Kevin Lewis – heavy metal

In the 1960s – 1980s, the NHS system actively encouraged dentists to save and restore teeth, thereby creating today’s ‘heavy metal’ generation, explains Kevin Lewis. Yet the NHS is conveniently ignoring its ongoing responsibility to these patients, and abandoning them to an uncertain future.

In the 1960s – 1980s, the NHS system actively encouraged dentists to save and restore teeth, thereby creating today’s ‘heavy metal’ generation, explains Kevin Lewis.

Yet the NHS is conveniently ignoring its ongoing responsibility to these patients, and abandoning them to an uncertain future.

Something was stirring in the 1960s and 70s, which is still capable of making a deafening noise today.

I refer, of course, to heavy metal. 

Bands like Led Zeppelin, Black Sabbath and Deep Purple burst onto the scene at the end of the 1960s, and were followed by Alice Cooper, Judas Priest, Iron Maiden and many others in the 1970s. 

But the subject of this column is actually a different form of heavy metal that made its appearance around the same time. 

Introducing fees

During the 1960s, UK dentists put down their forceps and elevators and picked up their air rotors.

The first post-war decade or so had witnessed the profession using the newly founded NHS to deal with the mountains of unmet needs and untreated disease that had long existed. 

Prior to 1947, there was no NHS, and few patients could afford regular private dental provision.

Suddenly – for a few short years – dentistry was ‘free at the point of delivery’ (the mantra that some ill-informed or unthinking politicians still roll out today). 

Because it was a fee-per-item system set at very low levels (a fraction of the private fees), the BDA had advised the profession against joining the new cut-price scheme. 

But the tsunami of pent-up patient need and demand created queues outside the practices of the early adopters and the ‘stack em high, sell em cheap’ approach still added up to a welcome windfall – albeit very hard earned. 

This demand overwhelmed the profession in those early years, and the treasury shortly afterwards.

So, the first patient charges were introduced for NHS dentistry in 1951 – enough to dampen down demand a little, but still much cheaper than private dentistry. 

The golden era

But it was the advent of the air turbine in the 1950s and their more widespread use in the late 50s and early 60s that opened up new horizons for UK dentistry – and new problems for the government. 

The arm wrestle between the government and the BDA led to the latter commissioning the Tattersall Inquiry, which first described the unwelcome ‘treadmill effect’ of how the fee-per-item system was operating to the profession’s detriment. 

By this time, it had become increasingly practicable to prepare and restore teeth – even extensively broken-down teeth – instead of extracting them.

The 1960s-80s became the golden era of ‘quadrant dentistry’. When I say ‘golden’ I mean ‘silver’, because there were seams of silver amalgam running wall-to-wall through the nation’s molars and premolars.

Drill and fill

By the 1980s, the terms ‘drill and fill’ and ‘restorative cycle’ had entered the lexicon, and there was increasing concern about the growing pattern of regular repair and replacement of fillings, each time leaving progressively less natural tooth tissue. 

This heralded another new era with root canal treatments (RCTs), crowns and bridges in the ascendancy. 

In 1990, a new NHS dental contract was introduced – the first for over 40 years – with 20% of the previous fee-per-item spend being diverted to fund ‘continuing care’ (registration and guaranteed access) and capitation fees for children. 

But the government quickly decided that this new contract was proving altogether too good for patients and dentists, so patient charges increased and fees were radically cut in July 1992.

That contract limped on for a further 14 years, interspersed with periodic reviews and reports, proposals and pilots, only to be replaced by the ghastly 2006 UDA-based dog’s breakfast. 

But this time, the government had stumbled upon its holy grail – almost complete control of spend and the ability to steal money back off dentists and dentistry year on year, and to make patients pay a gradually increasing share of their treatment costs (often, all of them and sometimes, even more). 

Sympathy for dentists

The BDA has done an admirable job of briefing the media and politicians and thereby controlling the public messaging around the recent and current NHS crisis. 

The current crazy system isn’t working, and it’s no surprise that 50% or more of the population can’t find an NHS dentist when the government isn’t providing enough funds to cover even that proportion of the population, let alone address a backlog that has reached an epic scale.

Nobody is blaming dentists, nor suggesting that they have selfish motives in leaving the NHS in droves. Indeed, for the first time in my professional life, dental practices are getting a more sympathetic hearing than medical GPs, who seem to have become the new villains of the piece.

Heavy metal fatigue

But here’s the point. 

The very people who are amongst the most disadvantaged by the dearth of provision and capacity to deliver NHS dentistry, are the heavy metal brigade. 

All those mouths heaving with the restorative legacy of NHS-sponsored, NHS-overseen, NHS-sanctioned and NHS-funded dentistry since the 1960s, now can’t find dentists willing and eager to suffer huge financial losses to maintain, repair and restore them. 

This ticking time-bomb was knowingly designed into the 2006 contract; it has certainly achieved its aim of deterring the over-enthusiastic provision of extensive treatment plans. 

But is the application of the healing tongs and filling the void with acrylic instead of amalgam really the best that the state can offer them after all this time, effort and patient charges?

Many of these patients are now in retirement and may be unable to travel hundreds of miles in search of a dentist able and willing to take them on. 

It was the government that reversed the 1990 contract and its ‘continuing care’ provision based on patients being registered with a named dentist.

From that moment in 2006, patients ceased to be registered with their NHS dentists. 

Recent TV interviews with desperate patients have often included references to not having attended a practice for many years and being surprised that they are no longer registered or guaranteed access to dental care and treatment.

But it’s difficult to argue that ‘nobody told you’ when you’ve chosen to stay away for so long. 

When things went wrong

Back in 1990, patients were initially registered for two years, and dentists were paid some token continuing care fees throughout that period whether the patient attended or not.

In return, the patient had an automatic right of access to NHS treatment if they wanted and needed it. It was a two-way street and the CDO of the day referred to it as ‘a fee for being there’.

But within a couple of years, the government inexplicably (or cynically) cut those 24 months back to 15 months.

And in 2006, the government removed continuing care altogether and pocketed all the money saved. 

Patients are entitled to be disappointed and angry and should remind their MP that this was the (then) government’s bright idea.

The public, the profession and every business in the country knows you get what you pay for (and can’t reasonably expect or demand what you elect not to pay for). Only the government seems not to have woken up to that yet.

The BDA and the GDPC are quite right to have adopted a ‘neutral’ stance on the government’s interim proposals. 

They’re a small start but can’t be a substitute or stop-gap for the long-term solution needed, and patients and dentists alike have been waiting far too long. 

How the government’s negotiators can believe that anything less than fundamental, comprehensive reform can rescue NHS dentistry from extinction now, takes insanity to a new level. 

Talking of which, Ozzy Osborne – the lead vocalist for Black Sabbath – has lamented, ‘of all the things I’ve lost, I miss my mind the most’. He might yet be persuaded to offer his services to the government in an advisory capacity and would appear to be a perfect fit.

In his own words, ‘I used to get upset by people not understanding me, but I’ve made a career out of it now.’ 

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