Kevin Lewis column

Kevin Lewis looks at who has been stealing the show as dentistry returns to the media spotlight.


War of words


Nobody will have failed to notice that the media’s summer ‘silly season’ is over, health is squarely back on the menu, and dentistry has started to reappear in the media. In recent weeks it has mostly amounted to verbal sparring, and in fairness some of it has been pretty good, whether you agree with the sentiments or not. What I have found interesting, in fact, is that it is difficult to disagree with quite a lot of what had actually been said by any party, because the spinning and gliding would have been good enough to have satisfied Torvill & Dean’s choreographer.

For example, Richard Daniels of the Dental Laboratories Association elegantly highlighted the massive drop in the volume of work being sent to dental laboratories since the new NHS contract was introduced. The distribution of the remaining work was also very different, with less complex crown and bridgework being done. Elsewhere it was stated that dentists were offering simpler and cheaper alternatives – acrylic dentures instead of chrome cobalt dentures, extractions instead of crowns, dentures instead of bridges.

Peter Ward (chief executive, BDA) was having none of it. The majority of practitioners, he reassured the public, could be relied upon to provide the treatment that was right for their patients – but he also made the point rather nicely that practitioners were working in the real world where income needed to exceed expenditure. The profession, he said, had been lumbered with a contract that nobody wanted, that was unfair and illogical in its design, and it was all the government’s responsibility, not that of the dentists – who were simply trying to look after their patients and make the new contract work.

Enter Barry Cockroft (chief dental officer for England), who pointed out that a fee-per-item payment system encouraged intervention. Intervention – and lots of it – had been necessary and desirable in post-war 1948, but that was no longer the case. The dental health of the population had dramatically improved and NHS dentistry now needed a contract which could maintain and reinforce that improvement. He agreed that less dentistry was being provided – fewer, smaller courses of treatment – but this, he argued, had always been the master plan. The whole aim of the NHS reforms was to encourage dentists to do less interventive treatment, and that is precisely what has been happening. Stunned silence. Well, thank heavens for that, then. And there were we, foolishly thinking that it had all gone terribly wrong – when in fact, it had all gone wonderfully right.

What nobody was asking, however, was the million dollar question. Was too much dentistry being done under the fee-per-item NHS? If so, perhaps the new, reduced level of intervention was actually nearer to being in the best long-term interests of patients, than the ‘old’ level. But who is going to tell the patients that were having all that treatment prior to April 2006 with the government’s blessing?

Up and down
There is of course a ‘windfall’ benefit of doing less treatment – lower lab fees, reduced consumption of dental materials etc – but what is a benefit to one person, is a disaster for another. What we are witnessing, as the new contract starts to bed down, is the gradual dislocation of the dental eco-system as we knew it.

How would you fancy being the owner of a large dental laboratory, facing a 50% drop in turnover? Or a specialist chrome cobalt laboratory (or specialist chrome technician) where stories abound of a reduction in throughput in the region of 80%-90%? There was a time when NHS dental practices were acquiring OPG machines as if they were about to go out of fashion. Well they certainly have now. And most dental wholesalers will confirm that far less of dentistry’s ‘raw materials’ are being purchased.

Just as the sales of bricks and other building materials is a fair measure of the buoyancy of the construction industry, these sales of dental materials are a useful measure of how much everyday dentistry is being done; even in the absence of the hard measures that once existed in Eastbourne. Another very obvious clue comes from comparing what dentists are buying in England and Wales, with what they are buying in Scotland and Northern Ireland, where fee-per-item still exists. If we are brutally honest, I think we are forced to concede that treatment patterns are strongly influenced by systems of remuneration. There is an abundance of evidence stretching back over many years to support this contention.

Fee-per-item didn’t encourage prevention and health promotion, and nor (I am sorry to say) does this contract. All the brave rhetoric of Options For Change in this connection is a distant memory, and that is a real tragedy, in my view. But it is also true that air rotors remove tooth tissue more effectively than caries ever will, and perhaps by providing some incentives to reach for the air rotor less often and to put it down sooner, we will be preserving more tooth tissue in other ways, after all. Come back Aubrey Sheiham – all is forgiven! You were right all along. Are you free for a TV appearance next Thursday?

It seems like only yesterday that the DPB’s Dental Data Services Division was trumpeting list sizes and the amounts of treatment of all kinds that were being carried out by NHS practitioners. More (of both) were seen to be good news then, and politicians (of all persuasions) dined out and took credit from the numbers that we were producing for them.

This year’s Alastair Campbell Memorial Award must surely go to Barry Cockcroft’s response to the reporter that asked him whether he was concerned about the sharp reduction in the amount of treatment being provided. Not at all, it seems, because this was exactly what was always intended. Now that lists have been abolished, and ‘less’ is apparently desirable, no doubt politicians will still be dining out and taking the credit for the reductions that we have facilitated? But don’t get too excited just yet – the auditors and Treasury haven’t had their say yet. Same money for less output? I don’t think so. The war of words has only just begun.

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