Dentistry: should it be in the NHS at all?
BMJ 2016; 355 doi: https://doi.org/10.1136/bmj.i5986 (Published 10 November 2016) Cite this as: BMJ 2016;355:i5986
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John Appleby goes halfway to answering an attention grabbing headline with a ‘yes’ , but he needs to go further.
Patient charges not only discourage the patients who need us most, they have reinforced the ‘otherness’ of dentistry in the eyes of both patients and policymakers. It’s an approach that only serves to pile needless pressures across an overstretched NHS.
Tooth decay is already the number one reason for child hospital admissions in Britain. Tooth extractions among under 10s under general anaesthetic which could have been avoided, are on the rise, while charges push a steady stream of adults with dental problems to GPs and A&E.
We’ve arrived here because the service has been an afterthought, left to fend for itself, without dedicated funding or a coherent strategy. While NHS dentistry is ideally placed to live up to the rhetoric of prevention set out in the Five Year Forward View we have to confront enduring health inequalities underequipped, shackled by government targets but without a penny of capital investment.
Yes, dentistry has been the poor relation in the NHS family, but casting it out is no answer.
Competing interests: No competing interests
Appleby examined the link between deprivation and use of dental services in England, Wales and Northern Ireland. [1] As the responsibility of NHS in Scotland is a devolved matter, Scotland decided not to participate in the adult dental health survey 2009 and the children’s dental health survey 2013.
Recent figures from the National Dental Inspection Programme in Scotland show some improvements in oral health of Primary 1 children, with 69% having no obvious decay experience in 2016. [2] Scotland, however, still lags behind countries of similar development, such as England and Norway. Comparable figures show that 75% of 5-year-olds in England have no obvious signs of dental decay, [3] with broadly similar figures for Norway (73%-86%). [4] In addition, health inequalities remain in Scotland, with only 55% of Primary 1 children having no obvious decay experience in the most deprived areas compared with 82% in the least deprived areas. [2]
In September 2016, Scotland’s Oral Health Plan is being put out to consultation for 12 weeks. It proposes a radical rethink of how patients are treated and dentists are remunerated. The document plans to introduce a new preventive care pathway, with the aim of moving dental services away from a restorative approach. The proposed pathway would provide a simplified system of charges for adults and children whose oral health is judged to be ‘stable’. Those with ‘poor and unstable oral health’ would remain on the item of treatment system. [5]
The consultation document also proposes to review the Statement of Dental Remuneration and introduce an Oral Health Risk Assessment (OHRA) for all patients at 18 years of age at regular intervals. The OHRA would determine the appropriate treatment and if they are on the correct pathway. [5]
[1] Appleby J. Dentistry: should it be in the NHS at all? BMJ 2016;355:i5986.
[2] ISD Scotland. Report of the 2016 Detailed National Dental Inspection Programme of Primary 1 children and the Basic Inspection of Primary 1 and Primary 7 children. 25 October 2016. https://www.isdscotland.org/Health-Topics/Dental-Care/Publications/2016-...
[3] Public Health England. Oral health survey of 5-year-old children: 2014 to 2015. 10 May 2016. https://www.gov.uk/government/statistics/oral-health-survey-of-5-year-ol...
[4] Norwegian Institute of Public Health. Dental Health in Norway – fact sheet. Dental health in children over 5 years. Updated 18.04.2016. https://www.fhi.no/en/mp/dental-health/dental-health-in-norway---fact-sh...
[5] Scottish Government. Scotland’s Oral Health Plan: A Scottish Government Consultation Exercise on the Future of Oral Health. 15 September 2016. http://www.gov.scot/Publications/2016/09/7679
Competing interests: No competing interests
While an increase in deprivation is related to poorer oral health, John compares the rates of extractions and crowns provided against deprivation as if they are treatment options for the same diagnosis.
Extractions are performed usually when a tooth is deemed unrestorable due to infection or material breakdown. Crowns are provided when the structural integrity of the tooth is questionable but the tooth is restorable with a promising prognosis. While he makes the distinction that crowns are a complex treatment option, he fails to explain that a crown, being relatively sophisticated, should not be placed in an unstable dentition whereby it is likely to fail, such as a mouth with active disease and poor oral health. He also does not recognise that 47.8% of NHS dental courses of treatment in 2015-2016 were provided free of charge to the patient. Unfortunately little has been done by the Department of Health since the introduction of the 2006 General Dental Services Contract to improve access and inequalities of dental health.
Competing interests: No competing interests
Re: Dentistry: should it be in the NHS at all?
Appleby raises the important question about the extent to which dentistry should be included in the NHS. [1] The main considerations in his very relevant and timely contribution are with respect to improvements in oral health during the last decades, increases in the number and activity of dentists, persistent social inequalities in oral health and the role of patient charges on access to, as well as utilization of, NHS dental services.
From a broader health policy perspective, maximizing population wellbeing given available resources is an important rationale when considering the extent to which dentistry should be included in a publicly funded health care system. [2] Oral health is determined by a broad range of social determinants including behaviours such as sugar consumption and oral hygiene, [3] and dental care has been considered a relevant means to improve population oral health. [4] Moreover, the idea that insulating patients from treatment costs may increase dental care use and therefore improve oral health, particularly amongst those worse off, has a very long tradition. More comprehensive public subsidies for dental care have frequently been discussed to overcome cost-related barriers to dental care. [5]
However, dental care use is determined by a multitude of different factors, only one of which is treatment charges. Other relevant factors affecting dental care use include, for example, the (limited) need for dental care as perceived by the patient, the number and type of dental professionals, and provider payment – that is the way dental professionals are paid for the work they carry out. [6] [7] It is also important to bear in mind the limitations of the traditional individualistic approach to prevention which focuses on delivering clinical preventive measures such as topical fluorides and fissure sealants and providing oral health advice to patients. This approach may produce positive outcomes in the short term for certain patients but is ineffective in reducing oral health inequalities across the population. [8]
We are living in a world characterized by demographic and epidemiological change, as well as continuing medical-technical innovation. On the other hand we are challenged by scarcity of resources. Accordingly, there is a need to make rational choices about the best possible resource use. If the goal of the NHS is to maximize population wellbeing given available resources, it is important to rationally and continuously (re-)consider population needs and to rely on health workforce planning that is responsive to these population needs. Moreover, careful choices need to be made according to the value for money of clinical, as compared to public health approaches and in comparison with alternative resource uses within and outside healthcare. [2] Such considerations also need to be transparent about the extent to which priority is given to interventions to reduce social inequalities in oral health. This applies not only to dentistry but also to any other part of health care.
Given that oral health is considered a basic human right and inseparable from general health and wellbeing, [9] societal preferences are likely to imply that dentistry needs to stay an integral part of publicly funded NHS. While population oral health has improved over time, this does not necessarily mean that further improvements in oral health may not be good value for money for society.
References:
[1] Appleby J. Dentistry: should it be in the NHS at all? BMJ 2016;355:i5986.
[2] Birch S, Listl S. The Economics of Oral Health and Health Care (May 20, 2015). Max Planck Institute for Social Law and Social Policy Discussion Paper No. 07-2015. Available at SSRN: https://ssrn.com/abstract=2611060
[3] FDI World Dental Federation: Oral Health Atlas (2nd ed.). FDI World Dental Federation, Geneva; available from: http://www.fdiworldental.org/publications/oral-health-atlas/oral-health-...
[4] Donaldson AN, Everitt B, Newton T, Steele J, Sherriff M, Bower E. The effects of social class and dental attendance on oral health. J Dent Res 2008; 87:60-64
[5] Palència L, Espelt A, Cornejo-Ovalle M, Borrell C. Socioeconomic inequalities in the use of dental care services in Europe: what is the role of public coverage? Community Dent Oral Epidemiol 2014; 42: 97–105.
[6] Listl S, Moeller J, Manski R. A multi-country comparison of reasons for dental non-attendance. Eur J Oral Sci. 2014 Feb;122(1):62-9.
[7] Grytten J. Payment systems and incentives in dentistry. Community Dent Oral Epidemiol. 2016 Nov 3. doi: 10.1111/cdoe.12267.
[8] Watt RG, Heilmann A, Listl S, Peres MA. London Charter on Oral Health Inequalities. J Dent Res. 2016; 95:245-7.
[9] World Health Organization. The Liverpool Declaration: Promoting Oral Health in the 21st Century. A call for action. September 2005. Available at: www.who.int/oral_health/
events/orh_liverpool_declaration_05.pdf
Competing interests: No competing interests