Brace yourself

With all the recent media headlines, are dentists starting to be portrayed as the friend and champion of patients, not the enemy, asks Kevin Lewis

Call me paranoid if you will, but I don’t recollect anyone blaming builders for the fact that lots of people cannot afford to buy a house, nor even that there are not enough houses for people to buy. Nor even – if I am pushed – that there are not enough houses for sale that people can afford to buy in the particular parts of the country where they wish to live.

January 2019 – and the closing months of 2018 – were notable for the press coverage of access to dentistry, and it was certainly a mixed bag. I have referred previously, and critically, to the desperately badly managed recommissioning of orthodontic services by the NHS in the south of England, which was a timely reminder that as far as NHS commissioning is concerned, cheapest is always best.

The latest manifestation of this arises in Gloucestershire, where a similar retendering process has resulted in a significant reduction in the number of providers of NHS orthodontic services for the new financial year commencing in April. Gloucestershire covers well over 1,000 square miles – much of it extremely rural – so this will cause massive and prolonged upheaval for many families who will regularly face awkward, long and time-consuming journeys, extending time off school and work for those concerned.

In the short-term, waiting lists will get even longer and some patients who have already been waiting years to start their treatment with one orthodontist, will have to join another queue for a different orthodontist that they did not choose for themselves in the first place. So much for patient choice that the NHS keeps banging on about. Perhaps the NHS should consider changing the name of the ‘NHS Choices’ website to avoid infringing the Trade Descriptions Act?

Commissioning orthodontic services from fewer providers creates added leverage to drive down the cost in return for offering extra volume, and that is exactly what happens. It’s classic procurement behaviour, but like most procurement, it is unconcerned about quality or patient experience or the impact on third parties. 

The inevitable economic consequence of this when the first round of retendering took place was that many practices who found themselves unwanted and unloved by the NHS, offered their orthodontic services privately rather than through the NHS. And the media was faced with the challenge of deciding who to blame for this – or rather, the media decided that this question needed to be asked, irrespective of whether or not patients were actually asking the question themselves.

The broad consensus of the media decided that the blame was shared between the NHS (for limiting its investment through the back door of the commissioning process), and a few dentists who were ‘gaming’ the system to pressurise and persuade parents to agree to having their children treated privately instead. 

Excessively long waiting lists for NHS orthodontics – as long as six years – were cited. A spokesperson for the GDC was quoted as having confirmed that some orthodontists were definitely deliberately denying patients access to NHS orthodontics that they were entitled to, so that they could make more money out of them privately. Thanks for that vote of confidence – nice to know that the ARF is being put to such good use isn’t it? Think how many more spokespeople the GDC could employ if we all chipped in a little more.

One strange (and probably incomplete) story claimed that a dentist had ‘deliberately’ delayed starting orthodontic treatment for a 13-year-old whose parents had refused to pay £3,000 or so privately in order to get started sooner. By the time the NHS treatment started, the young man was over the age of 18 and had to pay an NHS patients’ charge of £233. The missing part of the story, if true, was that the dentist did offer NHS orthodontics and did earn a lot less than he/she would have earned privately. Anyway, no dentist should be criticised for having been placed in that position. 

The blame game

The BDA was quick out of the blocks over the orthodontic commissioning issue in the first round, and again only a few weeks ago with press releases that took the media initiative and firmly grasped the agenda on both occasions. It did it again last month regarding the ‘disappearing dentists’ story concerning a million people not being able to find an NHS dentist. The story started life quite innocently, falling out of NHS England’s 2018 patient surveys.

The ‘one million patients’ statistic might make for a catchy headline, especially when twisted into ‘NHS dentists turned away one million people in pain’ (The Times). But the truth was that 22% of one sample of around 370,000 patients, reported that they could not register with an NHS dentist – extrapolate that and you get a million across the country. 

It tells us nothing about how hard they tried, or regional or local variations or whether or not they were in pain or whether it was even true. Nor does it throw any light on any back-story; it is hardly surprising that respondents who applied for treatment at a practice they had never attended before were less successful in getting an NHS dental appointment than longstanding patients and regular attenders at the same practice. 

Had it been the opposite, dentists would have faced the same criticism as car insurers and others who have recently been accused of overcharging loyal, uncomplaining, regular customers in order to offer discounts to new customers or those who kick up a fuss.

The media seems to have an inexhaustible archive of quotable members of the public who have extracted their own teeth with pliers. I am surprised there is not a national plier shortage. We got introduced to another one this time who, we are told, had waited 18 months to see a dentist. And that is all we were told – why spoil a good ‘DIY’ story? 

Before more pliers appeared, the BDA was at it again. This time with Henrik Overgaard-Nielsen holding the Health Secretary’s feet to the flames fanned by the open letter from 16 MPs UK-wide regarding NHS dental access problems.

The BDA has somehow owned and commanded the recent narrative to such an extent that most of the analysis concluded that it was all the fault of the 2006 contract in England and Wales (which ended continuing care and recalled attendance fees) and more recent commissioning changes, which have led to the government only funding dental care to a level that pays for half of the population to access dental care in any year. It is so simple and such a no-brainer that you just can’t argue with it – but NHS England was forced into having a damn good try.

Sunny side up

Even before the news broke about yet another shambles, this time involving the commissioning of paediatric dental service in London, and leading to major teaching hospitals having to put up the shutters to new patient referrals, NHS England quickly rolled out other findings from its own surveys.

Like the fact that two fifths (41%) of those who responded had not even tried to get an appointment with an NHS dentist in the last two years, 25% had never tried to get an NHS appointment and 16% had tried two or more years ago and hadn’t tried again since. And 93% of those who tried to see a dentist were successful in getting an appointment, a success rate of 95% when excluding the ‘can’t remember’ category (a classification that itself seems noteworthy?). Of those who saw a dentist, 85% rated their NHS dental experience as positive (52% very good, and 33% fairly good). 

And in one media report after another, all this became the story, helped along by another cracking good intervention by the BDA. Practices can’t fill vacancies or recruit extra dentists no matter how much they want to, because the government is taking money back off dentists and out of NHS dentistry, rather than reaching more patients by investing in it.

Eddie Crouch, as vice chair of the PEC of the BDA, continued: ‘…these aren’t just patients seeking a regular check-up. They are often people in pain, left without the care they need… It’s the patients who need us most who risk losing out.’ And, of course, Eddie is right.

I don’t think any of this would have happened five or 10 years ago. Over the years, The Mail on Sunday has hardly been slow to bash dentists when given half a chance – but even it ended up choosing the headline ‘£6,000 kick in the teeth: parents are forced to pay out for children’s braces the NHS refuses to fund.’

Overnight, dentists are starting to be portrayed as the friend and champion of patients, not the enemy. And isn’t it a funny old world when NHS England has little option but to enter the fray on the side of dentists in order to protect itself from criticism?

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