The tooth, the whole tooth and nothing but the tooth.

There a lot of changes afoot in NHS dentistry and I sincerely hope they are for the better because the current system is seriously failing you and your children.  There, I’ve said it.  But this is only my very humble opinion, of course.

Every ten years, a dental health survey on children and young adults is carried out by The Office of National Statistics.  The last one in 2003, showed that 57% of children aged up to fifteen had experienced tooth decay.  That means the latest statistical report will be due out this year and I predict it to have changed very little and probably worsened in some categories, especially in the under fives.

Since 2006, the previous government changed the way dental contracts worked in the UK.  Dentists in the NHS now have to work to a unit of dental activity (UDA) scheme. Each UDA is worth approximately £20 to the dentist.  This system was brought in to encourage preventative dentistry and to eradicate ‘over treatment’. It has been very successful in achieving that goal.  Unfortunately, it now encourages ‘under treatment’ and prevention is at the bottom of the list.

Many of you may think that dentists earn a lot and won’t feel sorry for them, however, with the incidence of oral cancer, heart disease, diabetes and obesity all on the increase, which all have a direct effect on your oral health and are intricately interlinked (angina and other serious cardiac symptoms can manifest as dental pain), dental professionals play a crucial role in prolonging your life.

The current system puts so much strain on finances that it may mean that you and your children are not getting the standard of care you deserve.  More dentists are opting out and moving to the private sector. To cover the deficit, dentists that were trained outside the UK, to an unstandardised level of practice, are being brought in to work for NHS dental corporates.

A dentist is expected to carry out an examination which includes a risk assessment for tooth decay, gum disease and oral cancer, as well as take radiographs, carry out a basic scale and polish (should it be deemed clinically necessary – staining is a cosmetic issue), apply fluoride varnishes and give oral health advice, all for 1 UDA.  They have to work to NICE guidelines and under the Care Quality Commission delivering standards of cross infection more fastidious than hospitals.  They have to document everything from the batch numbers on each individual local anaesthetic cartridge to print out reports on every cycle of sterilisation.  Obviously, to protect the patient from infectious diseases but mainly to avoid litigation in case a patient decides that the check up they had 6 months ago was responsible for their Hep C infection.

The advantage of UDAs is a guaranteed income but someone else decides how many UDAs the dentist needs to achieve in a year in order to get funding to treat patients on the NHS.  This means should they fall short of their UDA targets then they have to pay the deficit back. This encourages an influx of treatments in the months running up to April.  Why is it that all service provider sectors that are budgeted each year are rewarded for spending all the money?  Schools, councils etc have to spend any money left over otherwise they lose it the following year.  That doesn’t make sense.  Why not reward the ones that saved the taxpayer’s money?  If you are a dentist working to brilliant preventative measures then your UDAs will decrease.  Surely that’s a good thing and should be rewarded?

A dentist wishing to deliver a high standard of preventative care for your child would ideally take 10 minutes to thoroughly examine them, take radiographs if necessary, apply fluoride varnish and send them for a session with the oral health educator to give them instruction on diet and oral hygiene.  This is what research shows significantly decreases the incidence of tooth decay in children.  For all this, the dentist would receive 1 UDA.  A lot of dentists take no more than five minutes per person for examinations in order to reach their targets and absorb the more costly, time consuming treatments such as root canal fillings.  It appears it just simply isn’t financially viable for a dentist to carry out the full scope of preventative dentistry and remain in business or maintain integrity or sanity.

On the subject of root fillings, it’s unlikely they’ll even bother with root fillings that are generally loss leaders.  Tooth extractions rose by 18% in the two years following the new dental contract in 2006.  And what if patients are exempt from NHS charges?  In the last quarter to June 2013, 60% of non-paying patients received treatment in the third band category (12 UDAs) as opposed to 28% of paying patients. Does this mean that patients that are exempt from charges are more likely to be on a lower socioeconomic scale, smoke and drink more and look after their teeth less?  Possibly.  Or does it mean that dentists can carry out more expensive treatment plans without the patients complaining about the costs (£214) and therefore work towards actually achieving their targets?  Probably.

Dentists may also split treatment between check ups.  You arrive for your check up needing two fillings – one is causing pain, the other is not and you are unaware of its existence.  It is not uncommon for the dentist to just do the important one and claim 3 UDAs.  When you attend your check up in 6 months, the dentist will then identify the second filling and carry out treatment for another 3 UDAs.  Why not just do both together?  Because the dentist would only get 3 UDAs regardless of whether you had to have 1 filling or 10.  So ‘splitting’ occurs.  I have been reprimanded many times for pointing out a cavity to a patient that the dentist had been ‘saving for later’ – nothing was in the notes of this cavity’s existence so no one is none the wiser.  Is this fraudulent or illegal? Not always and it’s a stupidly grey area.  “There are no specific rules forbidding dentists from splitting up courses of treatment into separate claims for component elements, although it does demonstrate sharp practice on behalf of the dentist who earns more UDAs and collects more patient charge income than is necessary.”  Fraud does, of course, take place.  Dentists create ‘ghost’ patients to make false claims and claim for treatment that hasn’t taken place.  Not to increase their salaries mind, just to meet targets.

Back in 2002, a government document deemed that ‘scaling and polishing’ was a more cosmetic procedure and could save the NHS £70 million by not offering it as a separate entity as 50% of scale and polishes were crudely deemed to be carried out unnecessarily. So the new UDA system places very little value on scaling and polishing.

“Undiagnosed and untreated gum disease is one of the fastest growing areas of litigation and complaints in dentistry.”  It is nigh on impossible to treat gum disease on the NHS.  I regularly see patients with gum disease that require initial treatment plans of four to six appointments.  This totals 2-3 hours of my time and that is just the first stage of treatment.  A dentist on the NHS would be expected to do this for 3 UDAs.  Therefore, your 2-3 hours privately is likely to equate to 30 minutes on the NHS and that’s presuming they’ve actually identified any gum disease in the five minutes allocated for the examination.

Dentists, hygienists, therapists or oral health educators are not generally remunerated for visiting your child’s school and giving an oral health talk, despite government apparently setting aside additional budgets for schools to spend on health.  In order for a dentist to check your child’s teeth in school, each child has to have had consent from an adult given in the form of a signature and even then, the dentist cannot inform the parent if decay has been noted as they wouldn’t be present at the examination and confidentiality means a third person such as a teacher could not be informed.

It’s crazy to think that tooth decay is one of the most preventable diseases in the UK. But for preventative dentistry to work, they have to reward prevention in the first place.  There has to be routine use of hygienists, therapists and oral health educators and financial rewards for dentists that apply fluoride varnish and place fissure sealants.  Oral health professionals must be utilised to provide regular oral health messages in schools.

But let’s not lay all the blame and responsibility at the government’s door.  Parents must take responsibility for their child’s diet and oral hygiene habits.  If you expect your child to be responsible for their toothbrushing at the age of 5, then expect them to do an insufficient job and get tooth decay.  If your child regularly drinks anything other than milk or water, then expect tooth decay.  If you give your child sweets to keep them quiet/reward them/cheer them up, then expect tooth decay.

So, if you are lucky enough to have a dentist that nags you and your children when you see them, that makes you feel defensive because they question your dedication to your child’s oral health and advises you on how to make things better, don’t ignore them.  Just be grateful they still give a shit in the crappy system they’re having to work in.

In the meantime, I’ll be keeping my fingers crossed that this government make a few positive changes to help oral health professionals deliver a better service.  I won’t be holding my breath though.

2 thoughts on “The tooth, the whole tooth and nothing but the tooth.

  1. How right you are. This system is making patients numbers where UDA targets are more important than quality of care. March is the crazy catch up month otherwise below 96% triggers a breach notice with possible removal of your whole NHS contract. Molar endo versus a fissure sealant to earn 3 UDAs…… comment.

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