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A broken system and low morale threatens the NHS dental service in a crisis that few speak of

The NHS is in crisis, as many know. But few are privy to the unreported disaster that is the NHS dental service. Stories such as this, where patients are extracting their own teeth for want of a dentist, have circulated with appropriate social media shock. But where the public may be poised to blame dentists and practices, it is a broken and collapsing system that has been forcing these dentists to turn away their most vulnerable patients.

The last two years in England have seen just 58.2% of children and 51.4% of adults visiting an NHS dentist within the last 12 months. During 2015 and 2016, dental infections were the most common reason children aged 5-9 were admitted to hospital, and total expenditure on dental extractions under general anaesthetic for under-18s was £35.6million. To give these figures some context, dental decay is not inevitable, nor is it normal – it’s completely avoidable. Left untreated, as it so often is, an abscess develops and becomes so big that it ends up requiring intravenous antibiotics and an operation under general anaesthetic to treat, including up to a week spent in hospital. A child under the age of 5 having teeth removed like this costs the NHS £836 every single time, totalling a whopping £7.8milion in 2015.

It’s important to emphasise here that NHS dentistry in the UK is free for all children, and free for anyone claiming benefits. But statistically, you’re more likely to be admitted to hospital with a life threatening dental infection if you’re poor. So what’s going wrong? Put simply, the NHS isn’t paying dentists fairly. This suggestion may seem ludicrous, given the archetypal Mercedes–clad local dentist, but in the last decade it has become a reality that is driving many dentists to leave the NHS or leave dentistry altogether, as I have. I lasted one year as a general dentist before I decided to study medicine – a system slightly less broken but, thanks to our benevolent health secretary, it seems likely to meet a similar fate.

NHS dentistry is priced purely according to complexity of treatment (the banding system), not the actual amount of treatment that is needed. This means that a dentist treating a patient needing 10 fillings (roughly 1-2 hours worth of work plus materials and nursing staff) will be paid the same as a patient needing one filling (20 minutes at most). What this translates to is dentists being expected to treat patients with a lot of dental disease for free, and most, if not all dentists, just can’t afford to do this.

An example of this is the way root canal treatments and extractions are banded within the NHS. Root canal treatments save teeth. They save smiles, help you eat, keep you young, figure out your taxes – they’re simply wonderful. They’re also really very difficult and take at least 2 hours to complete. During my brief time as a general dentist, I never really mastered root canals anywhere near to the standard they should be. The alternative treatment is removal (extraction) of the tooth. It’s not only much easier, it also requires fewer materials and equipment and take much less time. Both of these treatments fall under the same band in the NHS system. This means that a dentist will get paid the same amount for a root canal treatment as an extraction. A 3-hour long, demanding, tooth-saving treatment versus a 20-minute extraction.

This often forces dentists to make a choice between making a financial loss on treatments, providing inferior quality treatment or just not providing the treatment at all. Because why would you offer a difficult, expensive, stressful treatment basically for free, over an easier, faster, cheaper one? There are very few other industries where workers are expected to provide such drastically different treatments for no extra financial reward. Ultimately, the system is failing both dentists and patients alike.

Alongside this, dentists are also shouldering the growing burden of an increasingly draconian regulator – the General Dental Council – that is constantly threatening litigation and de-registration should there be any whisper of dissatisfaction from patients. These ‘Fitness to Practice’ hearings leave their lasting mark on most dentists who subsequently find themselves questioning their clinical decisions for fear of another complaint. While I fully acknowledge the need for a robust complaints system, there is a growing trend of law firms actively encouraging patients to take legal action against their dentist without even discussing their concerns first.

A study conducted by the British Dental Association this year found that over 50% of dentists surveyed complained of feeling stress, anxiety or depression at work, with regulators, patient expectations and finance being the main sources of burnout. Fifty-four per cent said they’d like to leave the profession and 45% said their low morale had led to a decline in standards of treatment.

A new system for NHS dentistry is being piloted in some regions, whereby patients are assessed on a traffic light system: red for high risk, poor oral health and green for a clean mouth with no disease. The idea is that red patients shouldn’t be offered things like crown, bridges or dentures, because if they’re struggling to keep on top of their oral hygiene now, adding in a crown or bridge which needs extra cleaning to last will not be a great idea for them. This is a step forward as it pushes for a better focus on prevention, which the existing system currently doesn’t have room for.

The purpose of the NHS isn’t to provide whatever treatment a patient wants. However, helping patients improve their lifestyle, and therefore their risk for further disease, is more than simply telling them that smoking is bad for them. As GP practices have dedicated stop smoking teams, dieticians and alcohol services, dentists don’t have any resources for teaching patients how to keep their teeth clean, how to eat to prevent dental decay or how to prevent oral cancer. With both dentist and nurses being pushed just to provide treatments on the NHS, there is no time or money to sit with patients for 20 minutes and explain oral hygiene or cancer prevention. And so the pool of patients remain with a high rate of dental disease and no system to provide for them.

This myriad of issues leaves a lot of patients worse off, receiving either sub-par treatment, no treatment at all, or only the offer of private treatment – a realistic option only for the few and a frustrating example of the NHS not fulfilling its remit. For dentists, this results in the psychological burden of fulfilling NHS contracts while covering costs, constant fear of patient dissatisfaction and the stress of knowingly providing second-rate treatment with the inevitable complaint to follow.

Doctors, dentists, nurses – all health care professionals – have a responsibility to prevent as well as treat disease, yet prevention takes time and needs resources. The NHS is systemically propped up on the goodwill of its workers. But in dentistry, there isn’t even space for that.

Image from here.