NHS dentistry in the spotlight

Round table looks at The future of the NHS

01 February, 2016 / indepth
 Bruce Oxley    Mark K Jackson

The panel

Robert Donald is a GDP in a mixed practice in Nairn. He is chairman of the Scottish Dental Practice Committee and also a non-executive director of the Medical and Dental Defence Union of Scotland.

Sharon Letters is the clinical director for {my}dentist covering Scotland and the North East of England. She also works as an NHS dentist in Battlefield, Glasgow.

Gerald Edwards is a retired NHS dentist who ran a single-handed practice in Stonehouse, South Lanarkshire, for 25 years. He also worked as an associate in East Kilbride, Pollok and Queen’s Park, Glasgow.

I think that a lot of our colleagues are actually providing very high quality NHS dentistry under the NHS constraints

Sharon Letters

Arfan Ahmed is the managing partner of the L&T Dental Group. He has worked in mixed NHS and private practices during his career and he is also a non-executive director of a pharmaceutical company.

Jamie Kinnell works in private practice at Dentistry on the Square in Glasgow. He is currently studying towards his MSc in restorative dentistry.

Jonathan Dougherty works in Kilmarnock Dental Care, and Philip Friel Advanced Dentistry. He graduated in 2010 and is just in the process of finalising his diploma in restorative dentistry with the Royal College of Surgeons England.

Laura Milby qualified in 1984 and has a practice in Kilsyth in Lanarkshire. She got involved late in to dental politics around 15 years ago and also works as a practice inspector.

It’s not often that Robert Burns is brought up in a discussion about dentistry but, in opening the latest Scottish Dental Round Table, chairman Robert Donald quoted the following line from Scotland’s great poet: “facts are chiels that winna ding”. For those not familiar with Burns’ 1786 poem A Dream, it basically means you cannot argue with the facts, and the chair of this particular discussion had a few choice ones of his own to share with the group.

He said: “The reports on morale and motivation show a direct zcorrelation between net profit and low morale. So, if you’re a higher NHS-committed dentist, you actually have lower morale and motivation compared with your colleagues in mixed practice and there’s also a direct correlation between working longer hours to keep businesses afloat, which is also associated with lower morale and motivation.

“We know that the real net profit for practice owners in Scotland is down by 29 per cent in the last five years, we also know that the real net profit for associates in Scotland is down by 31 per cent between 2008/9 and 2013/14. These are the government’s own statistics and I think they’re quite damning of government policy.

“Scottish practices have the highest expenses to earnings ratio at 70 per cent. We also have the lowest turnover of all dentists in the UK. How do you feel we
can actually keep NHS dentistry in Scotland with statistics like that?”

Retired Glasgow dentist Gerald Edwards revealed that the stress and pressure of NHS dentistry contributed to his retirement. He explained that not having enough time for patients, keeping on top of your notes, the pressure to make money allied with all the rules and regulations make it an impossible situation.

He said: “It’s an impossible situation to be working in. It’s just not on. So, you’re going to have low morale of staff, you’re going to have low recruitment. I don’t want to put politics in to it too much, but the NHS and the Scottish Government up here haven’t done a good job.”

Laura Milby, who runs a practice in Kilsyth, asked if the table thought that part of the problem is that NHS dentistry is trying to be all things to all people. She said: “It can’t be all things to all people. I think that brings you round to the SDR. If we’re going to keep NHS dentistry to treat patients and maintain good patient care, then we can’t provide all these things that are currently on the SDR.”

Jonathan Dougherty felt that he saw NHS dentistry becoming more of a core service. To which Laura Milby replied: “I don’t even think just about dealing with patients in pain, I think it should be a basic service. I know they don’t like the expression ‘core service’ but to my mind, on the NHS, there is no need for patients
to have six veneers for example, I’m sorry but I just don’t think that’s NHS treatment.

“There’s a limited budget, we all know this, so if that’s the case we all have to spend that money wisely.”

Mydentist clinical director and Battlefield dentist Sharon Letters argued that it is “hugely important” to keep NHS dentistry but said that perhaps the answer is a core service with a greater focus on prevention. She said: “If you look at low socioeconomic groups, there’s still a huge variation between both the treatments that they get and the prevention that they get compared with other groups.

“I think we really have to look at a more preventative service for the NHS rather than just fire-fighting and picking up the pieces when things go wrong.”
Jamie Kinnell, an associate in Glasgow, said that he thinks it is very important for patients to have access to NHS dentistry but that patients often think it is an all-encompassing service, which budget constraints simply don’t allow for.

He said: “When patients require more complex treatments, the fee is simply not appropriate for the dentist to meet their obligations with the GDC. In terms of prevention, it comes down to the fee the dentist is getting and there needs to be an adjustment with fee per item and the SDR.

“You’re not encouraging prevention, there needs to be a higher examination fee which allows time for prevention as well record keeping and consent, given the standards the GDC expects of us.”

Arfan Ahmed, managing partner in the L&T Dental group, said he definitely felt it is important to have an NHS dentistry service similar to how it was 20 years ago. However, he argued that many dentists might be happy with the way the SDR is structured because it has allowed them to do more private work. He said: “I think it’s an absolute fact that very few governments in the world can afford to subsidise high quality private dentistry – it’s too expensive.”

Sharon responded by saying: “I think we’re maybe doing some of our colleagues a disservice here because I think that a lot of our colleagues are actually providing very high quality NHS dentistry under the NHS constraints.”

Gerald then said: “I think Sharon’s right but this is the government hiding behind the GDPs. We’re taking the stress. The government are getting away with murder because they’re not providing enough money for the service but dentists are doing more than they have to because they’re decent people.”

And Robert said: “The feedback I get from a lot of dentists is that they are providing high quality work in spite of the NHS and in some ways they are actually subsidising that treatment themselves every day.”

Jamie said that he knew of many dentists who are providing a far higher service than the NHS is paying them for but asked if that was sustainable. “I’m actually quite impressed a lot of the time that someone has provided that level of treatment within the fee structure of the NHS but it can’t be sustainable. If it’s not sustainable then a few years down the line, unfortunately for those patients, it won’t be there. Patients should have access to those range of treatments and not just a core service.”

The discussion then moved on to what needs to change to make NHS dentistry more

“They have to reduce the amount of items that are covered,” said Gerald. “I mean
molar root treatments, anything cosmetic, metal dentures, all these things, they’re not viable anymore.

“The trouble is the government doesn’t care and it doesn’t value NHS dentistry. But the GDC will be down on your back if you don’t do all this wonderful stuff. You’re meat in the sandwich, you’re being crushed from both sides.”

Laura said: “I had a patient a couple of weeks ago and I thought the best treatment for this tooth is a gold inlay. The lab fees for the inlay cost more than I got on the NHS fee scale to do it. Would I do it again? Yes, I probably would, because that patient has been coming to me for a long time and that was the best treatment for that tooth. I don’t think I’m alone in that – you just take the hit.”

Robert then asked how the dentists around the table would like to see the SDR changed to introduce prevention and not destabilise the system.

Jonathan took up the discussion by saying: “I would increase reward. I think you should get paid more for having to do less treatment. I know that sounds a bit silly but, if you’re trying to focus on prevention and your preventative advice is good, the patients will need less treatment. Right now we’re not getting that reward for providing preventative advice. We are getting rewarded for the more treatment we do. Therefore where is the incentive for promoting better oral health.”

To which Robert replied: “It’s almost like an obscene incentive isn’t it? If they want us to do more prevention, we have to take the foot off the treatment and the treatment pays the grants because it’s based on your turnover. So, the more work you do, the more money you get in your grant. The less work you do, if you did more prevention you would get less money for that.”

Jamie then argued that practices could be paid preventive fees based on a percentage of their previous year’s gross, and then the practice’s performance is monitored going forward. He said: “The incentive then is immediately for them to focus on prevention because, in the long term, the better the preventative approach and the quality of their work is, then the amount of work they’ll need to do should reduce which is beneficial for them. The fee that they’re getting can then be reviewed if items of service don’t reduce, but that immediately allows those practitioners to focus on a preventative approach.”

However, Gerald explained that the government is unlikely to see it that way. He said: “The problem with that is the politicians’ love of statistics. When you do a filling it’s a statistic, when you do nothing it’s not a statistic. If you’ve got prevention you can’t prove that it’s either prevention or it’s just neglect. You won’t know for 10 years and the politicians won’t go for that.”

Robert then argued that the government needs to change its mindset away from measuring treatments to measuring outcomes. “A successful outcome for dentists is not having to do any treatment whereas in their eyes a good outcome is ‘well we did record numbers of fillings this year or record numbers of extractions’.”

Arfan said that there are “some very simple changes that can be made to the SDR,” by focusing on what the evidence base is saying. He cited the example of over preparation of teeth to accommodate amalgam fillings for certain restorations. “The option of providing composite restorations that are remunerated appropriately should be considered,” he said.

Robert then asked the group whether they felt the current SDR encourages good record keeping. He said: “We work under a system where, instead of being judged by the quality of the treatment, in many cases it’s the records that we’re gauged on as to the quality of the treatment. The fact is the system does not properly fund or reward that level of record keeping.”

The feeling around the table was that the fee for an examination doesn’t allow for enough time to do everything and needs addressed. Jonathan described the pressure he feels to get notes done between patients. He said: “My notes are literally done between when the patient leaves and the nurse is quickly cleaning up before the next patient. You’re under pressure to get them finished because there’s another patient waiting.”

Jamie suggested multiple examination fees with guideline times so the dentist can choose the appropriate one. He said: “The examination price has to be dramatically increased, guidelines put in place for what’s included and then if they want to take other things off that’s fine. I think everybody would be much happier if they just had higher examination fees to cover the care that’s been provided to patients and also their record keeping obligations, consent, IRMER, GDC and so on.”

The table unanimously agreed that a change to the exam fee was essential and would improve the daily lives of NHS dentists, despite reservations from some members of the discussion that it would never happen due to ongoing budget restraints.

The conversation then moved on to the differences between NHS and private, with Robert asking: “Do you feel you work harder on the NHS compared to private? Can you compare the two?”

Arfan was the first to answer: “I think working within NHS dentistry can be extremely stressful. I qualified in 2008, completed my VT year and soon after virtually gave up NHS dentistry, because I found it quite stressful.

“I very consciously made the decision that I want to spend at least 30 to 45 minutes talking to my patients when they come in, really understanding what their needs are and spending time providing good quality dentistry. I’m not saying that NHS dentists don’t do good quality dentistry, but how many NHS dentists spend half an hour or 45 minutes doing an examination?”

Robert then asked Gerald if he had his time again, if he would still work under the NHS. He said: “I liked the NHS system but when I started it was a lot different. It was less stressful, hugely less stressful. Nowadays with the NHS you’ve got so many things you’re supposed to do.

“It became more and more onerous, more and more responsibilities – you get paid less and there is more aggravation.”

But Laura revealed that the reason she works in the NHS and will continue to work in the NHS is because she wants to care for the people that can’t afford to pay for private treatment. And, in order to do that, she has to supplement her NHS income with more private treatment.

Arfan said, with regards to affordability, it comes down to the type of dentistry you wish to do. He said: “You should not compromise on quality. You have your core principals and beliefs and that’s the quality you work to. It’s like doing half of a heart operation, it doesn’t make sense, but in dentistry you do half an examination and that’s okay. I find this mindset difficult to contend with.”

For Jamie, it is also about being paid appropriately for his time. He said: “I have moved from NHS to private over the last four years. The difference is time and I’m paid appropriately for my time. There’s some NHS practitioners, in terms of the fees coming in to the practice, they may not be that much different, but what they’re doing is they’re forcing themselves to work to a limited time. That’s where the stress is. It’s a constant grind. You ask anyone why it’s stressful, it’s a never-ending assembly line, it’s constant, there is no let-up.”

Robert then asked the dentists around the table to get their crystal balls out and predict what the future holds for NHS dentistry. Arfan said: “I think, despite people’s best intentions and people wanting to do the best for their patient, there is a risk the quality of NHS dentistry may deteriorate due to the significant burdens now placed upon associates and practice owners.” He also argued that there should be some form of licensing to limit new NHS practices opening up where there is already adequate provision. “I think this would have a positive impact on the long-term sustainability of NHS practices,” he said.

Despite graduating in 2010, Jonathan said he feels his time in the NHS could be coming towards an end. He said: “I think if the service continues going the way it’s going, I don’t know if I could continue working within the NHS. I think the stress created by working on the NHS is not only physically, but emotionally draining. I think the public’s view of NHS dentistry needs to change and I feel the government need to be honest with the public regarding this. We all know within the profession that it cannot continue the way it is currently going and the greater powers need to come forward and be honest about this.”

Laura explained that she thinks she will always be mainly NHS but she is realistic in that she will have to do more private work to “balance things out”. However, she said the big thing for the profession and the government to focus on is prevention for both the young and old. “We need a big push on education, I think the government has a lot of responsibility for the education of patients,” she said.

For Sharon, she believes a lot of dentistry will be patient driven as they use various technologies to research the private options open to them. She also argued that the rise of corporate dentistry will play its part. She said: “I think there will be more corporate dentistry in the future. The advantage of that is that it does take away some of those stresses that are on practitioners from day to day. Corporates provide support for clinicians, ensuring they remain compliant and can focus on the dentistry, both NHS and private.

“I also think probably some of the secondary care services that we’ve got at the moment will be pushed back in to primary care, I think that’s probably how I see it in the future.”

Jamie Kinnell echoed Jonathan’s worries about the stresses on dentists. He said: “I think practitioners that continue to work in the NHS as it is are going to burn themselves out. They will either leave the profession or go abroad. and again it’s the patients who rely on the NHS who will lose out.”

The last word was given to Gerald who said that he felt a core service is inevitable. He said: “Let’s face it, the government doesn’t like to spend money so what it should be doing is this dreadful phrase “core service”. It’s going to come. It will take out all the fancy stuff, bring in a longer examination period where you get paid a wee bit extra for the examination, you will get pain fixed, you’ll get the very basics fixed and if you want anything else it’s private. I think that is the fairest and most sensible thing to do, I think that’s the obvious solution.

“So eventually, you’ll have a two-tier system, I don’t think there’s anything wrong with that and I think that solves all the problems.”

Do you agree with the views of our Round Table? Email the editor at bruce@sdmag.co.uk to have your say.

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