Written evidence submitted by Anonymous (DTY0003)

What steps to improve access?

Access is related to fear. Fear keeps people from attending. Makes them cancel last minute and leave problems to excalate and become more difficult to manage. The fear factor stems from childhood and the lack of knowledge countrywide that NHS dentistry is free for children and that parents do not receive the correct information regarding their baby’s health. Too many children’s first experience of the dentist is when they have usually multiple cavities and the pain associated with sitting in the chair to have their mouth’s examined.

Schools play a large role in helping to iron out inequalities – teachers should be able to report anything they see in mouths that does not look right- encouraging dental attendance—in a gentle way—

Possibly when students start university—either leaving the family home or becoming less money-dependant on their parent/guardian/s – should be offered free NHS check ups-

Prioritising dental health in turn helps to find if mental health and physical health are an issue as well

Dentists are not only looking after mouths, they spot demeanour changes, they get told things in confidence and can help to direct patients to other health professionals as needed

There should be clinics dedicated to seeing and being paid appropriately patients who cannot access regular care due to lack of attendance. The urgent care centres are capable of keeping things ticking over and trying to help the fallout but people need to want to be helped. They are offered appointments in these urgent care centres yet do not attend—do not let anyone know- and waste time and money—they then get given follow up appointments for say another filling or extraction needed that there’s no time to do on the first appointment—and they then still cannot find a regular dentist.

Access issues can be dealt with via specialised clinics built around a model of salaried care—capitation and fee per item- so that when patients do not turn up- money is not lost—those on waiting lists will need to be means tested to check if they qualify for NHS care- of not they can join the private practices and be seen as per usual fee systems.

Inequalities in access be addressed

Lack of information especially from birth to school years causes many issues with children’s teeth.  I have heard multiple times that baby teeth do not need brushing, that dummy use is ok—this causes malformations and speech delays.

Adults- especially those who are on benefits, find it very difficult to be able to afford to bring their children to the dentist, they have job pressures and school fines to worry  about- the appointments after school get full for months on end and school holiday appointments are similarly packed—

Access to NHS braces should be related more towards means testing over malformations. Children with minor but still malformed mouths that do not qualify for NHS braces – turn into teenagers with social and mental health issues that cannot be bought out of—parents cannot improve self esteem through spending on braces, these teenagers may then not get to their true potential and this continues into adult life, they stay in a lower socio-economic environment and cannot escape the inequality they were born into. I have witnessed children have NHS braces but yet go to private school, have expensive holidays and whose parents choose only the best private care- yet feel entitled to their NHS braces—however parents who struggle, work all hours and cannot get away on holiday—are forced to let their children grow up with malformed mouths that do not qualify for NHS braces.

There should be- in my opinion- NHS dentistry for all people on benefits as well as low income, some people are better off on benefits with a lack of encouragement to do more hours – once they lose their benefits they then stop coming to appointments until their benefits can be renewed—it should not be like this—I’ve lost count of the number of regular NHS patients in good jobs with regular hours, a comfortable lifestyle asking to pay more as they cannot believe how little NHS dentistry costs—these people like the IDEA of being an NHS patient because they think their taxes have paid for this privilege—they could very easily not be NHS.

NHS dentistry would have a lot more funding to be put towards the high needs patients if all the well-off NHS patients became private and dentistry would be more like optometry. I see plenty of benefits patients wearing designer glasses so how come things cannot be shook up a bit so that an opt in and out of NHS and private work became much more clear cut.  There would not have to be the explanation of costs—only free to those who qualify and also those who can claim something like HC2, HC3—but are just close to this—maybe create an extra band of low income NHS access.

So NHS dentistry would be free to those who qualify. There would be an end to charges under NHS.

Any time anyone pays – they will know it is for private only—no confusion—much more funding and appropriate time dedicated to fulfilling all lengths of treatment plans – there should be a fee per item of work that is appropriate according to attendance and maintenance by the patient. A capitation for every patient under each practice that keeps patients on regular recalls.

In the past, I recall 50p per child a month when I first qualified and a £1 per adult.- circa 2002- I also think that until a patient is out of education—say aged 23 not 18 – would nip a lot of bad habits in the bud so that young people do not disappear from appointment books during their studies until they get into employment or have children and get on the benefit treadmill.

Unsure of exact figures but the capitation should be reliant on attendance at regular intervals and ability to maintain these patients. Once a 2 year lapse has occurred – this capitation will not be paid.

Many high needs patients require 3 month recalls and these should incur a higher capitation rate.

A ratio of need vs capitation could work and incentivise seeing people who need more, more often and try to prevent escalation of problems to dental hospital or a&e

Corporate dental companies come in to buy NHS practices and bring in a cosmetic name or logo and scare off patients and also staff and associates—they need to prioritise and have a certain amount of time in the day and day/s in the week directly for NHS care to stop waiting lists being extended.

Does nhs dental contract need reform—see above and below

The contract is not working, the incentive is to see as many people in as little time as possible in order to pay for all the incidentals that are required.

In recent experience, there have been patients accepted onto the books who have not been in many years or so- blaming covid??—odd—then when treatment plans are arranged they cancel last minute- usually for work or health excuses- these gaps are then left empty and cannot be used for other people in need—There are people who wait until the last minute and have had broken teeth and problems getting worse to turn up- refuse to have local- want referral to be told it may be a 12 month wait for the referral at hospital- they clog up the waiting lists and by the time they get appointments we get letters saying they failed to attend and then they return 5 years later with retained roots from leaving those other problems and then wanting the same again and the pattern repeats—

When the lab bills soar and the return on NHS fees does not match the bills, this causes issues, there needs to be a better incentive to perform the dentistry needed in more relation to how much this costs to provide. I think that lab bills should be entered into an online system and claimed back from the government in some way so that there is no penalisation to provide all that is required.

The fee per item should reflect more in terms of how a filling or extraction is done. Some fillings involve minor drilling, some major caries removal, use of local, lost of reassurance and time. The number of times a filling is done should be taken into account and how long each visit needs.

Some extractions take few secs, with topical, some 1hr with lots of local anaesthetic and difficulty—these need to be separated into different categories and return on funds.

Incentive to recruit and retain dental professionals

Newly qualified dentists are going straight into private dental practices with composite and smile design courses booked on weekends, getting themselves into debt and having no interest in seeing dental patients for regular check ups and providing general dentistry. They want to specialise and not start getting to know how rewarding a general practice role can be

Foreign dentists should not be falsely promised that they will be able to perform regular dentistry, they will need to specialise and pay for expensive courses in order to go private, they will not be able to do regular grassroots dentistry, people have high needs and low attendance, they can get easily put off by the need to take 3 months to complete treatment plans due to the lack of appointment space. How can they possibly understand that the more treatment required by the patients, the cheaper it is for the patient. The incentive is to wait for more work to be required so pay less.

What is the role of training in this context

There needs to be more training regarding treatment planning and stabilisation due to the neglect they may see once qualified. I have heard of newly qualified dentists attempting cosmetic work due to being worried about money over stabilising the basics of a person’s mouth – no oral hygiene instruction, no scaling—these are not paid items—but placing of cosmetics to disguise the underlying issues.

The training of simple techniques and more practically based skills should be encouraged, there is a lack of experience of basic fillings, extractions and not a full sense of the long term outcomes or continually changing fillings for purely cosmetic means over necessity. The restorative cycle of continual change and interfering with status quo does not seem to be understood well—These teeth are filled and refilled as the patient moves practices- then requiring root canals, that then can fail and then the tooth is lost—not all can afford implant replacement and many will not wear dentures.

Then the deterioration continues—the lack of replacement of missing teeth causes drift and overgrowth of teeth into places they are not designed to be and then in turn cause more tooth loss and also medical issues with digestion and mental health problems

The teaching hospitals triage in a manner that makes the referrals process very difficult and time consuming. A recent referral was rejected for gum problems due to there being very minor edges of fillings and small enamel decay under the overgrowing gum—these fillings need to be fixed in conjunction with the restorative departments—not sent back to gdp—how do you access the areas to fix without the gum problems being dealt with first?- chicken and egg—so by the time this has been dealt with and re-referred – she is now pregnant and unable to go and have the appropriate care- cases like this happen all the time- rejection delays- ridiculous treatment plans returned to gdp who referred due to inability to perform these processes- being told to make nightguards instead of the root cause of patient’s problems being dealt with- they do not wear these and they do not have improvement and the cycle continues.

There needs to be a way of maintaining and helping new graduates for a little while longer under general practice before they are allowed to go into cosmetic only procedures and forget how to do regular dental care—the patient treated as a person- not a money machine—where is the compassion?

Money is the major drive for all graduates—mainly due to increased debt but also due to the limited pool of students—all having to get A stars or A’s at A level—all entitled – all thinking and told they are the best at everything- limited common sense- all about the cut and paste notes—no personality—rude to nurses--- I am drawing these conclusions from many discussions and experiences—of course some normals come through but the love of dentistry as a caring profession and the thinking of patients as almost family members may soon to lost—to a generation of high achievers with the knowledge but also the capacity to persuade the vulnerable to have work that they do not necessarily need but are scared into having from a desperate need to maintain the pay checks and seeing people as money only.

Dec 2022