Care v Cash: co-payment in NHS dentistry

This week in the media dentists are being accused of greed, false advertising, hiding prices and misleading patients about their services.  Headlines included: ‘How greedy dentists are fleecing families’ and ‘Dentists falsely advertise NHS slots then refuse to offer appointments’.  Dentists have hit back stating that the NHS payment system is so complicated it is hampering dentists ability to provide care and that more money is needed to enable dentist to provide the quantity of NHS care that they would like to and to avoid the kind of shortage we have seen in the past.  This echoes arguments made in an earlier post on GP shortages.

This latest story builds on research published this week by Which? reporting that patients are finding it hard to access NHS dentistry and that information provided by the NHS on availability does not match the reality.  For example, 3 out of 10 dental practices advertising NHS availability were not actually taking on new NHS patients and even those that were taking on new patients often had long waiting times or made registration unnecessarily difficult.   In January, the same group of researchers found that half of dental patients were unaware of the cost of their treatment upfront and of which treatments were available on the NHS and which were not.  In some cases teeth are being extracted rather than restored as under the NHS payment system the dentists receive the same money for either course of treatment and extraction is quicker and does not require repeat appointments, and patients also felt unable to refuse expensive hygienist appointments and other additional expenses not included in the NHS tariffs.

This latest round of claims and counterclaims is merely the most recent in an ongoing debate about how dentistry should be provided and paid for. The discussion is built on twin foundations of the long history of co-payment within NHS dentistry and ongoing negative media representations of dentists and dentistry.

When the National Health Service was first introduced dental care was free at the point of use, in line with all other forms of healthcare.   As with other areas of healthcare the new dental services proved overwhelmingly popular and the huge public demand for dentures, nicknamed the ‘denture dash’ (BDA 2012) at the start of the NHS meant that within the first 9 months of the NHS 33 million artificial teeth had been supplied.  To limit public spending charges were introduced for spectacles and dentures in 1951 and eventually for prescriptions.  Unlike general medical services, dental services provided by general dental practitioners continued to be a mix of private and NHS care, with the subsidised charges for NHS dentures being followed by charges (co-payments) to cover routine dental care.  Charges were made according to an itemized list of treatments.  By 2006 over 400 treatments were separately itemized for charges.  The charging system was simplified for patients in 2006 but the co-payment system and continued lack of public awareness about the pricing structure and how it works, when combined with the drop in the number of NHS places being offered by dentists from the mid 1990’s onwards, makes for low patient satisfaction levels.

The difficult position in which dentists have found themselves with regards to co-payment from the very early days of the NHS is not helped by the consistent negative media representations of dentists and dentistry.  From the portrayal of the dentist as a mass murderer causing his patients extreme pain by experimenting on their mouths before killing them in the 1976 adaptation of Goldman’s ‘The Marathon Man’ to the ‘Little Shop of Horrors’ where the villain of the piece is a sadistic dentist called Scrivello who was encouraged to put his ‘talent for causing things pain’ to good use by his mother and become a dentist, the media is full of these negative images.  Even the Disney film ‘Finding Nemo’ features the dental surgery as a scene of threat and potential violent death at the hands of the dentist’s niece.

Dentists are often portrayed in a negative light in popular culture – Image: Still from ‘Marathon Man’, Laurence Olivier, Dustin Hoffman

With recent developments such as aesthetic dentistry, popular perceptions of dentists are slowly changing, and through the inclusion of dentists in programmes like ’10 years younger’ promoting the perfect smile as an essential part of the image makeover.  But the disquiet lingers along with the association with pain, fear, cost and greed.

I am not arguing that all dental practices are transparent and working within existing guidelines as they should, or that those who are not should not be held accountable.  Nor am I suggesting that there are not dentists that have gone in to the profession with the main aim of making money, research suggests that there are a significant number of these.   I am arguing, however, that through the negative portrayal of dentists and the separation out of dentistry for co-payment within the NHS, we have put those dentists who want to provide quality care for all patients regardless of the ability to pay, in a very difficult position.  Perhaps uniquely amongst healthcare professionals working within the NHS, we expect dentists to work to a business model where care is not free at the point of use.  They solicit payment from their patients as part of the dentist/patient relationship which fundamentally changes the nature of the relationship, and yet we judge them alongside other health professionals who do not have to negotiate this hurdle.    In a country which is still overwhelmingly pro a nationalised health system, free at the point of use, and provided as a citizenship right (regardless of the government’s systematic programme of privatisation) stories such as those seen this week will continue to be published, and provide a glimpse of the future for the rest of NHS healthcare if the government’s current agenda is allowed to continue.