patient gets an exam, or x-rays and a full cleaning, he or she pays just once for full treatment. Band 1 costs £18.80 and covers basics like exams, x-rays, dental molds, and some preventative treatments. Band 2 costs £51.30 and includes everything in Band 1 plus further restorative treatments likes fillings and root canal therapy, as well as extractions, and surgical periodontal (gum) treatment. Band 3 costs £222.50 and covers Band 1 and 2, as well as the more complex treatments like bridges, crowns, inlays, dentures, and orthodontics.
Reasons NHS Dental Care Isn’t Working
Though it seems fairly straight forward, this system is far from perfect—as evidenced by the 90% increase in claims against negligent NHS dentists in the last year. Some of the underlying problems include:
Dentists Offering “Private” Care instead of NHS Referrals
Prior to 2006, NHS dentists were compensated for treatment they gave each patient. But in April of 2006 the Labour government introduced a new payment system, under which dentists are allocated only a certain number of “Units of Dental Activity” (UDAs) annually. This complex system means if a dentist uses up all his or her units, they are no longer guaranteed payment from the government for NHS services. Dentists are required to be 100% transparent about allotted UDAs. However, the combination of human frailty and the NHS system means some dentists are vague about why they cannot perform certain services. Instead of referring patients to another NHS office, they offer to provide private treatment at a far greater cost. Some even go as far as to say they could offer treatments on NHS, but they will not be as good as the ones offered privately—which is a breach of the NHS contract. Another problem with allotted UDAs for a year means some dentists tell patients they have to wait for treatment, which can lead to disastrous results.
Dentists Not Getting Paid Enough for Varying Procedures
Because of the tiered pricing, dentists only get paid one set price for certain treatments, regardless of how many or how long it takes to restore good oral health. For example, say with the NHS dentists get paid the price for Band 1 for one filling and the same price for 10 fillings, going by completed treatment instead of separate items in a treatment plan. Sounds a bit harsh. Another example is dentists get the same “payment” for an extraction, which takes 20 minutes, as they do for a root canal, which takes two separate appointments and a total of 80+ minutes. See why the dentist is tempted to recommend an extraction, over the more taxing root canal, in an effort to save time and money? As a result, more patients suffer from gaps in their smiles and ultimately end up wondering why so many of their natural teeth had to be removed.
Dentists Not Spending Enough Time with Patients
Because the system makes dental care so affordable, NHS dentists often maintain a stressful schedule to try and accommodate all their patients. Some dentists see up to 45 people in one day and this leaves the dentist with only 10 minutes a patient, at best. This lack of time leads to several problems. First, dentists do not have time to connect one on one with patieints. In turn, patients feel rushed and neglected. This lack of time also means dentists run the risk of overlooking or misdiagnosing problems. Gum disease is a common example. Instead of giving patients a full scaling and root planning, which takes at least 30 minutes, dentists do not recognize the problem and only perform the routine cleaning, which takes only 10 minutes. Then, what started out as mild gingivitis, becomes the more severe infection called periodontitis. The disease not only causes inflammation and irritation of the soft tissue, but can also damage the supporting structures and lead to dangerously loose teeth. All from a simple misdiagnosis that might have been corrected with a bit more time.
Dentists Sticking With the Old Ways
The lower price for procedures also limits what NHS dentists can do and traps them in old techniques and materials. For example, the most common fillings are dental amalgam, a mixture of mercury and other metals. These can be toxic for patients. The dentist might offer a tooth-colored (composite) filling for front teeth, but often they are considered merely cosmetic for back teeth. Unfortunately NHS doesn’t make it easy for dentists to recommend the more advanced methods and materials. Private dental care, though more expensive, can provide the latest techniques and choices in materials, but is way more expensive. Also through private care, patients have access to more cosmetic options, like teeth whitening and veneers, in an effort to treat both health and aesthetic.
Dentists Not Treating Complex Problems
NHS dentists are not incentivized to treat patients with complex dental problems. Instead they focus on the most cost effective ways of reaching their allotted UDAs. This makes NHS care most beneficial for patients looking to get regular, low-cost cleanings and minor restorative treatments. Patients with more complex needs often get passed back and forth between dentists and dental hospitals, awaiting treatment. Also, patients are not given enough information to make informed decisions about optimal dental care, especially if they require more extensive treatments.
Dentists and Orthodontists Postponing Treatments
To provide treatment, all orthodontists must also have a contract with the NHS. As a consequence, there are not enough contracted providers to meet the demand. This leads to long wait lists and delayed treatment. Also orthodontic treatment has to be rationed. All patients under 18 must meet the Index of Treatment Need (IOTN) criteria before being accepted. For the most part it is an unbiased and reproducible way to determine whether or not a patient truly needs braces. Unfortunately, if the NHS will not fund a patient based on IOTN results, then patients must choose private care or no treatment at all. Also orthodontists usually wait until a child reaches 13 to 14 years of age before intervening in the alignment of teeth. So, rather than treating the problem with a simple appliance at an early age, they often need to remove teeth to create space for proper alignment.
Can Something be Done to Improve NHS Dental Care?
Dr. Barry Cockcroft, Chief Dental Officer for England, says: “Dentists are regulated health-care professionals and in the overwhelming majority of causes always do what is right for their patients.” But the British Dental Association (BDA) has a slightly differing opinion. They suggest, that while the vast majority of dentist do indeed put the interests of the patient first, there are undeniable inadequacies in the current system of funding. The chair of the general dental practice committee of the BDA, John Milne says: “The government needs to be honest with the public and the profession about what treatments NHS will provide and how many patients can be treated.
Greater clarity is needed to avoid confusion and conflict.”
While the flaws of the current system are well documented and reform is under way, the process is painfully slow. For the most part dentists would like to treat more NHS patients, but their ability is currently restricted by a cash-limited system.