‘She explained she had sold her dead mother’s jewellery to pay for the treatment’: dentist and clinical adviser Nishma Sharma opens up about the realities of dentistry right now, both for patients and for clinicians, and how a united front is the only answer to the NHS challenges ahead.
Please tell us a little bit about the impact the cost of living crisis is having on your patients
The impact is significant, extensive and affects everyone including private patients, NHS patients and dental teams up and down the country.
I work both within the NHS and privately and I am seeing worrying trends in both cohorts. For instance, a patient the other day who I’ve been seeing for years, who always, always goes for composite fillings, white crowns etc hesitated when I gave her the options. She asked if there was something cheaper as an alternative she could have.
She had to go for a £63 metal option against a £190 white one. She also asked if she could put treatment off into the new year. This is a lady who wouldn’t even consider amalgam before but now felt she had no choice.
People are really starting to feel the pinch.
Another thing I’m noticing is the number of patients putting off cosmetic treatments or cancelling last minute due to finances. Today I had two and a half hours of clinical time free due to last minute cancellations or patients who had been booked in for three fillings asking only to have one, due to money.
Out of toothpaste
But putting off cosmetic treatment is one thing, it’s quite another when oral health is at detriment. I had a single mother come in with her kids.
Her little eight year old had significant amounts of plaque on his teeth. When questioned, his mother explained it’s her fault as they ran out of toothpaste last week and she’d be getting some on Friday when she gets paid. I felt my heart break.
I asked my nurse to grab some samples to give to her. And I told her to come to me if she ever runs out again and I’d give her some more. People should never be in a position like this. It’s hygiene poverty and completely unacceptable in a country as wealthy as ours.
As patients feel the squeeze, the impact on hygienists is also significant. As a profession we are poor at promoting hygiene therapists as essential to treat and maintain gum health.
Instead, they are seen as a ‘cosmetic’ treatment option. This is, of course, worrying for DCPs and practice owners alike.
Patients not accessing care due to finances may also have a negative impact on the incidences of oral cancer going undiagnosed and thus untreated.
Knock-on effect
The stresses of the current crisis could lead to an uptake in undesirable unhealthy, behaviours in the population. For example, an increase in alcohol intake, and increase in the frequency of smoking and even comfort eating.
The knock-on effect being high caries rates, poor gum health, increased oral cancer rates and becoming a ‘high needs’ patient – precisely the type of patient finding it hardest to access care currently.
This then leads to the over-sensationalised ‘patients pulling out their own teeth’ headline which makes us all look like uncaring, greedy ba*****ds. I hate that.
It’s important to remember that the cost of living crisis doesn’t just impact patients. But will also take its toll on dentists and dental teams.
As patients stay away, and materials, stock and utility bills rocket, practices will again need to withstand the strain of unpredictability and uncertainty.
I especially worry for our dental nurses. They will probably be hit the hardest and welcome the small win of the GDC not increasing the ARF for DCPs.
I believe many are still suffering varying levels of PTSD since Covid; who knows how profound an affect the next few months will have on the mental health of the profession and the population at large.
How does it make you feel as a clinician?
It makes you feel dreadful when you have these incidents that are coming in thick and fast.
We are health care professionals at the end of the day and our duty is to our patients and their wellbeing, but it feels there is a tension between this and our ability to make a living.
A few weeks ago, a patient started crying at the end of her appointment when she saw the cost. She said she just could not afford it right now. So I was surprised when she booked in to have the treatment a week or so later.
She explained she had sold her dead mother’s jewellery to pay for the treatment, but not to worry as she ‘still had her wedding ring and chain she wore every day’.
I couldn’t believe how hard it was to hear that and could feel myself welling up. She said: ‘I can hear my mum saying just sell it love, you’re never gonna wear it and your teeth are much more important.’ It was horrible. My nurse and I worked in silence and the burden of guilt was immense.
Is this what we’ve come to? To sell off jewellery to access oral healthcare?
I’ve been asked to extract a perfectly saveable upper left 4 as the patient couldn’t afford a band 3, I refused as I just didn’t think it was ethical or the right thing to do. To be brutally honest, I also did not know where I stood medico-legally.
Questioning morals
I hate that we are in this position. I hate that the way we are remunerated puts us in this grey area of questioning our own morals, duties, integrity, ethics, ability to support ourselves, having to bear a burden of guilt.
There are times when I feel awful and overly privileged. I know what it is like to come from an unaffluent area living in a two up, two down terraced in Leicester, so I ask myself what more I can do.
I do think as a profession, we really need to step up and come together to tackle the hardships some in society are facing. We are healthcare professionals. There are little things we can do, like helping those who can’t afford toothpaste or toothbrushes.
We know when we have patients who are struggling, we should ask ourselves what can we do to show a little kindness, however small that may be. It could mean the world to them.
For instance, where we can do something on the NHS for patients in pain, we need to do it. We do have the capacity if we look hard enough. If we can see them and get them out of pain, this is the very minimum we should do as healthcare professionals.
Imagine visiting the doctor with a huge pain in your chest. But the doctor says: ‘I really can’t see you today on the NHS, I’m sorry, but I can see you privately for £200.’ We aren’t helping ourselves.
If a patient comes in and there’s a lot that needs doing but they just want one tooth looked at, then just look at that one tooth. We may not be able to take on full mouth rehabs for the ludicrous fees the bands attract, but helping someone in pain? Think of the karmic dollars!
What are the key issues affecting dentistry right now?
For who? Patients or the profession?
For the profession, the rock bottom demoralised NHS workforce and the two tier system that currently exists perpetuating the grossly obvious health inequalities in this country are the biggest challenges at the moment.
For patients, the inability to understand why they cannot access NHS or affordable oral health care when they or their children need it.
NHS dentistry is not at crisis point; it was at crisis point four or five years age – we’re way past that point. It’s now at breaking point and dying a long drawn-out death.
Contract reform is no longer a can kicked down the road. It’s a battered little ring-pull discarded in the long grass on the side of the M25.
It’s all very well examining the problem. I know too well how complex an issue it is having sat around the decision making tables myself with Eric Rooney a lifetime ago. Standing back and admiring the complexity of the issue is as useful as frozen composite.
We need a steer. We need answers. We need transparency. We need it now.
‘Nightmarish limbo’
The current system is failing everyone. Dentists, DCPs, dental auxiliary staff, other pillars of primary care, A&E, society.
It is despicable that we are in a situation of haves versus have nots. If you can afford private, you have access. If you can’t, you’re stuck in this nightmarish limbo of being passed from practice to practice, 111 to OOH service, practice to practice.
And, as always is the case, the ones most affected are those with the least. This is ethnic minoritised groups, people in lower socio-economic brackets, children, single parents, vulnerable adults, those without a voice. Always those who are most vulnerable in society.
Working in the NHS, for me, isn’t really about the money. But then that’s easy for me to say as I work in a fairly affluent area with minimal high needs.
For me, it’s the terms and conditions of service. It’s the bureaucracy, it’s the red tape, it’s the petty little forms and audits and tick-boxes. It’s the nebulous nature of the ‘shopping list’. It’s the idiocy of the banding. It’s the ill-feeling of the academics of dentistry not marrying up to the contract of dentistry. It’s the inner conflict of doing what’s right but taking the hit. Again.
DHSC needs to decide what it wants: a little bit for everyone, or a lot for a few? It cannot be both. It’s impossible under the current financial envelope.
What needs to happen?
I feel it is highly offensive to string along a professional workforce the way it has been. We are tired, physically and mentally and if push comes to shove, we will jump.
The only way to make it work is to get frontline, NHS practitioners onside by being open, transparent and reasonable.
Many of us want to work for the NHS. I’ve been doing it for 20 years, but it has to be better. There have to be incentives, so incentivise it. Make it easier, clearer, less stressful, fairer.
Remove the obstacles and red tape and the feeling that you are some how inferior to a private practitioner for working in a system that is fundamentally broken.
Remove breach notices, create agility to the contract, allow parity to the specific dental disciplines. Why is there not as much onus on periodontal treatment as there is on endodontics?
Survive the NHS challenges
Private dentists appear to be living the dream and this is the two-tier system I alluded to. There seems to be a drive to ‘go private’ like it’s the panacea. I don’t think it is the panacea, actually, but an alternative. There’s still a lot of pressure within private dentistry, such as books drying up, patient expectations, the fear of litigation.
The implication that if you work within the NHS you must be a bit rubbish. But if you work in private practice you must be better qualified and a much better dentist, never fails to offend.
We also need to highlight this to patients – that working as a private dentist does not mean you are more capable, experienced or qualified. I work in both sectors and teeth are teeth, patients are patients.
There needs to be more respect towards each other and our DCPs. We are in too a precarious state to turn on each other with infighting when a united front is the only way we will survive the challenges ahead.
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