WHY CAN'T I GET AN NHS APPOINTMENT ANYMORE?

For patients currently experiencing problems getting NHS appointments, you may be considering your options and even considering dental appointments privately, but might have reservations about going Private, not knowing what to expect, what the difference is and perhaps why you should pay more for Private Dentistry.

There are a number of reasons as to why this has happened and the country is facing an unprecedented NHS dentistry crisis.

As the practice owner of S3 Dental, the practice has for many years offered NHS care and we offered predominently NHS examinations to the majority of our patients, even if some opted for private treatment options.

The problem currently facing the country and importantly our patients is that there simply aren’t dentists willing to work on the NHS whilst the current NHS dental contract exists.

In recent times, some patients have accused dentists of being “greedy” and “only about the money”, but the matter is a little more complicated than that. Dentistry is a job and career and as such, anyone who works will surely expect to be paid for it. If we posed the question to anyone - if you asked any business owner, if they would like to be successful, it would start with a yes and the idea of success would atleast entail the business being profitable. The objection some people may have is to “how much profit” is being made.

So perhaps it is time to shed a little light on the current dental contract and explain how things have ended up as they have and why after so many years of providing NHS dental care, are dentists now refusing to provide it?

The NHS Dental contract that currently exists was imposed on dentists in 2006. It was not agreed or discussed and almost overnight was given to the profession as the new way of working. Prior to 2006, it was a little simpler, where dentists were paid for each item of service they provided and a very simple fee per item. Regardless of any reservations patients may have over unnecessary treatment, the premises was simple. However in 2006, the new contract may sweeping changes, and in an attempt by the government to control spending on NHS dentistry, it introduced the UDA - Unit of Dental Activity and a set of 4 bands for patients to pay.

Band 1 - Covering examinations providing 1 UDA

Band 2 - For all fillings, root canal treatments and extractions and denture additions and included anything in a band 1, providing 3 UDAs

Band 3 - For advanced treatments involving laboratory work such as crowns and dentures and included Band 1 and 2 treatments, providing 12 UDAs

Urgent Band - For emergency treatment to secure and maintain oral health providing 1.2UDAs

The fee paid by patients for each band was fixed by the government and since 2006 the amount for each band has increased.

It is now important to clarify that the payment dentists and dental practices receive is not actually what the patients pay for their treatment.

Dental practices were given a UDA target and a negotiated amount for each UDA they performed. Therefore this meant that each dental practice in the country had a different contract from the other, and two neighboring practices were paid different amounts for the same work. i.e a dentist working on the NHS in Bexleyheath may be paid a different amount than a dentist in Eltham. For reference, the average amount per UDA since 2006 is £20 per UDA.

So, just like employees may be paid different wages per hour, so were dentists. However, this was only the start of the problem.

As I explained, dentists are not paid for each treatment they provide, but rather for the highest band the treatment the patient needs falls in. So if a patient needs a filling, this is a Band 2 and the dentist is paid 3 UDAs. Therefore a dentist and the dental practice are paid on average £60 for the Band 2 treatment provided. If a patient required 1 or 5 fillings, then the dentist is still paid for the Band 2 treatment. Therefore regardless of the amount of treatment required, the number of appointments, or the complexity of each filling, the dentist and dental practice are paid the same amount. I hope that the general public can start to appreciate that this does not seem fair.

To run a dental practice, you need to have a building that is stocked and equipped with expensive equipment that is required to be serviced and maintained regularly, you need to pay energy bills as well as employ staff such as nurses, receptionists, and managers to comply with all regulations and requirement to be able to work. Dentists are required by law to have legal cover in place to ensure patients are protected in case of malpractice claims and our regulator the GDC takes one of the highest amounts in Europe for dentists to stay on the register each year.

Very simply for any business to stay viable it needs to generate a profit, and if the cost of each treatment being provided is unknown, the likelihood of remaining viable is very low. The way dental practices remained viable was by providing private dental care to supplement the NHS income that was being provided.

These days, we are all acutely aware of the cost of living and inflation, but the most damning thing with the government’s approach to NHS dentistry is that the amount of money the government pays to dental practices for NHS dentistry has not risen in line with inflation, so often year on year the increases in the pay towards NHS dentistry is below inflation - which is essentially a pay cut. Therefore as minimum wage increases, and other people’s pay may have increased in different sectors, dentists are being paid less today than when they started in 2006. Further to this, the amount patients pay for dental treatment has increased, but this has only been to offset the amount the government withdraws from NHS dentistry. In fact, the government only funds NHS dentistry for 50% of the population, which means there is an expectation by the government that not everyone should receive NHS care and an understanding that not everyone is going to get NHS dental even if they wanted it. Therefore patients have continued to pay a stealth tax over the years.

So reflecting on the fact that dentist earnings on the NHS are less OR at best their earnings in 2006, it becomes a problem for dentists who as they get older, have weddings, families, mortgages, and other living expenses to deal with, in today’s financial climate you can see why the NHS dental service remains an unattractive prospect. Historically, as dentists got older and moved into a stage in their life where they needed and wanted to earn more for their family development and left or reduced their NHS commitment, a younger batch of dentists would often take up this role as their started their careers. With fewer financial dependents and responsibilities, it was easier for younger dentists to work on lower pay as they developed their skills and gained experience.

The problem is that newer dentists do not want to work on the NHS and furthermore they find it incredibly difficult to work on the NHS. They cannot afford to live in 2022 and get paid 2006 amounts. In addition, the training they receive at an undergraduate level is not at the levels it once was with many dentists barely performing any dental procedures at university, yet are expected to provide dental treatment at high skill and speed for a low cost. They just do not have the ability to safely perform this treatment and meet the requirements the government sets for each practice to meet their UDA target. So currently young dentists are now looking for opportunities to work in nurturing environments without targets and pressures and private dental practice is one of the main avenues where dentists can nurture their skills whilst being mentored by an experienced clinician without fear of litigation and not earning a living.

From a patient’s perspective, most patients want an experienced dentist who is skilled and confident and has performed the treatments lots of times, whilst in reality, if they knew that the dentist was inexperienced, hadn’t performed this treatment previously, or only a handful of times, they would be very concerned. This is equally very stressful for young dentists because the risk and stress that goes with treatment and the fear of litigation make it difficult to justify doing it in the first place, at what is the cheapest price in the western world and Europe. The UK has the highest rate of medico-legal claims, which makes the cost of dentist liability insurance higher than anywhere else in Europe and nearly the world.

So if we come back to the original question - Why can’t I get an NHS Dentist?

Well, the answer should be a little clearer, the NHS system does not pay enough to dentists for the work required, but that is just the financial aspect of being the dentist performing the treatment. The second issue is how can a business operate as an NHS practice.

There are no government-owned dental practices in England, each dental practice is independently owned and run by private owners who have a contract to provide these units of dental activity for a fixed amount. So every expense from employing staff to the materials, and equipment is on paid for by the business. The business subsequently has to pay all costs, bills, and dentists for the work they provide, so in today’s current financial climate, how can a business stay viable and pay for employees if their own income is limited by what the government provides? A solely NHS practice would not be viable.

Dental practices have to compete to hire employees such as nurses and receptionists and if they do not pay enough to compete with other jobs then they simply will not have the staff to open. These last few years, many dental practices have struggled to find experienced staff to provide assistant clinical care because many nurses and receptionists have left to work in less stressful environments whilst getting paid significantly more.

Again, to put this into context minimum wage in 2006 was £5.35 and will be £10.42 in 2023, how could anyone afford to live working on that wage without considering other avenues of income?

So now we come full circle and consider why Private dentistry is so important to dentists and practice owners, because it essentially has sustained dental practices since 2006. So far, I hope you can appreciate that I have barely touched on the actual clinical differences between NHS and Private dentistry. Now I must at this point also highlight that the NHS dental contract that dentists have to comply with says that there should be no difference in the quality of dental care provided on the NHS or Privately. So for patients thinking a little deeper into this, how can a dentist and dental practice afford to offer you the best thing available if they are getting paid the lowest amount for it? How sustainable is it? - well you may have guessed it - Not very!

So for each dentist who wants to work in the NHS, now need to overcome the NHS rules if they wish to provide NHS dental care and supplement this with Private dentistry to earn a living, and unfortunately, it just is not possible. So dentists have left the NHS services in droves nationally because they cannot do it. They cannot work with restrictive covenants that essentially, mean they work for free or work at a loss. The physical demand and the mental strain of providing intense and highly skilled work are too much on the NHS.

The technological landscape today is very different from 2006. In 2006 when the dental contract was conceived we would still need to wait another 18 months for the first iPhone to arrive and the technological leaps have meant that dentistry can be provided in new ways, ways that many dentists would like to perform, and equipment they would like to invest in. At S3 Dental we have invested heavily in the dental equipment that makes dentistry modern and of the 21st century, but the current dental contract which has barely changed since 2006 continues to not adapt to the modern world and unfortunately is a testament to the state of the NHS and the governments which have overseen the decline of the NHS and this country.

So, what is in stock for the future of NHS dentistry? - well the government has promised dental contract reform for over 12 years with little real action. Dentists are fed up with the broken promises and patients are unhappy with the lack of NHS dentistry available. At S3 Dental, we have attempted to recruit dentists for NHS service provision, but unfortunately, we have failed, and the time comes when patients accept and need dental care that the only option is Private dental care options.

As such, S3 Dental cannot offer NHS dental care for much longer, and it is highly likely that in April 2023 we will not meet the NHS targets required for us to remain an NHS practice. So for S3 Dental patients who are seeking NHS dental care, unfortunately, we just do not have the dentists OR the ability to provide NHS dental services and our only avenue for patients is private dental care.