All entries for Monday 01 May 2006

May 01, 2006

Dentistry in Crisis

The new NHS dental contract is unfair to dentists, a bad deal for patients, and more focussed on bringing dentists under government control than actually providing a better service to the nation.

Contrary to what Rosie Winterton, Minister for Health, would have you believe, NHS dentistry in this country is facing a serious crisis with the imposition of a new contract that has had dentists across the country up in arms.

10% of dentists have refused to sign altogether, and though Ms Winterton believes this to be an acceptable margin, it has left over a million people stranded without the dental treatment that they need. What is even more worrying is that 60% of dentists have signed “in dispute” and may still pull out of the contract at a later date.

So why has this contract caused so much upset?

Previously, dentists were paid by item of service. There were over 400 different treatments available on the NHS, and every dentist in the country got paid the same amount of money for doing the same amount of work. While Acting chief dental officer Barry Cockcroft calls this method of working “outdated,” it was at least understandable and provided value for money for patients, even if the actual payments the dentists received were low enough for them to feel overworked and underpaid. The system basically worked, and, with a little tweaking, should have provided the best care for patients and the best working conditions for dentists.

However, instead of making minor adjustments to the old system – such as making the most expensive and non–essential treatments unavailable on the NHS and slightly altering the costs of others – what the government has done is overhauled the entire system and replaced it with an untried, target based one, which will cost the patient double, and in some cases triple what they were paying before, ensure that dentists are still overworked, replacing an old treadmill with a new one, but prove much better for the government because not only is it cheaper for them, it brings another section of the NHS firmly under their heel.

The government has said repeatedly that this new scheme has been piloted with success. This is an outright lie. It has not been tested at all. There have been schemes piloting a completely different system (PDS schemes) – and a much better one at that, which both dentists and patients were happy with – but this is not the one that has been adopted by the government, as it proved too expensive for their liking.

We have seen how the target based approach has done very little to improve the education system, with teachers now so wrapped up in red tape that they have barely enough time to teach, and children are examined to within an inch of their lives, and now Blair’s government seems set on a similar destruction of dental health provision in Britain. Dentists’ earnings will now be calculated using a system of UDAs, or Units of Dental Activity. Dentists will have to perform a certain number of UDAs per month in order to get their allocation of the money the government has provided to local Primary Care Trusts. However, the amount paid to dentists per UDA varies not only from region to region, but from dentist to dentist within that region. So firstly, this system is unfair because dentists across the country will be paid different amounts for exactly the same amount of work.

Secondly, this quota system is unfair on patients, because of what constitutes a UDA. A patient requiring 1 filling now pays exactly the same as one with 8 fillings, 2 extractions and 3 root–fillings, because they both count as the same number of UDAs. Patients who have looked after their teeth will effectively be penalised for it, by being made to subsidize those who haven’t. However, those people who do need a lot of dental work will also be penalised, because they will find it very difficult to find a dentist willing to treat them. If the same UDAs are being earned for several time–consuming, difficult procedures as for one simple one, few dentists are going to be willing to choose the former over the latter when they have a quota to fill, and are already working a thirteen hour day in order to meet targets. If a dentist extracts a tooth that could have been treated with an hour–and–a– half root filling, he will earn the same UDAs and save considerable time. Perhaps this choice seems to reflect badly on the dentist, but according to the Shadow Health Secretary, Andrew Lansley, for many dentists their main problem with the new contract is that their UDA target is far too high. They are being expected to work harder than they did last year, rather than having their workload cut by 5% as the government promised, in order to earn exactly the same money, and since most NHS dentists were overworked and under paid last year, Blair’s new scheme has just exacerbated the problem it was trying to solve. Dentists are still overworked, only now they are being forced to cut corners if they want to gather enough UDAs to get paid. This target driven system can only lead to a reduction in quality of care

The way the new system is being priced is also grossly unfair. Now, instead of 400 different treatments with their own individually calculated price, there are only three price bands, again based on number of UDAs. 1 UDA, the equivalent of a check–up will cost £15.50, 3 UDAs, which can cover anything between one filling and ten, will cost £42.40, and any more complex treatment which involves a lab technician and laboratory fees such as crowns or bridges will cost £189, and count for 12 UDAs. This may seem relatively simple, but this actually means that 69% of patients will be paying more for treatment, and on average costs will double. As already stated, this system also penalises patients with low treatment requirements, and the British Dental Association is concerned that this will therefore discourage people from regular visits to the dentist. Once patients realise that it costs the same to get one tooth filled as three, there’s an incentive to delay treatment to get value for money. If basic emergency treatment is £15.50, then it works out as cheaper to wait until a tooth is causing pain and needs filling than to make a routine appointment for the same filling which will cost £42.40: more than double.

One of the main aims of the new contract was to allow dentists more time to focus on preventative dentistry, but yet again it has failed spectacularly, and only served to make the problem worse. A patient now has to pay nearly triple what they used to for a dental check–up: £15.50, rather than £5.80. Many dentists believe this increased cost is going to act as a disincentive for patients, and hardly surprising, since the point of having a National Health Service is to make medical care affordable for all, never mind “free at the point of contact”. Under this new system it is the people in society most dependant on NHS provision who will be the most disadvantaged: the young, the elderly and those on a low income. Also, dentists now have no incentive to talk to patients about dental care, or to visit schools to educate pupils, because these activities have no UDA value, which in the long run can only be a bad thing, and will lead to more people needing dental care.

Despite all of this, the Government has been trying to con us into thinking this is a good deal for all concerned, instead of just for them. It has been asserted by Rosie Winterton and others that “an independent dentist with an average NHS workload can earn about £80K a year plus expenses,” and since the amount that dentists are being paid per UDA has been calculated on their earnings for the last year (which accounts for different dentists being paid different amounts per UDA) the government is now trying to persuade everyone that dentists will still be earning this amount under the new contract. This is absolute nonsense from beginning to end. If the new contract was really offering dentists salaries of £80K plus expenses, they would be mad not to accept it. Government figures themselves contradict this assertion, reports suggesting that average earnings for NHS dentists are closer to £65K. One has to wonder where Ms Winterton is getting her figures from, if it’s not her own imagination.

Apart from the deficiencies this contract will lead to in patient care, the government seems also to be underhandedly trying to gain an element of control over dentists in this country that is worryingly despotic. What all these reforms mean is that the government will be imposing a salary on NHS dentists, making them more dependant on government handouts, like NHS doctors, rather than allowing them to work in the more independent way that they are used to. Not only is this an unwanted imposition on the freedoms of dentists, but in the long run this will be damaging to the growth of NHS dental practices. What the government doesn’t seem to realise is that unlike doctors, dentists receive no financial assistance with setting up or running their practices. Everything comes from the dentist's own pocket; some own their own premises, there are no notional rent arrangements, no 80% contribution to staff salaries, no funding towards expensive equipment, nothing. And so for the government to try and dictate how a dentist runs his or her practice – towards which they have contributed not one penny – is, I find, somewhat unreasonable. The government is essentially a sub–contractor, and in any other business it would be impossible to find another sub–contractor who would dream of having the control over their contractors that the government wishes to gain over the dentists. Besides which, under the terms of this new contract, dentists will be unable to fund improvements to their practice without government funding, which has not even been suggested. They cannot increase their income by taking on more work for a month or so, as used to be the case, in order to fund the purchase of new equipment, for example, as they will not be paid any extra money if they exceed their UDA quota for the month. This means that the growth of individual practices will be stunted, and in time NHS dentistry will be unable to keep up with new developments in the industry.

The Government has systematically said publicly that they have been "negotiating" with the British Dental Association, the body representing dentists in the UK, but in fact, the truth is far from that. There were no negotiations. The BDA was summoned to meetings at the Department only to be told that new arrangements would be brought forward irrespective of any objections. Despite the BDA repeatedly telling Departmental officials that the proposals would be unworkable, they were unable to change anything but the most minor details. This, unsurprisingly culminated in a BDA walk–out of these "negotiations" last December. In short, although there have been some meetings since regarding minor issues, the BDA have been unable to influence policy one iota. I don’t think anyone who knew the meaning of the term could seriously call this “negotiation”.

Perhaps the most underhand issue about the whole business is the way that the government has rushed this new NHS contract through. The timescale for its implementation was ridiculous. Dentists were only given the new contracts eight days before the deadline for signing them, and some were given even less time, and were therefore not given enough time to seek legal consultation, or really think the new contract and its implications through before they had to make a decision. They were asked to make a decision that affected their entire livelihood in just over a week. They were put under enormous pressure to meet that deadline, or they would be unable to treat NHS patients, and since there is still a large number of dentists who want to be able to offer patients NHS care, despite the benefits of going private, many of them have signed the contract under protest. After looking at the contract in more detail, and seeing the shoddy deal it proposes, it’s a wonder any of them have signed at all.

May 2006

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