A crisis has been building in the dental sector in Northern Ireland over many years but the Covid pandemic finally pushed it over the edge. Last week, the British Dental Association appeared before Stormont’s Health Committee to plead for action in the face of a grave threat hanging over the provision of dental services. Absolutely nothing was done until today when a last minute, u-turn was forced from Minister Robin Swann under mounting pressure from political representatives like myself and adverse media coverage.
Today’s decision means that none of the five Covid Emergency Dental Treatment Centres will close as planned next Monday; instead they will remain open until the end of August. It averts the immediate threat that dental services will be denied patients but the potential and even likelihood of a grave crisis remains high.
Aerosol generating procedures
Opened at the start of the Covid lockdown, emergency dental treatment centres provided access to what are known as ‘aerosol generating procedures’ (AGPs), which include such minor procedures such as drilling for fillings or even teeth cleansing. AGPs result liquid spraying in the air and particularly increase the rise of viral transmission. As a result practitioners and staff have to wear respirator units and higher grade PPE than are standard.
Dental practices which have reopened in recent weeks have not been allowed to conduct AGPs but they were set to take on this workload when the emergency dental treatment centres closed.
Unfortunately they were nowhere near a position to do so; the Health Department indicated several weeks ago that it was unable to obtain the higher grade PPE required by dentists to safely conduct AGPs. Each practice was left to individually source its own supplies. To add even more to the chaos, dentists were not even able to secure face-fitting to practitioners and staff members – required for the safe operation of PPEs – because of the small numbers of fitting specialists in the region and the huge demand for their services right now.
The result of these factors was that it will be many weeks – potentially months before most dentists will be able to safely drill or provide fillings – and that was assuming they could obtain the needed PPE once they were fitted. The BDA estimates that more than 90 percent of dentists in Northern Ireland will not have properly face-fitted PPE in place for Monday’s reopening.
The economy of NHS dentistry under Covid
A further factor contributing to the crisis was that the PPE has to be disposed after each AGP – meaning an additional cost of anywhere over £27 for each practitioner and assistant.
Dental practices operate as small businesses contracted to deliver NHS services but able to charge for the majority ineligible for free NHS treatment. For those who pay, most people these days, dentists will charge a minimum premium of at least £30 if not double that for AGP treatments. But for those receiving treatment under the NHS – the cost of specialist PPE posed even greater problems.
Under the terms of their contract, dentists are not allowed to charge NHS patients anything extra. The cost of specialist PPE for AGPs on NHS patients would therefore be fully borne by a practice. While some practices might be able to bear a loss on such procedures, it would clearly discourage them from taking on NHS work.
Inadequate payments for NHS procedures
The situation is further complicated by the fact that payments to dentists for NHS treatments have been allowed to fall to unsustainable levels. Clearly part of a long-term neoliberal agenda of undermining NHS dental services. The figures are genuinely shocking. At present a dentist is paid a mere £10 for a small filling while for a large filling payment increases to £27. Taken against a non-recoverable cost of PPE of at last £30 for the dentist alone –and that is operating without an assistant – treatment of NHS patients under the current regime is clearly uneconomic.
The implications of this is that more and more dentists will be forced to turn away NHS patients requiring AGPs. As one concerned dentist told me, unless they were willing to absorb the loss for every patient, the only option they could offer someone in chronic pain was extraction – which doesn’t require specialist PPE.
The consequences of such an outcome across dental practices in Northern Ireland for dental health would be profound. It would set back public dental health decades. As most NHS clients are children, elderly, pregnant mothers and low-paid working-class people, it threatened a two-tier dental health society: those with the money could afford to keep their teeth while those without were forced to have them removed.
More needed than averting the immediate crisis
Today’s decision by the Minister avoids this scenario becoming a reality from as early as Monday – but the threat remains. As it stands, an NHS patient needing a filling will have the option of going to one of the five Emergency Treatment Centres in Northern Ireland. They won’t have to have the tooth removed. It’s far from satisfactory but it is an improvement.
The question however has to be whether this is the start of the end of NHS dentistry as we know it. For as long as this is the case, NHS patients will no longer be able to obtain anything bar tooth extraction from local dental practices and instead be forced to travel long distances to the limited number of treatment centres.
At the same time, even paying clients may find themselves forced to go to the Emergency Treatment Centres as the few practices which have been face-fitted and have higher grade PPE have it in very limited quantities. Today’s announcement by the Health Department was accompanied by a grant of £500 to practices for fitting costs but that doesn’t help in any way the difficulty of getting a fitting specialist.
In all scenarios we are facing an extended period of the most basic provision of dental health services; the backlogs for treatment will continue to mount.
But even once the dental PPE crisis is resolved, there are still major issues. The numbers of patients needing urgent and routine dental work is huge and growing by the day. Reducing the backlog will be hampered by the delay in getting PPE but it will also be impacted by a guideline known as ‘fallow time’.
The guidance for infection controls is that after conducting aerosol generating procedures staff must exit the room. They must stay outside for a minimum period of 60 minutes to let the aerosols fall to the floor. A twenty minute, deep-cleanse is then required. Between AGPs this means no activity can be conducted for a period of 80 minutes. The impact of this limitation on throughput is likely to be severe.
Dentists will go from seeing up to 15 or 16 patients in a morning to perhaps 2 or 3. Waiting times for treatment are already excessive are only likely to rise further.
The Socialist NHS model and dentistry
This crisis reflects the failure of consecutive Health Ministers to properly invest in dental health, as well as the lack of universal NHS dental provision. The low level of payments for NHS treatments is testament to the lack of priority given by Stormont and Westminster Ministers to services for low-income patients.
The NHS was founded by the Labour Left Minister Aneurin Bevan in 1948 and included dental as well as optical services. Such treatments were provided free at the point of delivery and funded through taxation.
The socialist NHS model faced attack from the very beginning. Bevan resigned his post as Minister for Labour in 1951 when his party shifted rightward and introduced dental charges.
Attacks on access to dental services
The lynchpin of the NHS was that it was both universal and free at the point of delivery. Those principles were critical to the NHS model, once they were breached the door was open to ever further attacks. The principles meant health services were provided not on ability to pay (wealth) but on need. It was implicitly a socialist system.
In the passing decades there have been more and more attacks on NHS dentistry. Fewer and fewer workers are eligible for free dental work. Now the future of NHS provision has been called into question by the exceptional stresses arising from the Covid pandemic.
The NHS is perfectly positioned to source protective equipment. State-owned manufacturing could produce PPE but even if it was sourced abroad, the NHS offers savings through bulk purchase discounts. Fit-out of masks for medical and dental workers could be rolled out comprehensively and efficiently through the integrated NHS.
Reliance on contractors and a network of suppliers leaves basic dental health services threatened by repeated private sector market failure.
NHS dentistry – the real solution
The long-term solution to dental health services is a return to the original NHS model. Dentists should be employed on decent pay, reflecting their expertise and contribution to society, directly by the NHS itself. Instead of NHS work being treated as a charitable activity, dental health must once again become a political objective.
Given its inherent size, and economies of scale, the NHS could deliver dental health at a fraction of the cost. Under socialism, the surplus generated by state-owned powerhouses would pay for universal access to dental provision. It was possible to pay for dental services through general and progressive taxation in bankrupted Britain in 1948; imagine what could be done under socialism!
Readers shouldn’t hold their breath waiting for any of the neoliberal, sectarian Stormont parties to enunciate such a perspective. It is one that working-class people need to demand. Today’s announcement only staved off the crisis but without urgent action NHS services will be further cutback, degraded and privatised. Workers must mobilise to demand an NHS providing for all our health and social care and indeed dental health needs.