Government Health Committee - NHS Dentistry Inquiry
Written Submission of Evidence - Christopher Hilling, SpaDental group
NHS does not provide an income commensurate with the skills of the trained, professional dental team members. The current UDA system (even with recent increases) since it was implemented has not suited conscientious dentists.
Following the changes to NHS directives in 2022, a major aim should be to utilise fully dental therapists to examine and triage patients who present without pain, with a referral system in place for concerns, second opinions, and treatment outside of their scope of practice, to be escalated to appropriate dentists. Logically this should be common practice - the norm, not the exception. Each team member will then work at the higher end of her/his Scope of Practice.
To make this work there needs to be a culture change within the dental sector encouraging referrals both up and down the skills ladder to the appropriate member of the team. For instance, a suitably qualified nurse can provide oral health education, or a therapist most of the treatment for younger children, with more complex treatment completed by dentists. All the clinicians being remunerated appropriately for their skills and experience.
This would increase the number and range of clinicians providing direct access to the general public, thereby rapidly improving access to NHS dental-services.
The dentist’s performer number effectively costs a further c£20k in lost practice revenue and, if required, Performers List Validation by Experience training expenses. It is not logical, especially in a mixed practice, that a dentist can treat private patients by not NHS patients in the same practice..
The market for private dentistry has grown, and the current crisis is widening the gap between those who can afford private care and those who cannot. Private treatment is not limited to cosmetic treatments or better-quality crowns, it is the whole patient journey from general preventive dentistry to complex cosmetic reconstructions which is becoming the norm in many parts of the country.
Patients who have regularly attended there NHS dentist for years can no longer access NHS care: A patient review: “It is a shame there are no longer NHS dentists… An older woman came in and cancelled her appointment as she could not afford the treatment – that is poor.”
Is it time to consider means-testing? This already happens to some extent with patient charges and remissions for children and patients on various government credits. Is it time for a more nuanced, tiered structure with higher patient contributions? Some groups could remain fully funded as they are now: for example, children and exempt patients. It would be an unpopular and politically alienating move but without this debate NHS dentistry will continue to fail the public and in particular fail the under privileged.
Failure to attend an appointment wastes a lot of clinical time but still incurs staffing and overhead costs which the NHS do not pay. It is also missed treatment opportunities for those in need. We have systems in place to charge private patients for failed appointments, this is easily extendable to charge NHS funded patients directly for missed appointments. It is important patients respect the time allocated to them and as this charge would be payable by the patient it would not increase the NHS funding requirement.
In practice, for example, the NHS would pay for a basic crown or denture, but the patient could elect to pay an additional cost for a crown or denture of superior material. This allows the dentist to make a sensible living for the service provided while the NHS is still funding basic dental treatment for all.
Changes in funding framework, training and ethos are necessary for the system of mixed skilled teams to work fluidly.
The UDA bands cannot reflect the complexity or nuances of each patient’s treatment. Over the years, the UDA system has encouraged a culture amongst some dentists of benign negligence, to the detriment of patient care, especially of those with high treatment needs. Remuneration needs to directly reflect the reality of the treatment provided and the skills of the clinician providing the treatment.
The NHS needs to ensure that any incentive is directed towards increasing the pool of dental professionals in England and not fighting each other for the same clinicians.
This requires the GDC to register candidates in a timely manner and provide those that need to pass additional GDC administered exams more opportunities to take these exams.
By organising events, both academic and recreational, they can make their locations more appealing to professionals from outside their region. For instance, Cornwall could arrange various CPD events linked to an afternoon of trying surfing or walking on the moors, a larger city may organise theatre or museum visits.
It is time for a change of culture away from the insular current working practices of dentists to a team culture that embraces the mixed skills of professionals. Integration and appreciation will enhance communication, helping groups work together for the benefit of the patients.
Christopher Hilling, SpaDental group – 25th Janaury 2023