By Ollie Jupes (the pseudonym of a retired NHS dental practitioner)
Imagine for a moment, that you are a freelance reporter and for one of your clients you have a contract to provide 1200 words per week for a fixed fee. You have been working for this client for many years and although the work is time-consuming and the amount you earn from this work isn’t phenomenal, it’s certainly useful and helps pay the overheads.
Then one day, the client comes to you and says “I’m making a change to your contract” (also imagine there’s a clause in there that would make it feel immoral to refuse). “From now on, I want you to produce as many words as I demand, when I demand them, for the same fixed fee.”
Unreasonable? Well…er…yes, but this is EXACTLY the situation NHS dentists faced in 2006 when the Labour Government introduced a new contract for contracted health service dental practitioners. Other than from hospital or community-based dentists, all NHS dental work is carried out by independent contractors who are responsible for providing their own buildings, equipment, materials and staff.
Before the introduction of the ‘new’ draconian system, NHS dentists had been working under a long-established ‘fee-per-item’ system where practitioners had been paid per filling or per extraction or crown. Even that system was underfunded. A single-surface (simple) filling attracted a fee of £6.80 at a time when the overheads of many dental practices (at that time) ran at roughly £60 per hour per surgery. In those days, if I was carrying out a filling on an adult molar in a youngster – especially for the first time – there was no way that I could complete the task in anything less than half-an-hour without a lot of gentle persuasion and a few tears (mainly mine). You don’t have to be Professor Brian Cox to work out that at that sort of pay rate, it’s going to be a struggle to pay your overheads – but at least with the old system, if you provided two fillings, you were paid for two.
The introduction of the dental contract in 2006 meant that patients with high needs – for example, someone who hadn’t attended for many years and presented with many gum problems and numerous decayed teeth which needed fillings, gum treatment and/or extraction – had to be treated by the dentist at the same payment scale as a regular attender who needed only one filling. I personally ended up, on one occasion, treating a patient with a dozen fillings and a couple of extractions for about £60 in total, earned over a number of appointments and about three hours work.
The new contract brought with it a new term – a Unity of Dental Activity (or UDA as it’s more commonly known) which was an arbitrary unit plucked out of the air and bore no resemblance to the work that actually goes on in a dental surgery. For example, a simple one-surface filling was given the same UDA value as a complex molar root-filling, which can on average take up to two hours to complete. With the rise in dental litigation and complaints made against dentists in the UK, it is no wonder that many dentists are now refusing to carry out challenging and complex work like root-fillings, preferring to refer to specialists, who operate, of course, privately.
With the rise in the cost of medical indemnity insurance and the exponential increase in complaints due to the aggressive solicitation of business by dental litigation lawyers, it’s no wonder that dentists are leaving the NHS in droves. The rate at which dentists have to work in order to meet their overhead costs and make a living can increase the risk of making an error. Despite having been a committed NHS dentist all my working dental life, I don’t blame anyone who wants to leave the stress behind and work in a more relaxed way AND provide quality treatment. New graduates in particular are moving into private work very quickly after they have finished their post-degree training posts. Building new dental schools in Dorset (as proposed this week) won’t stop the exodus away from the underfunded system.
And before anyone thinks “Ah yeah. You say all that, but my dentist has a Tesla” – I personally went into retirement under an Individual Voluntary Arrangement with my creditors, having paid my nursing and support staff a living wage over the years and preferring to work at a (slow) rate in order to deliver quality care. Fair enough, it was MY choice, but I felt (as many dentists who still persevere in the NHS do) that I couldn’t deny taxpaying patients NHS treatment – especially as I had been trained in the 80’s when I had no university fees to pay AND I received a full grant.
So where are we now?
As I write, Mouth Cancer Action month is under way and the BBC News has just reported that latest figures from the Oral Health Foundation have shown that oral cancer killed 3,000 people in 2021, up 41% from ten years previously. The report highlighted the plight of one gentleman who couldn’t find an NHS dentist to deal with what he thought was a dental abscess. When he paid to go privately, he was finally diagnosed with an aggressive tumour and had to undergo extensive facial surgery to remove jaw bone and form a new jaw from bone taken from his leg.
The fact that many people cannot access NHS dentistry – 90% of UK dental practices were not accepting new adult patients according to a BBC investigation last year – means that they are not being examined routinely for potential malignancy. Many may not be aware that dentists routinely screen for mouth cancer at every routine examination and every treatment visit. Over a thirty-year career, I picked up three mouth cancers from lesions that my patients weren’t aware of and they were referred urgently. These lesions are being missed because patients are unable to access health service dentists.
And if the risk of people missing out on important mouth cancer checks doesn’t move the
Government, then the plight of countless numbers of people who out of desperation are removing their own teeth, highlighted by the Toothless in England campaign, are bound to fall on deaf Government ears.
But as far as this Government is concerned, the job is done. At end of an item on BBC’s Breakfast programme, viewers were told the Department of Health said “they’re making progress boosting dental services for adults and children.
In October 2022, the Government DID bring in changes to the NHS contract, but they were minimal. It meant, for example, that a complex root-treatment would attract a higher payment. But that was pretty much it. No overhaul of the contract, just a little tweak.
Despite a Select Committee condemning the dental contract as ‘unfit for purpose’, Rishi Sunak’s claim earlier this year that the UK has more NHS dentists since those very new contract changes were condemned as a ‘grotesque misrepresentation by British Dental Association Chair Dr Eddie Crouch.
He said ‘The facts are there are no new dentists, no new contract and no new money.
All we’ve seen are tweaks at the margins. We need honesty, ambition and investment to save a service on its last legs.’
Prior to 2006, many of my colleagues were of the opinion that the Government was trying to ease the ‘greedy dentists’ out of the system by the back door. I’d say “mission accomplished.”
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