We need more co-payments – not less. But “Stealth dentistry charges bring in millions for NHS”

Co-payments are an important principle in Insurance. They reduce claims. There is no incentive to reduce claiming on the 4 medical health services, except waiting lists/times and in England, prescription charges. In ophthalmology, and in dentistry there are big co-payments. Dental care is riddled with worrying incentives, and the contract with dental surgeons needs changing. But before it is changed we need to re-examine the whole ideology of the health services. With the poorest getting more obesity, and more sugar related dental decay, many in the professions are expecting a rise in streptococcal heart disease. Does the recent rise in scarlet fever (The Mirror) and scarletina reflect this risk increase? Rationing (restricting, prioritising, excluding)is usually reasonable, but it should not be covert. or unequal, or subject to a lottery of where one lives.

Chris Smyth reports for the Times 4th April 2018: Stealth dentistry charges bring in millions for NHS (Be sure to read his analysis at the end

Hundreds of thousands of patients are paying a “stealth tax” when they have an NHS dental checkup, making the government millions of pounds a year.

Within five years NHS patients at a third of surgeries will be paying more than their treatment costs as dental fees continue to rise, an analysis has shown. This will raise £20 million for the government, leading to claims of a “rip-off” tax on treatment.

Just over half of NHS patients pay for their dentistry, with children, pregnant women and those receiving low-income benefits exempt from the charges, which are considerably lower than private treatments.

After charges rose at the weekend, a checkup costs £21.60, fillings and teeth extractions cost £59.10 and complex work such as crowns and bridges costs £256.50. These fees go to the government. Dentists are paid through an arcane system for each “unit of dental activity” (UDA) that they perform.

An analysis of NHS payment data by The Times and the British Dental Association found 331 surgeries that are paid less than £21.60 for each UDA. This means that patients are paying subsidies to the NHS of up to £10 at each checkup, making the government £1.3 million over the next year.

Henrik Overgaard-Nielsen, the association’s chairman of dental practice, said: “When patients put in more towards their care than the government pays to provide it, NHS charges cease to be a ‘fair contribution’.”

The government pays most of the cost for fee-payers at 68 practices. Last year The Times revealed that half of dentists with data available were not taking on new NHS patients.

Charges have been rising by 5 per cent a year. If this continues until 2022, and payments to dentists increase at the previous rate of 1.5 per cent a year, then 2,128 of 6,300 high street practices will be charging patients more than their treatment costs, raising £20 million for the NHS.

Neel Kothari, a Cambridgeshire dentist, said: “For many patients, NHS dentistry has become a fixed price service largely funded by themselves. It raises the bigger question: how much should the government be contributing towards NHS dentistry?”

Dentists say that a fifth of patients have delayed treatments because of their cost, while the UDA system has led to concerns that dentists are incentivised to rush appointments to maximise their pay.

A Department of Health spokesman said that access to services was increasing. “Dental charges remain an important contribution to the overall costs of services and this increase will ensure there is no shortfall in the costs paid by users and those met by the NHS.”

Analysis
Dentists rarely kill patients. While this is good, the low risk of toothache puts it way down the NHS priority list (Chris Smyth writes).

Ministers have delayed fixing the NHS payment system that rewards dentists for seeing more patients. The system as it is creates worrying incentives: Desmond D’Mello caused the largest recall in NHS history after secret filming showed him not changing gloves and equipment between patients. D’Mello, who earned £500,000 a year from the NHS, was struck off but not before five patients turned out to have hepatitis C.

For almost a decade the government has been saying that it wants to shift to a system that rewards dentists for preventing illness, but little has been done. At a time when the NHS needs money, increasing charges is an easy way of raising it. But the government profiting from this looks wrong. Ministers may claim that this is the least-worst option, but they should own up to what they are doing.

Dentists are overwhelmed. Patients and politicians are in denial. Rheumatic fever may follow… “The NHS dental service is broken”

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The freedom of movement which is inherent in our society may be threatened for doctors…. Coercion has no place in a modern society. We must train more, (long term) or buy in more from other countries (short term)…

The European Convention of Human Rights insists on ones ability as an individual to move ones labour across borders. We may well be abandoning this element of our legislature when we Brexit. However, why should only one group be punished in this way? What about teachers, architects, dentists, lawyers and surveyors? What about plumbers and electricians who emigrate after training  for that matter? And what about the Welsh trained doctors who move to England or other parts of the UK. We have a net 20% loss of graduates annually in Wales. Should they be punished for leaving Matthew Paris’ “dustbin” to work elsewhere in the UK as well? 

Social mobility is to be encouraged. We regret parochialism, and we usually reject any form of racial discrimination. Coercion is not a good thing.. Despite having the lowest proportion of overseas immigrants we voted for Brexit – first time that is. Brexit, if implemented “hard” will cause more expense, not less, in training doctors, and more shortages of staff.

The perverse incentive for every government to train too few doctors needs to be removed. If we aim at an excess of 10%, use modern methods of education in the community,  we can solve the problem in 10 years’ time. Meanwhile, it looks as if it’s going to get worse, as is student debt.

Laura Donelly reports in the Telegraph 20th January 2018: NHS “should consider forcing doctors to pay back training costs if they quit”.

Junior doctors who go abroad to work after benefiting from £220,000 worth of world class training should be forced to pay back some of their costs to the NHS, healthcare leaders say.

Niall Dickson, the head of the NHS Confederation, which represents senior managers, said shortages of staff were now the most pressing concern facing the health service, as he called for major changes to retain more medics.

The former head of the General Medical Council said the NHS should consider forcing doctors to remain loyal to the NHS, by making them commit to at least four years’ service, as happens in the military.

Jeremy Hunt, the health and social care secretary, floated similar ideas at the Conservative Party conference in Autumn 2016, when he set out plans to train an extra 1,500 doctors a year.

However, the idea of penalties for those who leave Britain soon after completing medical school was put…

 Young doctors must repay debt to taxpayers before moving abroad …

Doctors could be forced to work at least five years in NHS under plans …

Jeremy Hunt unveils plan to fine doctors who move abroad after … The Independent 2016

NHS CRISIS: Make doctors leaving UK pay back training fees, says … The Express 2017

Newly trained doctors to be tied to NHS for four years, announces … Pulse 2016

The Social Mobility Dustbin – Matthew Paris in the Times 20th Jan 2018

extract:

…Might an unintended consequence of the loss of manufacturing and mining coupled with the decline of the class system and increases in the mobility of labour — all those cultural changes we call “upward social mobility” — be a corresponding increase in downward social mobility? I’m hardly warning of an influx of Old Etonians into “sink” estates, but of the possibility that “ladders out” of deprivation, if climbed, have consequences for those who do not take them as well as those who do. I would never use a word like “residue” for an individual human being — every human being has the possibility of defying the odds — but I wonder whether we have accidentally created self-reinforcing pockets of deprivation that have something of the residual about them? What has the sale of council houses done to the status of those who didn’t buy?….

Private Medical Insurance options… Going to get more popular? Our leaders show us the way.

PMI or Private Medical Insurance is going to get more and more popular in the next few years. There are several choices to be made, especially regarding the company, the excess and whether to go for full cover, family cover or even “group” cover. It is not inconceivable that groups of professionals or trade unions might club together to get a group policy. These are much cheaper than individual cover.

As the standards fall, and complication rates rise, infections will get more common, and the risk reduction by going private will be the greater. Don’t forget that Private Medicine escapes from complications either by prevention (No shit in this theatre) or by transferring to the UK’s 4 health services when things go wrong.

Private Medicine does take away from health services’ waiting lists, and as such the gain to the 4 health services is much greater than the loss of £250 million annually. However, as the percentage of citizens who choose PMI or just to pay outright increases, there is a more obvious health divide. Those who can afford it have operations at a time they choose, from a consultant and not a junior, and have less complications and get back to full function more quickly. The morbidity of waiting for 160 weeks as in N Ireland cannot be measured, but we know that heart complaints and obesity are likely.

Choosing a high excess means a lower premium, but the reason you take out this option is for disasters. These might include an exclusion from a NICE approved cancer treatment in your particular post code. I have not been able to research helicopter transport options to Tertiary Cardiac Surgical centres. In remote areas of the country citizens are too far from such centres to reach them in time for a stent in the event of a heart attack……

Casualty (A&E) services are degenerating as well as planned care. It may not be long before ambulances ask if you might like to go to a private A&E ….. These are NOT covered by most policies.

40% of what a GP sees has a psychiatric element to it, and 40% of GPs in training do not get psychiatry in their rotations. PMI can be perverse in its application, especially in Mental Illness. In Australia the actuaries have commented: “Insurers offer perverse incentives on mental health claims”. (Banking and Finance in Australia) Mental Illness can be long, and making a claim is laborious. Once claiming successfully there is less incentive to get back to work quickly than there is with physical conditions, according to actuaries.

Whether you decide to pay directly or insure, remember that premiums rise as you get older, and are higher still for those with pre-existing conditions, Even if your cancer is cured and 5 years old, you may well be loaded or even rejected.

NHSreality predicts PMI will get more popular, and that there may be differentially higher rates in regions whose services are worst, as more claims will be made. Our “leaders” will show us the way…

Chris Smyth reports October 20th in the Times: NHS spends £250 million patching up private care

Paul Gallagher for Inews reports: Junior doctors in private hospitals ‘left in charge of up to 96 beds each’

MoneySupermarket offers a comparison website. as do many others.

The big UK players are: AXA PPP,         Aviva,        Western Provident,         BUPA

and of course there is the Benenden low cost option (Mutual) which excludes cancers, and only operates when waiting lists are longer than their policy (always these days)

23rd August 2017: Best private health insurers revealed by Which?

In Dentistry the same players offerings can be compared, as well as Denplan

Drivers for more PMI: (Our leaders show us the way) Waiting times, Choice, Standards, Risk reduction….

Government officials, former Chairmen and CEOs of Health Trusts, and Politicians all choose PMI. Why? (The Express 18th October 2017: Anger as new NHS watchdog chief REFUSES to give up private …)

As the UK disintegrates there will be competition for professions in shortage. GPs are the gatekeepers and the single reason the system has been “efficient” in the past. Now there are Concerns Cornwall could lose GPs to Devon over pay

NHS problems and Waiting Lists are unacceptable : NHS Health Check: Hunt says NHS problems ‘unacceptable’ reports Nick Triggle for the BBC on 10th February.

NHS Health Check: Which part of the UK is doing the best/ (worst)?

Faye Kirkland and Phillipa Roxby report: NHS Health Check: A&E waits for January ‘worst ever’

Full article The 10 ‘longest’ hospital delays exposed

l article How one GP practice tackled waiting times: 

Jeremy Hunt: We must do better on NHS waiting times

Full article UK’s short GP consultations ‘crazy’

Full article Nine in 10 hospitals ‘overcrowded’

Full article Upfront charges for foreign patients

MPs urge action on lengthy wait for autism diagnosis

Children waiting up to 18 months for mental health treatment – CQC

NHS ‘sleepwalking into winter crisis’ as waiting times soar to nine …

NHS surgery waits run into years in Northern Ireland

There is no substitute for experience in medicine, especially General Practice and Surgery, but all specialities. The experience Doctor/Surgeon knows when NOT to take action as well as when to interfere.

After failing to tax sugar – Doctors want warnings on sweets and chocolate to scare children off sugar…

Lets face it, it’s the same ignored and disenfranchised families in the Grenfell tower as the people who don’t get to the dentist. They are an important sub-group. The dental contract needs renewal, and dentists are altruistic enough to want a service that prevents both long term and short term complications. If the BDAs approaches have failed to make caries important (short term) then perhaps the emphasis on preventable heart valve disease (long term) will make government see sense. NHSreality still feels there are too many perverse incentives in a system where the surgeon is the same person as the assessor…

Chris Smyth of The Times reports 30th June 2017 on the BMA ARM conference: Doctors want warnings on sweets and chocolate to scare children off sugar

Warnings on sweets and chocolates are needed to scare children off sugar and help to fight tooth decay and obesity, the British Medical Association has said. The labels could include pictures of rotten teeth and overweight children, although milder “traffic light” warnings may also be considered.
The BMA also wants free toothbrushes for children under five, and for schools to teach children about brushing their teeth to help cut the “shocking” number who need surgery.
A third of children are overweight or obese when they leave primary school and tooth decay is the most common reason for children to be admitted to hospital. The BMA said tougher action was needed after Theresa May dropped plans to curb promotion of junk food in a government obesity strategy last year.

Iain Kennedy of the BMA said 18,000 children under five had been admitted to hospitals in the past two years to have teeth removed, often under general anaesthetic. He said: “Doctors are calling on the government to help prevent further children from needing these operations by regulating food manufacturers to place warnings on sugary foods.”
Mick Armstrong, chairman of the British Dental Association, backed the plans, saying: “These simple steps could ease a huge burden being felt across the NHS. Political indifference has allowed a preventable disease to become the number one reason for hospital admissions among children.”

Graham MacGregor of Action on Sugar said: “We should have warning labels and they should show rotten teeth, people who are obese and amputated legs, because that’s the reality.”

Dentists are overwhelmed. Patients and politicians are in denial. Rheumatic fever may follow… “The NHS dental service is broken”

The most common operation on children – dental extraction or clearance. At risk – a generation lost to good dental care

Five million children failed to see a dentist in past year..

How do politicians of all parties maintain that the NHS is free at the point of delivery? Dental care is certainly not..

Open Wide – The system for dental care is letting patients down. Regulatory gaps need filling and dentists seem to agree..

Patients at risk as GPs face forced shutdown – will Primary Medical Care follow Dental Care into being covertly rationed?

Health Services (England) dentistry “for sale”.

Dentistry is important – for an important sub group…

 

A general practitioner is trying to follow the dentists into private practice – clients will initially be the retired rich, but eventually many more of us.

A general practitioner is trying to follow the dentists into private practice. NHSreality has warned that this was likely, and that when patients demand a choice from their ambulance – (private or public A&E?) that will herald the end of Aneurin Bevan’s dream. The perverse incentives in private care need to be exposed.. but even if we get an honest debate I think rationing by price and access may be acceptable in Bournemouth, but not away from the retired rich, and the tooth fairies… It will be interesting to see if Dorset tries to stop/discipline this Dr… watch this space. If it is allowed it will spread…

Laura Bennett reported in the Sun 14th Feb 2017: WANT TO SEE A DOC? THAT’LL BE £145 – GP warns general practice ‘on brink of collapse’ as he launches private service in NHS surgery – Patients can cough up to see a doc or pay £40 for a phone chat – Dr Tim Alder ( Poole Road Medical Practice – Bournemouth ) has launched a new private service at his NHS surgery so patients can pay to skip the four-week wait for an appointment

AN NHS GP surgery has told patients they can skip waiting lists to see their doctor – if they cough up £145.

The surgery has launched a private service – operated by exactly the same NHS doctors – to run alongside its NHS services.

But patients have to fork out £40 for a 10-minute phone consultation, £80 for a 20 minute face-to-face appointment and £145 for a 40-minute consultation.

Dr Tim Alder warned general practice was on “the brink of collapse” and “heading for privatisation” as he decided to launch the controversial Dorset Private GP Service at Poole Road Medical Centre in Bournemouth, Dorset.
NHS patients at the surgery have to wait four weeks for a seven-minute appointment with one of the practice’s four doctors if they are not eligible for its same-day walk-in service.
But critics have slated the move as a “kick in the teeth” for the NHS and patients, claiming it creates a two-tier health system and goes against the principle of reducing inequalities in healthcare.

Dr Alder said increasing demand, a recruitment crisis and lack of funding as well as private provider Virgin Care taking over practices across the country meant the new service was the only way to safeguard the surgery’s future.

He said: “The Government is not trying to save general practice and now it is on the brink of collapse. But when it’s gone, they’ll realise how good we have been at blocking access to the hospitals. By then, it will be too late.
“We have to try something different now to make ourselves stronger in anticipation NHS primary care will be even worse.
“The worry is that Virgin Care, who are already buying up practices, are going to come in and would then just take us over.
“I suppose we’d rather be in charge of our own destiny.”

A humanitarian crisis – and the goodwill of staff has disappeared. When will the public ask for private A&E?

Many A&Es are failing now. As delays, standards, and staffing gets worse, more and more demand will come for private A&E and ambulances.

The risks of private care… overstated?

When will private hospitals begin to offer alternative A&E option?” NHS worse in Wales”. Close the doors!

Why were doctors treated differently to dentists? Perverse…

The English Health service has changed it’s mind. Doctors working part time may avoid public declarations of non-NHS / locum income. If this ruling had been enforced it would have to apply to Dentists, Lucum Nurses and Physiotherapists, Consultants etc. (Possibly even politicians!) But the other jurisdictions may choose to be different…. Readers should remember this is a market controlled entirely by government. Undercapacity and under resourcing are political rationing choices made over decades. Failing with a cap on pay is punishment for poor manpower planning…..

Chris Smyth reports in The Times 10th Feb 2017: Doctors win right to keep non-NHS income private

On October 4th he reported: Doctors split over NHS ‘loyalty’ plans

But earlier, on September 20th he reported: Doctors told to reveal all income from private work

On Jan 26th 2017The Times reported: GP plan to charge for weekend appointments

Jan 4th: Locums defy NHS pay curbs to take home £300,000 a year

July 9th 2016: Locum paid nearly £500k despite curb on agency costs

Sarah-Kate Templeton reports: NHS breaches pay cap for locum doctors

 

The Training of doctors…. unfortunately it is too late to recover in even the 5 years promised by government… Decommissioning of operations

A Times leading article alludes (correctly) that undergraduates are less value to the state than graduates who enter medical school. But Zawad Iqbal in “Doctors’ training needs streamlining before it’s too late” does highlight the problem of declining standards, and lowest common denominator medicine. The problem with the new GMC suggestion is that too low a standard may be deemed acceptable in order for us to have enough doctors in the short term. The fact that NHSreality would never have chosen to start from here is omitted. Long term rationing of medical school places, as well as too many undergraduates and too few graduates is to blame. A ten year program of capacity management may be undermined if we admit too many overseas doctors suddenly.. On the other hand, if the bar is set high enough… OK, I forget, nurses can do the job of a GP can’t they? NHSreality feels it is already too late, and it’s going to get worse… (Katie Gibbons reports from Kent: NHS operations postponed to save cash). Decommissioning is going to get worse still.

In a letter to The Times 3rd Feb 2017 Prof Derrick Wilmot of Sheffield writes: on DOCTORS’ TRAINING..

Sir, A medical licensing assessment for doctors is long overdue (“Doctors face tough new test on basic skills”, Feb 1). There is a similar situation for dentists. A third of the dentists entered each year on the General Dental Council’s register qualified at an overseas university. UK graduates are not tested by a common examination but by the individual university dental schools, which do try, mostly with success, to maintain sufficient quality and commonality. Many of the overseas new dentists entering the UK come from EU countries and cannot be tested. Brexit is the ideal opportunity to introduce a new robust common assessment for all doctors and dentists registering in the UK.

Recent years have seen a frightening increase in medical and dental litigation. Evidence for an association is weak but if a basic clinical education is lacking problems surely lie ahead both for the practitioner and, more worryingly, for the patient.

Emeritus Professor Derrick Willmot of Sheffield University, and past dean, Faculty of Dental Surgery, Royal College of Surgeons: Doctors’ training needs streamlining before it’s too late

The news that thousands of newly qualified doctors aren’t confident enough to perform basic tasks such as taking blood is a real canary in the coal mine moment — a warning sign that the way we teach doctors urgently needs to change.

Part of the problem is that the basic structure of medical training hasn’t changed in more than a hundred years. The General Medical Council sets the standards for undergraduate medical education and supervises the training and education of students. But the content and length of a medical degree varies widely, depending on which institution you attend, and the different medical schools are allowed to set their own criteria for licensing doctors.

There is no common standard to practise in the UK. Doctors from the European Union can work here if they’ve passed relevant exams in their own country. Doctors from other parts of the world are given a separate test, resulting in a confusing system with no overall benchmark.

So it’s a relief that medical regulators now want to introduce a standard test. But that’s still some years away and frankly it’s not enough. We should seize the opportunity to conduct a bigger and more wholesale review of how we train our doctors and whether these decades-old methods are up to scratch.

What doctors needed to know ten years ago is often a world away from what they need to know today. Basic science and clinical science remain the core modules on medical courses but healthcare delivery is becoming ever more important. As well as introducing a common approach to basics such as taking blood samples and performing lumbar punctures, areas such as data analysis, IT skills and interpersonal ability must play a bigger role in medical training.

One of the biggest opportunities being missed is in postgraduate medical education. This is because postgraduate training falls under the NHS rather than a university or medical school. Our doctors need to keep learning new skills if they’re going to give their increasingly well-informed patients the best treatments. The doctor of the future will not necessarily carry a stethoscope around his or her neck but will more likely be one of a specialist team working alongside health technicians, pharmacists and nurses.

Rather than introduce a new standard test for doctors after they have qualified, they and their patients would be better served if medical schools standardised the courses they begin at 18.