Category Archives: Dentists

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

Up to the 18th century Rheumatic Fever and Rheumatic Heart disease were a significant killer. Dental prevention, allied to better diet, fluoride in the water (or tablets) and teeth cleaning has reduced this awful killer to a minimum. The current failing dental service could facilitate recurrence. Failure to implement a policy on sugar and sugary drinks, denial of the need to ration, and a “head in the sand” approach to the potential effect of poor dental health on poor people……… Looks like we will have to wait at least 2 years to get a new contract, and with too few dentists (rationing of places) the omens do not look good.The NHS dental service is broken

Image result for broken dentist drill cartoon

Ollie Jupes in The Guardian 12th Jan 2017 reports: The NHS dental service is broken – and its rotten payment system is to blame – A rise in hospital tooth extractions for children in England and Wales is alarming. But this is just one symptom of the growing crisis in NHS dentistry

lmost as soon as I stepped into dental school in the mid-1980s, an enthusiastic and wild-eyed child dental health lecturer thrust a Venn diagram in my face. Few who are not professional mathematicians can say that a Venn diagram shaped and guided the whole of their working life, but this one did. The equation the three intersecting circles in this particular diagram represented was this:

Plaque + Tooth + Sugar = Decay

On Tuesday, the Local Government Association (LGA) released figures showing that in 2015-16, there were more than 40,000 hospital operations to remove teeth in children and teenagers in England and Wales. This represented a 10.7% rise in such procedures since 2012-13 and in the period from 2012 to 2016, the cost of funding these surgical operations has been estimated at £129m.

Representatives of the British Dental Association, the Faculty of Dental Surgery of the Royal College of Surgeons and the LGA were quick to (quite rightly) reinforce their calls for the speedy introduction of the “sugar tax” on soft drinks and for the government to support public health campaigns to remind parents of the importance of their child’s oral health. While these are critically important and valid calls for action, I don’t believe they give the whole picture of why hospital child extractions are rising. I think my hypothesis is best summed up in another Venn diagram. I would add a fourth circle.

Plaque + Tooth + Sugar + Absent Dentistry = Child Hospital Extractions

I’m not talking about a lack of availability of NHS dentists – everyone in England and Wales has the right to be allocated an NHS dentist by their local NHS area team. Rather, it is as a result of the deficiency of appropriate care at ground level in the General Dental Service (GDS).

Up to 2005, dentists working in general NHS practice were paid a fee-per-item of treatment they provided. While many felt that this system was seriously underfunded, it sort-of worked. Treatment was carried out, and dentists were paid for providing it. Significantly, in that same year, the National Audit Office said in its document Reforming NHS Dentistry: “Oral health in England is improving generally, with oral health in 12-year-olds the best in Europe.”

One year later, a new system was introduced into the GDS that was probably created by a James Bond villain: “No, Mr Bond, I expect you to die – but not before financially ruining you and taking the shirt off your back and, dammit, your boxer shorts.” Hospital extractions have increased ever since. The new dental payment system meant that dentists, no matter how they tried, could rarely hit the targets set for them in order to maintain their average income. Not hitting targets results in a dentist receiving clawback – where the local area NHS team sends a metaphorical “heavy” around to take their money back.

All general dental practitioners (GDPs) who wanted to stay in the NHS were forced to enter into this deal. The current system is based on units of dental activity (UDAs) and a dentist is contracted to complete a specified number of UDAs per year. In essence, a dentist carrying out a course of treatment involving one filling will earn exactly the same fee as if that patient required a dozen fillings and hours were needed to provide the treatment. The government imposed the new system in 2006 (it was condemned by a parliamentary health select committee in 2008 as “unfit for purpose”), claiming that the new system would give dentists freedom to focus more on prevention than active intervention. It did nothing of the sort.

Deciduous (baby) teeth have thin coatings of enamel and caries (decay) can rip through the teeth very quickly if oral conditions – either diet or cleaning – aren’t right, if the patient fails to attend appointments, or if a child is difficult to examine adequately because they are fractious. And even if you do have cooperation from a child, treatment often takes twice as long as for an adult.

What we currently have is a failing dental service where clinicians are having to be too focused on targets to spend adequate time on giving individual prevention advice, are overwhelmed by sheer patient numbers and are constantly banging their heads against parental brick walls. I once had a patient spread out a picnic with cookies and soft drinks in my surgery for her children while she had her check-up. Very quickly, teeth become grossly decayed, infected and require the drastic measure of general anaesthesia and extraction. It’s thanks to this new payment system that dentistry has now joined the NHS crisis.

Childhood obesity: a plan for action – Publications – GOV.UK

 

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

Dentistry pay dividends in poor societies. The incidence of dental decay is related to that of heart disease and severe untreated caries is a cardiac risk. This was known by the Victorians but recently seems to have been forgotten. The Perverse Incentives in the dental contracts have all led to perverse behaviours. Why cannot the assessment be separated form the treatment, as in Medicine where a GP refers to a surgeon? A recent Times leader explains and is reproduced below.

Dentistry now outside the Health Services for most of the nation

Getting to see a Health Service physio – like getting to see a health service dentist

Shropshire whistleblower dentist tells job tribunal of ‘witch hunt’

NHS losing billions to ‘fraud by doctors and dentists’

Dentists demand a deposit from NHS patients

The Times leader:

Trips to the dentist are unsettling enough already. That dentists are rushing patients out of the door in order to stack appointments high and maximise their income, as our investigation today reveals, is unlikely to calm anyone’s nerves.

Root canals, which save troublesome teeth, take twice as long as extractions but both procedures are worth three “units of dental activity” (UDA). Dentists are paid per UDA, so they are financially better off performing two extractions than one root canal. Some patients, therefore, end up losing teeth that they could have kept. Likewise, with a check-up counting as one UDA, some dentists are ploughing through their consultations to get through as many as possible.

The Department of Health needs to step in. A new sort of contract is clearly required to iron out perverse incentives. It could be modelled on the arrangement for GPs, who are paid according to the number of patients on their roster. The government should also consider capping the amount of appointments that dentists can heap into a day, to prevent such “conveyor-belt” dentistry. Regulators should also take responsibility for keeping dentists in check, not point the finger at each other.

Britain’s dental health could do with a check-up. More than 50,000 children have teeth removed each year, costing the NHS £20 million. The sugar tax proposed in George Osborne’s March budget will be a straightforward way of addressing both Britain’s obesity crisis and its dental problems. The new government must press ahead with the policy.

This may also help to level out the country’s staggering oral health inequalities. Unskilled workers are ten times likelier to be missing teeth than those in the professional class. The present regime for public dental health is clearly not working. It is time that legislators and regulators took a second bite at the apple.

Update 9th August 2016: Chris Smyth in the Times. The great dental rip-off

Thousands of teeth needlessly extracted as surgeries accused of putting profit before patients

Letters 9th Aug 2016:

Sir, The overwhelming majority of NHS dentists want to see the back of a contract that has failed patients and practitioners alike (“The great dental rip-off”, August 6). This article claims that dentists are putting profit before patients, when the reality is that this contract forces them to put government targets above all else. Either we hit our quotas, or we get penalised. Further, when we do more, we don’t get paid for it.

It’s a contract that rewards dentists for ticking boxes for treatment and repair, not for improving our patients’ oral health. It was meant to improve access to NHS dentistry and put prevention at the heart of the service, and it has failed. Sadly, the government seems unwilling to let go of activity targets. A watered-down version of this system won’t cut it. We need a contract that really puts prevention first.
Mick Armstrong
Chair, British Dental Association;
Henrik Overgaard-Nielsen
Chair, General dental practice committee, BDA

Sir, I am an NHS dentist and believe the current contract is the worst thing that has happened to NHS dentistry. Three UDAs [units of dental activity] are awarded for a course of treatment (including examination, x-rays, fillings, extractions and root canal), not for a single visit. A patient may need ten visits, and the payment will be the same as for one visit. Show me a builder who would build a ten-bedroom mansion for the same price as a one-bedroom flat. The majority of ethical NHS dentists struggle to provide good basic dentistry under the current system.
Mandy Hewitt
Ruddington, Nottingham

Sir, Dentists have been pleading with the government to change this system since it was imposed ten years ago.

This is why: the patient has a check-up, scale and polish, x-rays, preventive care and advice for one UDA (£25 on average). Once a treatment plan is agreed, the payment from the NHS to a dentist for all the treatment the patient needs to secure dental health, apart from crowns, is a further two UDAs: £50. Cost of two single-use rotary nickel titanium files for a root filling (essential): £20. Money remaining to cover all other costs: £30. Minimum time for a patient who requires a root filling: 40 minutes.

Each of my surgeries costs me about £94 an hour to run before I can make any profit.
Celia Burns

Wylde Green, Sutton Coldfield

Sir, Your report and editorial suggest that dentists can claim as many UDAs as they like. On the old system, dentists could earn more by carrying out more treatment, and the annual dental budget could only be estimated. The current contract was designed to allow a budget to be set in advance. Each dentist is contracted to carry out a certain number of UDAs a year. If a dentist exceeds the number of UDAs contracted to them they get no additional pay. If they fail to complete the contracted number, their fees are clawed back. The dentists have to tender for contracts each year. Whose fault is it if dentists are paid for a large number of UDAs?

However, to claim that the upper limit of patients is 30 per day is unrealistic. In the 1990s I used to work with three staffed surgeries and treated 70 to 80 patients a day. That would equate to more than 30,000 UDAs a year. On a four-day week, I hardly ever ran late.
William Eckhardt
Retired general dental practitioner
Haxey, S Yorks

Sir, In view of the “great dental rip-off”, will the cabinet secretary recommend that all dentists become economical with the tooth?
David lilley
Ashby de la Zouch, Leics

Whistleblowing in the US – helping to change the organisational culture? No comparison with state owned organisations.. Exit interviews better and less destructive..

Whistleblowing in the UK health services is akin to a jihadist setting off his own detonation. Initially it could change organisational culture, and if there is sufficient compensation it might be worth it (for some). Surely the answer lies in confidential, depersonalised and amalgamated “exit interviews”: much less destructive. Retiring doctors and nurses could all contribute – together as a year class. I think the result might surprise politicians for the classes of 2014, and 2015..

An interesting article in the Economist 5th December 2015 reports: The age of the whistleblower – Life is getting better for those who expose wrongdoing, but companies continue to fight back—often against their own interests but makes no reference to public companies such as Health Trusts or Education departments. Recent evidence from Sussex and Mid Staffs is not encouraging for Whistleblowers, and most are much worse off afterwards. Usually they have to leave their jobs. In Hospitals and in General Practice whistleblowers have to move area…

Whistleblowing.pdf (from the Economist) contains the graphic below. It would be interesting if there could be similar from the public sector. The Economist could do us all a great favour by ranking and publishing yearly..

Corporate crime - Whistleblowing Ranking

The same edition of the Economist exposes the difficulties Swiss employees in the food industry are having. Whistleblowing in Switzerland – Rough terrain – Two court cases illustrate the struggles of employees who allege wrongdoing

There has been a sea change in Wales as the BMA is openly advocating the honest language of overt rationing, and exit interviews for all staff. The exit interviews, if conducted by a third party (Patients association, Community Health Councils) could be a really useful way of avoiding the need for whistleblowing and career self-destruction…

terroristschool-vi

NHS whistleblowing ‘problems persist’ – Patients First has yet to demand open exit interviews

Whistleblowers are promised more protection and new jobs – trying to change a culture of fear. Trusts to commission “Exit Interviews”?

Mr Cameron has to instruct CEOs, Board members and Chairman to give exit interviews

 

 

A reminder in poetry: “I am a child of the NHS”

On the 60th Year of the NHS I read a poem “I am a child of the NHS”… Unfortunately I don’t have the author… Reader –  let me know..

I am a child of the NHS
And despite my complaints you cannot guess
How grateful I am for the service I get.
Sometimes I reflect on the media and press
Which are patently unable to cope with the stress
Of  projecting the truth to the Nation.
The whole concept
Of cradle to grave
Caring for the dying, the elderly, the depraved,
(of nothing to pay, and no duty to save)
For that rainy day or medical surprise
Is “in place of fear”; A fantastic idea.
Aneurin Bevan was the constructor/designer
But time and reality are mean destroyers
Budgets and acronyms abound
To confuse the public in getting around
The shape of a wonderful dream
Which is becoming a nightmare
Said our friend Anne today:
“you can go to hospital well (if you dare)
And come out smelling of MRSA”.
So what is bringing back the fear?
And to compound the rationing, beware
For now both Dental and Physio care
Are unavailable to most – were you aware
That those  words “commissioning” and “fund-holding”
Were parodies of the truth?
And hidden deep in the morass
Of a beurocracy this crass
Is absenteeism so perverse,
It is shamed by every organisation
In the whole Universe
A reflection of a system designed
For the assertive, with morale much worse.
Forget Equity, Forgive Access,  Remove Choice, Allow unfairness
Remain National, not regional,
Counter litigation paranoia with no-fault compensation (none can afford lawyers)
And save my NHS.
So who is the “gatekeeper” in this mess? Your GP,  would you guess.
(that person who does sustained, unpredictable, often imperative, multitasking, for individuals families or groups)

I am a child of the NHS
And, still, despite my complaints you cannot guess
How grateful I am for the service I get.

and it’s worse in wales..

NHS cuts back on IVF treatment due to cost pressures – The Mail 3rd November 2015

Dentistry now outside the Health Services for most of the nation

Dentistry is now outside the Health Services for most of the nation. Nicola Harley in The Telegraph reports 21st August 2015: Half of adults failing to go to the dentist – New figures released by the Health and Social Care Information Centre reveal a drop in the number of people seen by an NHS dentist amid a rise in patient apathy

Half of adults have not been to the dentist in the past two years, it has been revealed, as health chiefs warned about limited access to NHS dentists – and a rise in patient apathy.

Figures released by the Health and Social Care Information Centre (HSCIC) showed a drop in the number of people seen by an NHS dentist.

The number of dental patients in the two years leading up to April fell by 0.3 per cent to 30.08 million compared to the previous two-year period. The total comprised some 22 million adults – 52 per cent of the adult population – and 8 million children.

The data also showed that the number of children treated by an NHS dentist in the year to March 31 was 6.9 million, just 60 per cent of the child population.

Professor Nigel Hunt, dean of the faculty of dental surgery at the Royal College of Surgeons of England, said the data revealed “a decade of inertia” in access to dentistry.

“In the past two years approximately 50 per cent of adults and a third of children haven’t seen a dentist. Routine visits to the dentist are vital to maintaining good oral health.

“It’s appalling that tooth decay remains the most common reason why five-to-nine-year-olds are admitted to hospital; in some cases for multiple tooth extractions under general anaesthetic – despite tooth decay being almost entirely preventable.“Visiting the dentist regularly is crucial in providing rapid diagnosis and treatment to prevent both children and adults from being hospitalised due to tooth decay. The new Government needs to urgently review why access is not improving and launch a national campaign to stress the importance of seeing a dentist,” he said.

Adults are advised to visit the dentist between every three months and two years but the National Institute for Health and Care Excellence recommends the maximum gap between appointments for children is 12 months.

London was the only region where the number of patients seen by an NHS dentist increased.

The South of England had the greatest number of people treated in the 24 months to the end of June, at 7.3 million – a 37.2 per cent share of all patients in England, which may be in part because the region has the highest success rate in obtaining a dental appointment.

The Royal College of Surgeoms said that the nation’s poor dental record was a combination of patient complacency about caring for teeth plus access to dental appointments, both of which need to be addressed by the Government.

Richard Lloyd, executive director of the consumers’ group Which?, said: “Our research shows just how difficult it is for patients to get an NHS dental appointment, as information about availability doesn’t reflect reality.

“The regulator must ensure the existing rules are put into practice, so people can easily find an NHS dentist.”

Dentists demand a deposit from NHS patients

NHS Dentistry &

Dental Training – There is no control

Fraud in Dentistry- a case from Scotland: ‘I’m ashamed any dentist could behave in this way’

Dental Training – There is no control

Dr Josie A Beeley of Glasgow University writes in The Times 25th April 2014:

The General Dental Council has no control over 17% of the dentists on its register – and more are coming

Sir, Amid the discussions about the qualifications of doctors who trained outside the EU, little attention was paid to EU/EEA-qualified dentists.

Of dentists registered with the General Dental Council (GDC) 72 per cent are UK qualified, 17 per cent are EU/EEA qualified, and 11 per cent are from overseas. Overseas graduates have to pass an overseas registration exam which is of the same standard as the final examination in UK dental schools, and also includes basic science.

However, there is no such requirement for non-UK, EU/EEA- qualified dentists. Moreover, while UK graduates also have to complete a period of supervised practice to be able to practise in the NHS, this is not required of other EU/EEA graduates.

The Association for Dental Education in Europe is trying to achieve harmony in dental education throughout the EU/EEA, but these standards are variable.

The GDC validates training in the UK, but such a national supervisory body is not the EU norm.

Currently the GDC has had no control over the qualifications of 17 per cent of dentists on its register, despite having been set up by Act of Parliament for this purpose. With the proposed reduction in the number of UK dental school places and countries such as Romania producing five times as many dentists as they have employment for, this figure seems likely to rise.

Dr Josie A Beeley

Association of Basic Science Teachers in Dentistry, University of Glasgow

Sometimes it’s right to tell voters they’re wrong

David Aaronovitchin The Times 6th June reports:

“Everyone knows some hospitals must close to improve healthcare. Politicians on all sides must make the case

What should politicians in a democratic society do when they believe the public is wrong about something? Such as, say, hospital closures.

Expert professional and medical opinion, from the think-tank the King’s Fund though the royal colleges to the patients’ group National Voices all points in one direction: as a country we spend too much money and effort running too many hospitals and we should close a number of them and put the resources elsewhere. If we fail to do this, they warn, healthcare, already sub-optimal, will suffer.

But people don’t want “their” hospitals closed. Faced with the choice between the abstract proposition of a better future and the (literally) concrete one of an existing and visible set of buildings, they vociferously choose the latter. In other words — from the policymaker’s point of view — they’d rather die than change.

Unfortunately they aren’t the only ones who’ll die. If they successfully frighten politicians away from making the right decisions, then most of us are affected by the resulting bad decisions…..”

Its hard to find a Doctor who does not want the highest standards of specialist care for himself or his family, but I did find one in my own practice who felt choice was unimportant – I expect until the reality of what is available in the particular situation hits him. Finding employees to speak out on NHSreality has not been easy: many say they will but then “fade away”. Even with the new theoretical spirit of openness people are afraid and effectively gagged.  Post code rationing is happening today all over England,  Covert rationing by restriction of choice is happening here and now in Wales.

I am happy to receive digital audio interviews from any NHS staff, of any level, but reserve the right to reject if they are unprofessional or libellous.

 

 

Public services ombudsman for Wales wants more privacy power … Gag the press as well as the professionals

BBC News reports 5th May 2013:

“Wales could become the first UK nation to have an independent watchdog with the power to stop the publication of some of its reports and to prosecute those who go against its wishes.

Public Servicers Ombudsman Peter Tyndall wants more confidentially powers to protect vulnerable people.

It would mean complainants could face contempt of court charges if they go to the media.

But some warn it would mean less transparency.

Mr Tyndall has legal powers to review complaints about public services such as hospitals or councils in Wales…..”

So once this is law, the people of Wales won’t necessarily know what is going wrong! It will affect us all. The differences will have to be explained to them from outside Wales, in the same way broadcasting uses propaganda to undermine Middle Eastern despotic regimes, and inform its people of the truth! Not much chance of public confidence in stopping gagging, reducing post-code rationing, encourage commissioning for quality, and provides an immediate perverse incentive not to correct problems.

Now we pull out our own teeth: Boom in DIY dental kits as patients cannot afford NHS fees

The Sunday Express (Lucy Johnston) on 12th May 2013 reports:

“Now we pull out our own teeth: Boom in DIY dental kits as patients cannot afford NHS fees.

Unable to afford soaring charges, almost a fifth of people have all but given up going to their dentist, the Sunday Express has discovered.

There has been a surge in sales of dental kits at pharmacies including chemicals to whiten teeth.

Experts say that up to 200,000 DIY dentists risk injuring themselves and missing out on potentially life-saving check-ups.

Up to a third of adults no longer have an NHS dentist, according to the latest figures.

Gulf War veteran Ian Boynton, 46, from Woodmansey, East Yorkshire, pulled out 13 of his teeth with pliers because he was in agony and could not find an NHS dentist to treat him.

In another case a 46-year-old man from Wandsworth, south London, needed major surgery after he stuck a crown into his mouth with super glue which rotted the bone in his gum…..”