Kevin Lewis examines why patients, dentists and the government all want to control the frequency of attendance.
‘Do you come here often?’
Probably not the most original chat-up line, I grant you, but a question which keeps cropping up in discussions about the delivery of primary care dentistry.
I participated in a lecture series 35 years ago around the UK on behalf of the British Dental Association (BDA) and the Department of Health. My fellow speaker on that tour was social researcher Helen Finch, who had just published her team’s research (jointly commissioned by the above parties) on falling patient attendance patterns at that time (Finch, 1988).
The catchphrase of the time was ‘the missing 50%’, which seems rather quaint against the backdrop and scale of today’s dental crisis. How today’s government must wish that they could claim that 50% (or even 30%) of the population was seeing a dentist reasonably regularly.
Back in 1988, it was the patients who were missing and the dentists who were looking for them – in 2023, it is the dentists who have gone missing and the patients who form the search party. But the result is the same in that dentists and NHS patients have once again become involuntarily estranged.
Low on the priority list
Helen Finch’s research challenged some traditional assumptions and suggested that the patients who were staying away in 1988 were not all doing so for the same reasons – the list included cost, fear/anxiety, a family history of dental apathy and/or patchy attendance, accessibility and practical logistics (such as for the elderly, medically compromised, disabled and those with large families or who are reliant on public transport in rural areas).
There were huge geographical variations in the distribution of dentists and dentist-to-patient ratios across the UK, which created a problem for some. The reality for many was attending less often, rather than not attending at all, while for many patients with no immediate problems, visiting a dentist just wasn’t sufficiently high up on their list of priorities. It’s that simple, although sometimes, we tend to overthink it.
Critically, the conclusion of each episode or course of NHS treatment summarily ended the contractual relationship, anyway.
Within a couple of years, the government had decided that there needed to be a more binding and lasting attachment between NHS dentists and their patients. To engineer that, it introduced in 1990 the concept of patient registration (continuing care and capitation), which guaranteed access, 24/7 emergency care and a number of other patient rights and benefits, initially for two years at a time.
This more onerous new level of commitment wasn’t matched with any new money, however, because it was funded by diverting 20% of the previous fee-per-item fees.
It only took about nine months for the government to decide that dentists and some patients were now seeing each other too often, each time re-triggering a new period of continuing care and capitation and creating the opportunity for dentists to provide treatment and generate revenue on exempt patients without the restraining effect of patient charges.
Meanwhile, dentists were even being paid for the patients who stayed away, which was somewhat rubbing salt in the wounds. To counter this, the continuing care period for adults was slashed after barely a year of the new scheme from 24 to 15 months.
So, millions of patients found themselves ‘registered’ with a dentist one minute but not the next. Given that their registration with their medical GP was continuing and open-ended, they were understandably baffled and blamed the dentist for ‘de-registering’ them.
Weaponising dental charges
NHS dental patient charges are another device used by successive governments in a variety of ways over the years.
There were no such charges at the start because they had promised a ‘free at the point of use’ service, unmet dental needs were colossal, and politically, they needed patients through the door. But a few years later, the government didn’t like how much all that ‘free’ NHS dentistry was costing, and the first charges were introduced to apply the brakes.
Charges are often simplistically and mistakenly seen as primarily (or only) a covert means of revenue collection, but while NHS dentistry remains free at the point of use for charge-exempt and remitted priority groups, charge-paying patients pay most or all (or for some, more than) the actual cost of their treatment.
But even for those who pay the lion’s share of the cost, the NHS delivers price control, and indeed caps the cost to patients irrespective of where they happen to live and work, at a level way lower than private dentistry would cost in the same area – and that is an undeniable if unheralded benefit.
Charging systems are used as a strategic weapon too, in that they have been shown to deter attendance both generally and for specific patient groups with different levels and types of need. As Finch pointed out, free dentistry only becomes a benefit if you attend.
Likewise for the government, but in reverse – the current charges system is loaded so that it costs the government little or nothing (and can even generate revenue) when the charge-payers attend. The main risk is that too many exempt patients will attend, needing lots of treatment.
Notionally, to remove a perceived barrier to attendance, there have been periods when all checkups were free in England and Northern Ireland (not any more, of course).They are still free in Scotland and for target groups in Wales (the under 25s and over 60s), but this wide variation illustrates that these are primarily political decisions with very little compelling research to justify them.
The classic example of that was the original National Institute for Health and Care Excellence (NICE) guidance on dental recall intervals. In truth, the subplot was all about fracturing the relationship between dentists and patients, and the dependency of patients on the apocryphal ‘six-monthly checkup’.
Governments don’t like these cosy little cabals of dentists and their patients regularly spending the Treasury’s cash, so plan ‘A’ consists of keeping them apart for as long as possible and plan ‘B’ is to ensure that wherever possible, the patients who do attend are spending their own money, not the Treasury’s.
Relationships and rapport
While there’s a strong body of evidence to support the view that extending recall intervals isn’t materially detrimental to the oral health of most patients, the adverse impact on some patients is massive.
Nobody sues the government or NICE when an oral cancer is missed. Stronger relationships and rapport cannot be built overnight or in absentia, and while absence may make the heart grow fonder in some areas of life, dentistry relies on a relationship of trust and confidence which benefits from regular face-to-face reinforcement.
The government’s understandable wish to keep costs under tight control doesn’t justify its denial of the many collateral benefits of regular attendance. There is overwhelming evidence that risks are much greater when treating patients that you see infrequently and/or don’t know well, and similarly that a clinician’s best protection against complaints and litigation is the deep well of goodwill that exists when relationships are strong and regularly reinforced.
Many dentists like patients to attend more often than NICE or the government might prefer, but for different reasons that are no less valid and should be respected on their own merits. But creeping up on the rails is yet another twist in this debate, which is the proliferation of ‘single episode’ dentistry targeting big-ticket private treatment procedures, particularly of a cosmetic nature.
A specific dental procedure becomes a one-off, often branded, commodity which can be promoted online and on social media, bought and sold like so many other consumer products. Surfing the wave of consumerism and self-image, it maximises short-term income and profit, and builds a client channel from past ‘successes’ and online testimonials with minimal ongoing commitment.
The aim is not to lay the foundations for long-term routine care and maintenance, because that’s a different, less attractive and less profitable market. The nirvana is a series of lucrative ‘one night stands’ with relative strangers, and the direct opposite of the traditional long-term family GP approach, the intention of which is to provide long-term, holistic, continuing care whereby yesterday’s child patients become tomorrow’s young parents and the cycle of care continues.
The government’s mood music is to re-introduce some form of NHS registration, but on what terms this time around, we ask? And for whose benefit?
The government is deluded if it believes that keeping the regular attenders registered but at arms length will create an irresistible back-draft to suck in all the non-attenders. The relationship between dentists and their patients is personal to the parties, and political attempts to subvert, undermine or interfere with it, however well-intentioned or honourably motivated, need to be ‘outed’ for what they are.
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