Why the NHS never gets the message about dentistry

Prevention and oral health promotion should be a first priority, but have always been an afterthought in NHS thinking – expected but never funded, says Kevin Lewis.

A lot has been said and written in recent weeks about what a satisfactory resolution of the Russia-Ukraine war might look like. I am at a slight disadvantage here, as I am writing this column ahead of any such resolution but in the hope that one is imminent.

The world had closed its eyes and sat on its hands when Russia invaded, occupied and effectively annexed Crimea a decade ago but especially since the new US president was installed, it has seemed increasingly likely that history would repeat itself in relation to the occupied territories in eastern Ukraine and Russia may yet be allowed to keep its ill-gotten gains.

What this might presage for the new world order, for Taiwan, for other parts of Eastern Europe, for the Middle East (not to mention Greenland and the Panama Canal) and elsewhere is unthinkable – but nevertheless a chilling reality for us to contemplate. If ‘help yourself to whatever you fancy’ is OK for some countries, who is to say that it is bad for other countries?

Reward and behaviour

Long, long ago, when my two offspring were still young, I was travelling to Ireland to speak at the annual conference of the Irish Dental Association for the very first time – a privilege that I subsequently enjoyed on several further occasions. One of those times was when one of the aforementioned offspring had grown up, graduated and was himself lecturing on the same conference programme. A treat indeed.

Anyway, in the airport on my original trip to the IDA Conference my attention was drawn to a book featuring a large carrot on the front cover. It was written by a US business guru Michael LeBeouf shortly before he retired, and was called How to Motivate People. This chance addition to my book collection ended up teaching me a lot, and in many unexpected ways.

LeBeouf asserted that in all aspects of life you get more of whatever kind of behaviour you reward the most. This statement is often slightly misquoted as ‘the things that get rewarded and appreciated, get done’– although that’s probably true too. But the underlying principles relating to reward apply to parenting as much as to business management and indeed, to most of our dealings with third parties.

The corollary is that when somebody acts in a way that pleases you, but you don’t show or voice your appreciation, then you have no right to expect that they will invest the same amount of time and effort next time around. And it follows that if you reward (or fail to act upon) the wrong kind of behaviour, don’t be surprised if you get more of it. The parallels with Russia’s illegal invasions of Ukraine in 2014, and again three years ago, are striking. Economic and other such sanction do demonstrate disapproval – but they don’t restore the status quo.

Carrots and sticks

Successive governments here in the UK have used carrots and sticks in varying measure to drive the behaviour of both companies and individuals. We have seen it in the differential taxation of motor fuels, and in relation to engine sizes, to incentivise home insulation and energy efficiency, to penalise the use of fossil fuels, and in the duties on alcohol and tobacco and (next year) vapes too.

Dentistry and oral health got a glimpse of it in 2018 with the introduction of a sugar tax – or more precisely, the Soft Drinks Industry Levy (SDIL) to encourage the lowering of sugar levels in soft drinks. But dentistry had been introduced to the approach from 1948 at the start of the NHS, when the government needed to persuade initially reluctant and distrustful dentists to offer NHS treatment notwithstanding the emphatic advice of the BDA not to do so.

The carrot was an almost limitless supply of patients and huge dental need, and a wholly fee-per-item system (albeit at bargain basement pricing relative to the going rate privately). At a time of post-war austerity, NHS treatment was free to all patients so there was no disincentive for them to seek treatment either. Within three years, the government was shredding the carrots and reaching for any sticks it could lay its hands on – cutting the fee scale, adding a range of terms and conditions for certain treatments, and introducing NHS patients charges for dentistry. The incentives were clearly never intended to work that well.

But the advent of the air rotor in the late 1950s and 1960s meant that dentists’ productivity and output rose exponentially and a remuneration system created for a different set of circumstances no longer made any sense in the new world – especially not to the government which again responded to successive rises in dentists’ gross earnings, with successive fee cuts – the so-called ‘treadmill effect’ of the fee formula in place at that time.

Reverse incentive

Matters had come to a head by the early 1960s and the 1964 Tattersall Report concluded: ‘There is no future for the profession, or indeed for general dental practice as an art and a science, in the system of remuneration as presently operated’. He was referring not just to a fee-per-item system, but one which incorporated an annual rebalancing mechanism designed (or at least, intended) to deliver an agreed target gross and net income to individual dentists.

In reality, what it achieved was an outcome where the majority of GDPs earned less than the intended net income – so each year they worked harder and longer to catch up and in doing so the average gross income rose, the collective balancing mechanism kicked in and fees were cut. And so it continued…

‘The very idea tells us that there are some sensible and rational people working either in general dental practice, or in the bowels of DHSC – but not both’

Successive reports from Tattersall, the Dental Strategy Review Group (1981), Bloomfield and the Health Select Committee (1992/93), Options for Change (2002), Steele (2009) through to the dental recovery plan a year ago – and many other stops in between – all stressed the urgent need for a more preventive approach. But each and every time, the system continued to reward active treatment interventions, productivity and output/volume, rather than specifically rewarding prevention.

Even the 16-year experiment with capitation (for children) 1990-2006 was clumsy in design and implementation, despite the additional one-off ‘entry payments’ and Jarman deprivation adjustments having blunted some of the disincentives to taking on children with high dental needs.

Blind spot

The blind spot in successive remuneration systems has been the failure to recognise and reflect the costs side of the general dental practice equation. Learning no lessons from history, the ‘new patient premium’ has been the latest (albeit stunted) carrot offered for seeing ‘new’ patients that haven’t attended for two years and need Band 1 treatment (+£15) or Band 2/3 treatment (+£50).

Word has it that this incentive hasn’t delivered the anticipated transformational increase in acceptance of these groups, and the ‘bung’ may yet be withdrawn. Such an act would be an uncomfortable reminder of the cynicism of the government, but the very idea tells us that there are some sensible and rational people working either in general dental practice, or in the bowels of DHSC – but not both.

Whoever would have expected a transformational effect in the first place? Meanwhile, choices made by the government are continuing to add to dental practice operating costs, with the hike in employer national insurance adding to the pain next month. An incentive ceases to be an incentive at all if it is overtaken by additional costs and it is insulting that GDPs are seemingly viewed in the same light as laboratory mice.

Tattersall spelled out the designed-in flaw in the balancing mechanics that costs are not the same for all practices, and if he could work that out 60 years ago, one wonders why and how it can still be so difficult to grasp today. Even in the same part of the UK, in the same dental deserts, even in the same high street, you would need to incentivise practices differently to achieve the same outcome because they all start from a different position cost-wise.

Cynical approach

In the 1960s-1980s the fee per item system rewarded and encouraged volume dentistry because it was much more cost effective and profitable to treat multiple teeth at the same sitting than place a single restoration on a single tooth. This applied to both fillings and fixed restorations and by 1986 the Schanschieff Report on the prevalence of unnecessary dental treatment followed a TV exposé Drilling for Gold.

In 1990, with a fee per item system still in place for adults, registration and continuing care introduced a further incentive and just as in 1948, GDPs found the lure of ‘extra’ continuing care payments irresistible – not realising perhaps that they had been bribed with money that was already theirs in the first place, but had simply been stripped out of the fee scale and redeployed. But here again, the government got more of the kind of behaviour it had chosen to reward the most. So much more, in fact, that they hated it and started changing the rules and cutting fees within little over a year. The government’s supply of sticks seemed inexhaustible.

If the government really is as serious as it now claims to be about wanting to encourage prevention and oral health promotion, they will need to find a way to incentivise it, after 70 plus years of just expecting it while actually penalising it and preferring to reward things that are more tangible and more easily counted – like courses of treatment and treatment activity within them, and patients seen.

Unfortunately, the longer the government sits on its hands, the more patients drift off to the private sector and that – for government if not for patients – is a win of sorts unless and until they are called out on the cynicism of that approach.

Why the NHS never seems to get the message about dentistry