Published: 31/10/2002, Volume II2, No. 5829 Page 33
With the nation's oral health improving, dentists are having to turn their attentions to pressing new areas of innovation - and maintaining income is high on the list.
For most of us,£60,000 a year would be inadequate compensation for messing about with the snaggle-toothed mouths of the average Briton.
And it would seem that the dentists agree.
The Audit Commission's report on dentistry is not the first to identify the way dentists are paid for their NHS work as being at the root of a problem which manifests itself in perverse outcomes for patients.
1It also, no doubt, contributes to the fact the general dental service is one of the most significant areas of fraud in the NHS.
The fee per item of work system of payments appears, in the view of the British Dental Association, to have turned dentists from professional healthcare providers into businessmen, 'and they have responded admirably'. The news that dentists' work may be driven more by the way they are paid than the needs of patients will not come as a shock to most people.
While directly linking dentists' NHS earnings to the volume of work they undertake was a straightforward way of ensuring that the enormous unmet dental needs of the population were tackled quickly, what was appropriate in 1948 very soon became a problem.
Anyone aged over 40, for example, will testify to unnecessary drill and fill treatment - which in turn has meant regular return visits to repair weakened teeth.
But alongside the essentially unchanged payment system, Britain's oral health has been improving for years - thanks in part to changes in caries interventions, better diets, water fluoridation and fluoride toothpaste.
With less 'traditional' work to do, but with unchanged expectations for the size of their incomes (and with the number of dentists growing at 3 per cent a year), dentists have turned to new treatments to maintain activity, and hence payments. Orthodontic treatment is, for example, one of the fastest areas of growth in dental work, with payments doubling over the last five years.
However, as the commission's report notes, such treatment (and others such as the use of white fillings, which do not last as long as amalgam but look better, and scaling and polishing activity - up by 12 per cent since 1991) are often more cosmetic than medical.
The view that dentistry has for years been sliding out of the domain of medicine and into the realm of the cosmetic perhaps explains successive governments' laissez-faire attitude to GDS. It also partly explains the almost total lack of control and direction NHS commissioning bodies have over GDS: 'Commissioners cannot regulate numbers of dentists or where they practise... nor influence total costs or prioritise what is spent where, on what and on whom.'
Changing the payment system to one more reliant on capitation rather than fee per item can change incentives, improve patients' and dentists' satisfaction - as evidence from personal dental service pilot schemes have suggested. But PDS currently covers just 1 per cent of the population. What is needed, argues the commission, is not just a change in the payment system, but possibly more effective management levers for NHS commissioners and greater empowerment (ie more information) for patients so they can obtain dental care appropriate to their needs.
Toothache: from the patient's mouth
'I am in for a bad time. But then so are you. You have got to look inside my mouth.
My lower teeth are merely very poor. But my upper teeth... I have a bridge that runs from ear to ear. All That is keeping it in, as far as I can tell, is habit. The whole trouble is hereditary, together with inadequate care early on. My mother had okay teeth and bad gums. My father had okay gums and bad teeth. I've got bad teeth and bad gums.'
Author Martin Amis talking to his dentist before being informed: 'The uppers are shot. At any meal you could be sitting there with your teeth in your hand. They go Monday. You do not have a choice.'
Experience. Jonathan Cape, 2000 (p77-78).
'I am constantly reminded that if I do not come in for regular (six monthly) checkups, then I will be struck off as an NHS patient.'
Patient, London. Audit Commission employees' survey.
'A client had to have four teeth removed. The bill came to£354... He paid£100 and continued to pay the remainder in small amounts when he could afford to. The dentist would not provide him with his replacement teeth until the full bill was paid... two months after the extraction [the client] complained that he was not able to eat properly.'
National Association of Citizens Advice Bureaux. Unhealthy charges: CAB evidence on the impact of health charges, 2001.
'You're totally in their hands. You hear horror stories of people that have had 20 fillings, paid x amount of money and didn't need them in the first place... You have got absolutely no way of knowing.'
Patient, London. Audit Commission focus group.
'[I] am 'encouraged' to go for private treatment - for example, white fillings, as I am told that this is better in the long run for teeth. Obviously, I have no idea if this is true.'
Patient, London. Audit Commission employees' survey.
'Some of them like working within the NHS, what they call 'Bash the Nash' Somebody who needs four crowns, they fit six instead... It is a mess.'
Dentist. Silvester S et al . Public or private? Dental practitioners' beliefs, values and practices. Centre for health services studies, Kent University, 1998.
'The current remuneration system is poorly matched to present needs. It has lost the confidence of the profession and others.'
DHSS. Improving NHS Dentistry. Green paper. HMSO, 1994.
REFERENCE 1Dentistry: primary care dental services in England and Wales.
Audit Commission, 2002.
John Appleby is chief economist, King's Fund.