Dentistry: a service in decay

A glance at their dental colleagues should be enough to waken other health professionals to the prospect of the two tier system which may await, with those with the cash paying for the treatment they need – and those without waiting longer, or even doing without.

This was not how services were designed yet the current funding crisis is forcing hands.

Earlier this week the British Dental Association warned those dental practices that still provide NHS services would struggle to remain financially viable and were now increasingly reliant on private work to subsidise health service dentistry.

In the past decade fees for NHS dentistry have fallen by almost 25% which in turn means that revenue from NHS services is slipping further and further behind those that can be gained from private work.

Anyone who has had to register with a new dentist in the past few years will be well aware of this – if you are happy enough to pay, it’s not a problem, if you’re not, good luck with the search.

It is worth pointing out that many in the profession are far from happy with this state of affairs – they feel they are being pushed out of NHS dentistry and are extremely concerned at the implications for health inequality.

It is incorrect to assume that all dentists are motivated solely by income, many also believe in the foundational principles of the health service, the most basic of which is that it is centrally funded and free at the point of delivery.

Dental services were heavily impacted by the pandemic. Whilst routine inspections were possible procedures such as teeth cleaning and fillings are "aerosol generating" and as such were judged to be a high infection risk.

As a result surgeries needed to be cleaned, and left empty for a while to allow any aerosols to settle which in turn reduced the income that a practice could make during the course of a day by as much as 50%. This also led to a backlog of cases.

The Department of Health responded by introducing a support scheme to help dentists. This is being wound up from April and will be replaced by a scheme to rebuild dentistry through increasing fees paid by 25%. This is down from the original offer of 35% which has had to be reduced because of budget uncertainties.

It should be contrasted with the 70% introduced in Scotland.

This week the British Dental Association stated: “Health Service dentistry simply cannot continue on this downward trajectory, where what is paid bears no correlation with the actual costs to deliver the service. The latest  offer simply does nothing to address those real costs of delivering dental care, or provide anything by way of future certainty. Practitioners have had enough. Unless this is remedied, we are likely to face a possible exodus of dentists away from Health Service dentistry".

The statement continued: "Stress levels have soared. Morale has reached an all-time low. And we have a crisis of confidence among GDPs in Health Service dentistry having a viable future. It isn't practitioners wanting to step away from their NHS patients, this is the government pushing practitioners out.”

The BDA has now published its election manifesto which elaborates on this argument, stating that the downward trajectory in earnings is exacerbated by the increasing cost of delivering Health Service dentistry. It claims that more than half of Northern Ireland’s dentists are now in the private sector as a result.

There’s a skill shortage as well with more than  two thirds of dental practices reporting at least one unfilled dentist vacancy last year.

Each vacancy translates into 1000s of patients unable to access care and 40% of practices say a reluctance to work in Health Service dentistry is the key difficulty to recruiting.

At the same time Community Dental Services are creaking, facing a looming workforce crisis. They serve the most disadvantaged in society and a high percentage of staff is now close to retirement age.

To help reverse the numbers leaving NHS dentistry the BDA wants to see the restoration of commitment payments, whereby those committed to the health service were rewarded. This was phased out in 2016. Bringing it back would cost £4 million but it believes it would help halt the exodus.

In the meantime our two tier system is taking its toll. Northern Ireland  residents are twice as likely to have filled teeth as counterparts in England, and children are three times as likely to have multiple teeth extracted under General Anaesthetic. Children in our most deprived communities are least likely to be even registered with a dentist.

The gap is stark with nearly 80% of children registered in our most affluent communities, falling to 63% in our most deprived and the gap in attending the dentist widened during the pandemic. Obviously ability to pay for private dentistry is a factor in all this.

And Northern Ireland starts from a bad place. Dental decay can easily be prevented through reducing sugar consumption, regular brushing, and adequate exposure to fluoride, yet it is the number one reason why children aged 5 to 9 are admitted to hospital in the UK, and the number of hospital admissions for tooth extractions is rising.

In Northern Ireland alone, before the pandemic more than 5,100 children were admitted to hospital for tooth extractions every year.  In 2016/17 dentists extracted 22,699 teeth, of which 88% were baby teeth, taken out due to decay and by the age of 15 just under a fifth (19%) of children in Northern Ireland could be considered to have good oral health overall.

This places us  bottom of the league table when it comes to children’s oral health outcomes in the UK, with 40% of 5-year-olds showing signs of decay, compared to 25% in England.

Finally more than a fifth of 5 year-olds eligible for free school meals have severe or extensive tooth decay, compared to 11% of the general population and by the age of 15 the gap has widened to 26% and 12% respectively.

There are so many important learnings here. Chief of them is that if you allow health services to drift away from the principles on which they were founded the result will inevitably be widening inequality and unfairness.

None of our parties say that that’s what they believe in. None therefore should ignore the BDA’s cry for help to save our dentistry.