Another short-term solution has been the opening of "phone and go" dental-access centres. These solutions are designed to offer the full range of dental treatments to those who have been unable to register with a dentist. But they are costly to run — on average, £80 per patient, which is more than a normal dental practice charges. They prioritise emergencies, not routine checkups, and offer no continuity of care. They are not a long-term solution. Which is why the government has started to put more money into dental schools. The number of training places is set centrally, and until 2004 stood around 800 each year. From October this year, the figure will rise to 1,000. Bristol University Dental School, for instance, is admitting 82 students this year rather than 53. But the students won't be fixing teeth until 2010. Even then, there's no guarantee they will be fixing them in the UK.
NHS dentists are paid a set fee for each item of work they do. It's an accounting nightmare. There are 400 separate fees for individual items of work, whether it's a filling or a crown, but as the fees are not high they end up seeing 40-50 patients a day. That compares with private dentists, who average 10-15 patients a day. NHS dentistry is about keeping the chair busy; it's all about drill and fill. So private dentistry is tempting. Especially when, according to the Consumers' Association, fees are three times higher than in the NHS. But only 1,000 UK dentists are exclusively private. The rest mix private work with the NHS. Some treat children on the NHS, but only if the parents are prepared to go private. When NHS dentists say they feel unrewarded, it's all relative. The average dentist earns £60,000 a year, but there is a huge disparity. Some NHS-only dentists earn £30,000, while others, especially in the southeast, earn six-figure salaries. In 2003, for the first time, dentists' private earnings topped their NHS earnings, with 51% of their overall income coming from charges, according to the analysts Laing & Buisson. Dr Stephen Shimberg sees both sides.
He has his own private practice in Manchester and an NHS practice in Oldham. "Generally, dentists do well — NHS and private," he says. "Private is more relaxed. The patient comes in, and agrees or disagrees with the treatments and the fees you propose. NHS is different. Fees are small, so you have to work harder to achieve your salary on the treadmill."
The running cost of a dental surgery averages at £100 per hour. It's classed as a small business, and attracts business rates. It needs highly specialised equipment — typically worth £40,000 — which is bought and maintained by the dentist. The dentist is solely responsible for the cost of implementing guidelines such as disabled access and cross-infection control procedures, and staffing the surgery with at least one nurse and one receptionist. To have an NHS crown fitted, for instance, a patient needs to visit the surgery at least twice. The impression is £5 and the laboratory fee £40. If the crown fits the first time, and no more visits are necessary, the dentist's profit is £15. That is then split with the practice. There is no income if the patient is a bad payer or doesn't keep their appointment. And that is a crown: one of few dental procedures that makes a clear profit. "If a new patient comes in for an NHS denture," says Shimberg, "it would be cheaper to give them a £10 note and tell them to go elsewhere. There used to be compensations. Doing fissure sealants for kids, for instance, was always well paid. Not any more. But dentists have to stay on the right side of the red line. When your bank manager asks about your income, there's no point saying, ÔIt doesn't really matter because I'm great with my patients.'"
Like private dentists, NHS dentists run their business for profit, and some have been tempted to "work the system". It's one reason why the number of complaints received by the General Dental Council (GDC) has increased steadily since 1995. "Studies show that dentists replace fillings far more than necessary," says Aubrey Sheiham, professor of dental public health at University College London, "and if they suffer a drop in income, they replace their patients' fillings more often. What these studies show is that replacing fillings is not closely related to the need to replace them but to the Ôbusiness' of the dentist. Because the criteria for replacing fillings are vague, it is not difficult to convince a patient that a filling needs replacing." In other words, the existing system encourages fraud.
The 2006 contract should get round that. Instead of paying dentists for every item of work they do, it will pay them a salary and — in theory — give them more time to focus on the patient. The new contract is being piloted in 25% of Britain's dental practices and has been well received. But it's only a pilot, so nobody knows what to expect when it comes into effect next April.
The government has worried dentists by talking about performance indicators called Units of Dental Activity. Essentially they are targets. "But you can't really target patient treatments," says Dr Shimberg. A recent online poll suggested that over 50% of dentists were unhappy with the new contract and would resign from the NHS if it were not redrafted. Another survey indicated that charges under the new scheme would increase for at least 70% of patients.
It's easy to see where Americans got the idea that we have bad teeth. Before the advent of NHS dentistry and fluoride, British teeth were a scandal. The higher standard of living in the US always afforded people better dental care. Besides, in Britain there was the notion that better dentistry was a vanity. But that's changed. We have gone, in less than a century, from a world where it was regarded as inevitable that we would lose our teeth to a world where we expect to keep them. Even improve on them.
The NHS, with its ideal of a national dental service free at the point of use, raised our expectations. But it couldn't deliver: it worked out too expensive. Hugh Gaitskell helped pay for the Korean war by imposing charges for dentures, and successive governments added to the ever-growing list of NHS charges. Each time it happened, the relationship between the government and the dentists became more and more uneasy. Then, in the 1970s, fluoride toothpaste was introduced. Decay fell by over 40%. The government, understandably, reckoned that in the future fewer dentists would be required and closed two dental schools. But it takes more dentists to make sure healthy teeth stay healthy, not fewer. Before long, the shortage of trained dentists started to become an issue.
Less than 20 years ago, only 5% of a dentist's income came from private earnings. But it all changed in 1990 when the government agreed to pay dentists a set fee for every item of dental work they did. It worked so well that the government decided dentists were earning too much and cut the budget. Dentists lost 15% of their income overnight. Bitter and disillusioned, they began to drift away from the NHS. Patients followed them. Private dentistry, worth £289m in 1994-95, was worth just under £2 billion in 2001-02. Now, for the first time since the NHS was created, dentists are earning more from private dentistry than they are from the NHS. But many patients can't afford private. In 1990, 32m patients were registered with an NHS dentist; it's now nearer 18m. That leaves a lot of patients without any kind of dental care.
And the world has noticed. When The Guardian wrote to floating voters and warned them off Bush, middle America was livid. They wrote back. "Brush your goddamned teeth, you filthy animals," said one. "You yellow-toothed pansies," said another. "May you have to have a tooth capped," said one. Even today, our teeth are seen as a symbol of what's rotten in our society.
But Lorne Matthews, manager at Fen House in Spalding, where they're piloting the new contract, is hopeful for the future. "Under the set-fee system," says Matthews, "if we wanted to do work that came to over £375, we had to write to the PCT and Dental Practice Board. The idea was to stop over-prescribing. Now we control our own budget and make decisions ourselves." The budget is paid in a lump sum up front, so the practice knows where its money is coming from.
