12/02/2022
It’s been a while since we’ve updated our Facebook followers about current circumstances, and we remain very grateful for all your patience and understanding as the fallout from covid continues to severely limit us at the practice.
Can we reassure you that, if you have an emergency, you can always call us and we will endeavour to see you immediately. Routine check ups and treatment is being booked and we will contact everyone who is due to be seen. This process will take some time yet, but we are getting there.
For everyone’s information, a colleague of ours has penned the post below which perfectly explains the major problems we now face in NHS dentistry. We hope it helps everyone understand what we’re up against when trying to recover from the pandemic, and what the future might hold if things don’t improve. It’s a fairly long read, but a really good explanation that’s worth 5 minutes if your time.
Thanks again to all our loyal patients.
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To understand the current crisis facing NHS dentistry in Scotland, you first have to understand the basics of how the current system works. Most 'NHS' general dental practitioners are not actually employed by the NHS, but are self employed contractors who are contracted to provide NHS dental services. When you pay at the desk after having had your NHS treatment, you're paying a fee set by the NHS, who top this figure up by 20% and then pay the practice. For people who are exempt from charges the NHS pays the full fee inclusive of the 20%. This income is then split between the practice (who generally require around 50-60%) in order to pay for nursing, reception and other support staff, materials, utilities and other overheads, and the dentist performing the treatment. If you require a device such as a denture or a crown, then the treating dentist must employ the services of a dental lab to construct this and must pay them directly for this from their own pocket. The NHS does not deal with dental labs directly in any way in the general dental service. There is an extensive document which details treatment available under NHS contract, the caveats of providing each item and how much that they'll pay for each one. This document is called the Statement of Dental Remuneration (SDR).
The SDR is a document first published in the early 90's based on the dentistry of the 70's and 80's. It is an outdated document which our own Chief Dental Officer Tom Ferris has gone on record as saying is no longer fit for purpose, so what are it's issues and why is the government so dead set on keeping it going? Even at the point of it's original introduction, the amounts paid for treatment significantly undercut the actual value of the treatment when compared to just about any other first world nation. In order to make a decent living and keep the practice going based on NHS income alone, dentists have traditionally had to carry out a lot of work very fast: lots of check ups with a scale and polish, and lots of fillings crammed back to back When translated to figures, this looks good for the government because more people are being seen. What they want is to be able to say X number of people were seen and had X amount of treatment carried out in a timely manner, which is more than last year. To them you are a statistic, however to us you are patients and more importantly people. We don't want to see you, fill your teeth and get you out the door, we want to help you get to the point where you don't actually need any fillings at all. This is the first big issue that most dentists have: the SDR rewards drilling and filling, not modern, evidence based preventative dentistry. Working within the confines of the SDR it is often impossible to provide treatment which is up to a modern standard, and where it is possible this involves incurring a financial loss.
The brings us to the second issue with the SDR: the pricing. Staff wages, materials, overheads, utilities, insurances and raw materials have all increased in cost exponentially since 1990. Working fast is no longer enough to make up the difference, and even if it was the massive increase in time devoted to bureaucracy and record keeping mean that it's no longer an option. NHS dentistry has gone from being profitable when produced in high volume, to about breaking even, to actually incurring a loss, particularly on lab work. As mentioned before dentists pay the labs out of pocket, however the NHS does not set the prices labs charge which means that labs now charge more than the NHS actually pays (and rightly so, this isn't a dig at labs – technicians have been working themselves to the bone for rock bottom prices for years to meet NHS demand and are no longer able to offer this AND stay afloat) meaning that to make your denture or your crown can actually cost dentists and/or the practice money. Even routine treatment which doesn't involve the lab can result in a net loss for the practice when the time taken to complete the treatment, staff wages and the cost of the materials used are taken into account. The only real way to offset this loss is through carrying out private work – which is why many dentists are being forced to decrease NHS commitment simply to stay open. Private treatment also has the handy bonus of not being shackled to the SDR, meaning better outcomes for patients through more modern dentistry and far fewer bureaucratic headaches. It shouldn't be this way, but the government at this stage seems to be absolutely committed to ensuring this document remains in place, despite it being clear to see that it's bringing about the sort of two tier system that the NHS is supposed to prevent.
There's an old stereotype of greedy dentists bleeding the NHS dry, but funnily enough it's actually the other way around. The SDR is an extremely complex and convoluted document by design, which means a lot of the caveats and conditions to carrying out certain treatments can be easily missed or misinterpreted, meaning that appropriate treatment delivered to a high standard which the patient and dentist are both extremely happy with can be considered 'misclaimed'. This can be due to something as silly as a spelling error or phrasing in the clinical notes. When the powers that be find something like this, they demand that the money is given back. Not just the 20% they topped it up by, but the patient fee which you paid as well (you don't receive any of this money back, by the way). And they don't stop there. They can demand the dentist pay back all the money paid for every time they carried out that same treatment over a period of time, regardless of whether that same error was present or not, regardless of the actual outcome of the treatment. Imagine if your employer docked you potentially tens of thousands of pounds due to a minor clerical error despite you doing an absolutely perfect job? Recently unearthed meeting minutes show that not only are the people in charge well aware of the complexity of the system making it prone to errors, they actually have a financial target to hit on reclaiming money from dentists. As a colleague succinctly put it: we are working under a system which is literally reliant on us misunderstanding it to work.
They also cleverly absolve themselves of any blame or issue regarding treatment available on the NHS. NHS treatment regulations state that only work which is strictly necessary to secure and maintain oral health should be provided under NHS contract, a statement which is deliberately vague. Veneers, for example, have a section in the SDR which means that, technically, they are available on the NHS. If you don't know, veneers are used generally to mask discolourations or malpositioned teeth in order to improve the appearance. Cosmetic work is specifically not allowed under NHS contract. A dentist can't say 'no veneers on the NHS' because they're in the SDR, and if a patient complains to the NHS that they've said this they can get in trouble for it, but on the other hand if they actually do a veneer on the NHS they can end up getting in trouble for *that* along with having the money taken back because it's a cosmetic procedure. It would be most accurate to say 'I can't do a veneer on the NHS in your case', but you're always worried that this sort of thing can come back to cause you problems in the future, because not every patient is willing to accept that the system is extremely limited.
Both patients in general and regulatory bodies are becoming more demanding with the calibre of work which they expect and the NHS system simply is not equipped to handle this. The government has repeatedly refused to engage with the profession in any sort of meaningful way, and simply wants to press on with returning to this broken system. Pretty much every dental practitioner wants a fair and effective healthcare system that benefits both patients and team members, but the myriad of problems discussed as well as a number of other factors have resulted in NHS dentistry becoming an extremely toxic, stressful and demoralising area to work in for every member of the dental team. Because of this, many are simply leaving the NHS, with those left behind gradually reducing their commitment. This is why NHS dental appointments are in such short supply and unless something is done this will only get worse. Practices which can will go fully private, and practices which can't will go bust.
