Down in the mouth
Observations on dentists
"We are going back to the dark ages of dentistry," says Richard Daniels, chief executive of the Dental Laboratories Association. Eighteen months on from the introduction of new NHS contracts, discontent within the dental profession is growing. The DLA says the current contract "forces dentists to make prescription decisions based on financial resources rather than clinical need" and claims there has been a 57 per cent reduction in "Band 3 treatments" such as crowns and dentures.
The British Dental Association shares DLA's concern. "The contracts are not going to provide quality oral health for the patients. We've got wonderful techniques and equipment now but we're not being encouraged to use them," says Lester Ellman, chairman of the BDA General Dental Practice Committee.
The new contracts were intended to solve an intractable problem. Before their introduction, there were more than 400 fee tariffs for NHS work, which left patients bewildered. Now there are just three and the contracts focus on providing cheap and affordable basic care, not on expensive, often unnecessary, treatments.
The old "payment by procedure" system, whereby dentists were paid for each item of work they undertook, was certainly open to abuse. An Audit Commission reported in 2002 that it gave a "perverse incentive" for dentists to carry out unnecessary work.
The NHS contracts are the latest attempt by the government to reverse years of decline in state provision - a decline triggered by the Conservative government's ill-thought out reforms of the early 1990s. These linked dentists' pay to the number of patients registered. When more patients than anticipated registered, the government reacted by cutting fees rather than increasing funding.
The result was a huge exodus of dentists to the private sector. In 1990, only 5 per cent of dentists' income came from private work; now it is more than 50 per cent.
The private dental market, virtually non-existent 20 years ago, is now worth more than £2.4bn.
Even a salary of £80,000 a year, guaranteed under the new contract, was not enough to persuade a further 2,000 dentists from leaving the NHS. Meanwhile, private chains and insurance companies are rubbing their hands in glee. In the year to April 2007, Denplan announced a 25 per cent increase in take-up of its schemes. In the same period, Oasis, Britain's largest dental chain, reported a doubling of profits.
But for the millions unable to pay to go private, the situation goes from bad to worse. Sixteen months on from the government reforms, an estimated 1.4 million additional people are thought to be without an NHS dentist.
In the sixth richest country in the world, thousands are forced to fly abroad in order to receive dental care. This year it is estimated that more than 25,000 Britons will travel to Hungary for dental treatment. An even more alarming trend is the number of children deprived of proper dental care.
Up and down the country dentists are telling parents they will no longer provide NHS treatment for their children. The long-term consequences for oral health is calamitous.
For most of the postwar period, access to an NHS dentist, paid for out of general taxation, was taken for granted. The idea that by the first decade of the 21st century, 60 per cent of Britons would not have access to an NHS dentist - and that one in five would be deterred on grounds of cost from going to the dentist - would have seemed unthinkable to a member of the public in the 1960s.
In 1999 Tony Blair promised that within two years everyone would once again have access to an NHS dentist. But the experience of the last decade shows that a flourishing private sector is incompatible with the notion of a state-financed system. We have enough dentists: the number has risen to more than 21,000 compared with 12,360 in 1977 and 15,400 in 1992. But so long as dentists can earn up to four-times more by going private, NHS provision will be threatened.
Ouch! British dental care the most expensive in Europe
Europe-wide study reveals huge gulf in dental prices
Dental treatment in England is the most expensive in Europe, according to an unprecedented survey which is likely to fuel the exodus of patients seeking treatment abroad.
The survey of nine European countries found the total cost of a standard filling ranged from €156 (£117) in England to €8 in Hungary. That total included the cost of x-rays, materials, drugs and overheads, as well as the dentist's time.
The findings come amid growing dissatisfaction with dentistry in Britain and shrinking NHS provision. The Government admitted last March that two million patients who wanted NHS treatment were unable to get it, eight years after Tony Blair pledged at the Labour Party conference in 1999 that everyone would have access to an NHS dentist.
Dentists have dramatically increased their private work over the past decade, at the expense of their NHS work, and when a new NHS practice opens, desperate patients queue to register.
Dentists with their own practices earned an average of £105,000 in 2004-05. More than half their total income (52.4 per cent) came from private work, up from 41.8 per cent in 1999-2000. In 1990 it was 6 per cent.
While England topped the table as the most expensive country for dentistry at €156 for a filling, it was closely followed by Italy (€135) and Spain (€125). Costs in the other western European countries were less than half as much, ranging from €67 in Germany to €46 in France.
In all European healthcare systems, the greater the cost of carrying out dental work, the greater the level of government subsidy required to keep the price of dental treatment down for patients.
The cheapest countries for treatment were Poland (€18) and Hungary (€8), the main destinations for dental tourists from Britain. Savings of thousands of pounds are promised by agencies that arrange treatment in these countries, even after paying the cost of flights and hotel bills.
It is the first time that the cost of carrying out a dental filling has been compared across Europe. Siok Swan Tan, of the Institute for Medical Technology Assessment, at Erasmus University Rotterdam, and lead author of the study, said differences in dentists' earnings were the most important reason for the variation in costs. "Without exception, labour costs were the most important cost driver in all countries and practices," she said. "They accounted for 70 per cent of total costs in England. They ranged from €0.09 per minute in Hungary to €2.88 a minute in England."
The figure for England included material costs which "makes straightforward comparisons difficult", she said. The procedure was a filling in a molar tooth in a 12-year-old child.
High costs and the difficulty of finding NHS dentists have combined to make dental tourism the fastest growing category of medical tourism. Of 77,000 travellers from the UK who went abroad in 2006 for medical treatment recorded in the International Passenger Survey, an estimated 43 per cent sought dental care, according to the agency Treatment Abroad.
Keith Pollard, its managing director, said: "Dentistry is the biggest part of the business. The number of providers targeting the UK at the moment is phenomenal. It is driven by the high prices charged in the UK and the difficulty of finding an NHS dentist. When you find a private dentist the prices are shocking."
NHS patient charges are in three bands ranging from £15.90 for a check-up and x-ray to £43.60 for one to six fillings, to a maximum of £194 for crowns or root treatments. Private charges are two to three times higher.
The British Dental Association rejected the research as "deeply flawed". Peter Ward, its chief executive, said it was based on a sample of four practices out of 10,000, and was "riven with problems".
"It is a very small sample, it is not representative and it is not comparing like with like," said Mr Ward. "The dentists selected were community dentists who normally care for patients with special needs who need more staff and take longer to treat. It is impossible to make a sensible comment on a set of flawed data."
The survey is part of a wider study, commissioned by the European Commission, comparing the cost of a range of medical procedures among the nine countries and is published in the journal Health Economics.
Professor Reinhard Busse, of the department of health management at the Berlin University of Technology, who led the research, said: "We wanted to see if we could explain differences in the costs. The aim of the research is to help governments plan what levels of reimbursement may be necessary if, as we expect, cross-border medical tourism increases." The European Commission is due to publish draft plans which would open EU borders to medical tourists, allowing citizens of any of the 27 member states to seek treatment in a neighbouring country with the home country, in certain circumstances, picking up the bill. If the proposals are approved, it will focus attention on the performance of the NHS against other health systems.
The dentistry survey showed that in all cases the total cost of providing a filling exceeded the charge to the patient and in most it exceeded the payment from patient and government combined.
'I had to ask if the treatment was really needed'
Kath Diamond says her daughter Meg, aged 10, has "great teeth". So when she took her for a routine check-up at an NHS dentist in Putney a month ago, she didn't expect to embark on a series of appointments that would end in a bill for several thousand pounds.
But that's what happened after Meg was referred to an orthodontist in West Hampstead, who "immediately" said her teeth were not of the standard to qualify for further NHS treatment. According to the orthodontist, Meg had an "overshot" jaw and "mild crowding" in the lower jaw.
The proposed solution? A night-time head-brace and a removable day-brace for six months, plus 12 to 18 months of "railway track" braces on the upper and lower jaw.
After that she would need another brace every night for a period, followed by a day-brace a couple of times per week for the next decade – until she was 20 years old. After a "long consultation process", a bill was presented for £2,500 on Tuesday.
Mrs Diamond was staggered. "In the end," she says, "I asked, 'Is there a physical need for this treatment?'. They said Meg's teeth would be difficult to clean when older, and I think that is probably not true. It was all to give her the 'perfect' set of teeth."
With understatement, Mrs Diamond adds: "But that would have involved invasive treatment." Reflecting on the episode, she says: "There wasn't a sense of openness about it being what was, essentially, cosmetic surgery".
NHS dentistry 'tops cost league'
Dental treatment in England is the most expensive in Europe, a survey shows.
The poll of nine countries found the total cost of a filling - to the NHS, not what the patient pays - was £117 in England compared to £6 in Hungary.
The findings of the study, led by the Erasmus University Rotterdam, in Holland, are mostly do to with variations in the cost of living.
Dentists said the Health Economics journal report was flawed as it was not comparing "like with like".
However, the findings still pile more pressure on NHS dentistry which has been criticised following the introduction of a new contract in 2006.
The deal was meant to entice dentists back to the NHS but has so far made little impact, with 2m patients complaining they still cannot get access to services.
And it comes as an ever-increasing number of people from England go abroad to have dental treatment.
Researchers looked at costs from things such as x-rays, materials, drugs, overhead and dentist pay.
NHS dentistry is subsidised by the state with patients contributing to the cost of treatment. In the case of fillings, patients in England contribute £43.60.
England was followed by Italy and Spain as the most expensive places.
Lead researcher Siok Swan Tan said the differences were primarily to do with the increased costs in certain countries.
"Labour costs were the most important cost driver in all practices, comprising 58% of total costs.
"Overheads costs were the second most important cost component in the majority of countries."
Peter Ward, of the British Dental Association, said the report was flawed as the dentist surgeries quizzed in England tended to have a high number of special needs patients.
"It is a very small sample, it is not representative and it is not comparing like with like.
"It is impossible to make a sensible comment on flawed data."
NHS dentistry crisis deepens
Worsening access to NHS dentistry could see more people going private and an increase in demand for corporate cash plans, it has been claimed.
The comments by cash plan provider HSA followed the release of figures suggesting that over 7m adults in England and Wales have not been to an NHS dentist since April 2006.
The survey by the Citizens Advice Bureau (CAB) found that nearly one in three people said failure to find a dentist to treat them was the reason they had not been to one in nearly two years. CAB said this is the equivalent of about 7.4m people, of which 4.7m have sought private treatment and 2.7m have gone without treatment altogether.
David Harker, CAB chief executive, said: “These figures show the scale of the lack of access to NHS dentistry, reflecting the evidence which bureaux across England and Wales have been reporting since the early 90s.”
Norman Lamb, Liberal Democrat shadow health secretary, said the elderly and people on low incomes are particularly affected.
“Patients are suffering under a two-tier system as only those with access to money and transport get to see a dentist,” he stated. “This makes vital prevention almost impossible and means that those who need treatment most are missing out.”
Glenn Rhodes, head of B2B marketing at HSA, said the issue affected the wider working population, too. He suggested that worsening access to dentistry would increase demand for cash plans and dental plans as people are forced to go private.
“In the last couple of years we have seen more employee demand for dental benefits and I expect that we will continue to see this happening,” he said. “In March 2009 primary care trusts will no longer have a ring-fenced dental budget. Instead, they will have a budget for healthcare and I have a feeling dentistry won’t be seen as a high priority. I think we will see an exodus of NHS dentists next year, which will make the situation even more challenging.”
Health minister Ann Keen said improving access to NHS dentistry is a “national priority” and announced a funding boost of 11% for 2008/09.
“We are working hard to improve access to NHS dentists and the government remains fully committed to expanding services,” she said.
Dental treatment in England is the most expensive in Europe, according to recent research by the Institute of Medical Technology Assessment at Erasmus University Rotterdam. The survey of nine European countries found the total cost of a standard filling ranged from t156 (£117) in England to t8 in Hungary.
Pensioner makes 2,000 mile trip for dentistry
A pensioner travelled more than 2,000 miles on a round trip across Europe to get his teeth fixed, after his dentist went private.
Colin Foster headed from Bardsea to Budapest after discovering his dental work would cost less than half what it would at home.
Armed with the results of a national survey, which found six per cent of English patients had resorted to home dentistry, campaigners in the Lake District are urging health bosses to plough money into NHS surgeries, to prevent the area's dental drought from worsening.
Retired Mr Foster, 69, became one of an increasing number that head abroad for oral work after his NHS dentist went private and he was quoted thousands of pounds for work on a single tooth.
He has just returned from his third trip to Hungary, with nearly £2,000 of dental work to show for his travels, including an implant, two replacement crowns and two new crowns.
For full story see the October 19 edition of The Westmorland Gazette.
My brush with a root of pure evil
I woke up, began to lift my head off the pillow and discovered that this most simple of tasks was quite impossible without feeling as if my jaw was about to explode, says Bryony Gordon.
It was on Thursday morning that I cried for the first time in 18 years due to physical pain (the last time was when I had a stomach ache, during which my mother said, "You'd better not be faking this to get a day off school"; three hours later, I was wheeled into theatre to have my appendix removed, which I still make her feel guilty about).
Anyway. Thursday. I woke up, began to lift my head off the pillow and discovered that this most simple of tasks was quite impossible without feeling as if my jaw was about to explode. Wahhh, I thought. Arghh, I screamed, which was a mistake, because I now found that unbeknown to me, my mouth had been wired up overnight and opening it caused a sensation akin to my head being given an electric shock. Boo hoo, I cried.
What was wrong with me, you may be wondering. I'll tell you what: I had toothache. Wisdom-toothache, I think.
Go on, laugh. See if I care. Toothache may not be a burst appendix, or a broken leg, or even a sprained ankle, but I would rather any of those before suffering the effects of a monstrous rogue tooth that serves no purpose trying to burst through your gum, and then through another tooth that is actually quite useful to you. How dare it? Who the hell does it think
it is? What does it want from me?
I stumbled into work, where a colleague took one look at my lopsided mouth and tear-stained cheeks and announced: "You need to go and see a dentist." As if that hadn't already occurred to me, and I hadn't already tried, and failed, miserably, to do just that. I cried again.
That's the thing about having appendicitis or breaking a leg – it may hurt, but you can go and get it fixed immediately for free. You may catch MRSA in the process, but let's not be ungrateful here – it's not as if we live in a country with a First World health system. They're doing what they can with what little they have got.
Anyway, if you try to find a dentist because you have a simple case of toothache, it's like turning up in the Sahara in search of water, or locating an honest person in the House of Commons. Tricky, to say the least.
There are supposed to be quite a lot of NHS dentists in London, but I was damned if I could get an appointment before the 15th of Never, by which point I would have gouged out the tooth at the back of my mouth with a rusty Allen key, the anaesthetic provided by one of those mini bottles of Bell's whisky that you only ever see in the hands of tramps and alcoholics.
Even if I could have got an NHS appointment, they're eye-wateringly – or mouth-wateringly – expensive, all things considered: some procedures will set you back £198. Last week, a man appeared in Manchester Crown Court, having threatened hospital staff because, he claimed, 30 NHS dentists refused to see him. "I can't afford private work," said Martin Pearson. "When I try to get NHS treatment, I am refused. My mate pulled the tooth out with pliers." He was given a year's community service, as if he hadn't already suffered enough.
In 1999, Tony Blair said that everyone in the country would have an NHS dentist within two years. In 2009, one in three people still can't find one. Some say that Labour's "reforms" of the dentistry system have led to a million people losing a dentist. Quelle surprise: another empty Blair promise. Not that Tony has to care about dental bills, what with his multi-million-pound public- speaking career and all that.
It costs £170,000 to train a dentist – and then most of them are forced into private practice by a complicated system that is all about targets. It's rotten to the core; just one on New Labour's long list of betrayals. Tuition fees, weapons of mass destruction, the Gurkhas…
"You should go to Hungary to get that sorted," suggested a friend. I should. Perhaps we all should.
Open wide for your next holiday
Last year 20,000 Britons went abroad for dental treatment. Lisa Bachelor finds out the drill
Property investors and skiers have long known about the advantages of a trip to Eastern Europe, but growing numbers of Britons are now jetting off to the likes of Hungary, Poland and Bulgaria to cut the cost of their dental bills.
Fifty thousand people in the UK travelled abroad for medical treatment last year and 20,000 of these did so for the sake of their teeth. The average spend on dentistry was £2,500, according to website Treatmentabroad, which surveyed 300 clinics, medical tourism companies, hospitals, doctors, dentists and healthcare providers overseas that are promoting their services to the UK market.
Cost is the biggest factor driving people overseas - savings of more than 80 per cent can be made on some forms of treatment - but the rise in dental tourists has also been due to changes in the NHS in the past year. 'The biggest growth in dental tourism appears to have been fuelled by the changes to NHS dental contracts, especially for people who want more complex procedures carried out,' says Keith Pollard, spokesman for Treatmentabroad. 'They are either struggling to find a dentist to do it or when they do are being met with costs of £10,000 to £15,000 in some cases.'
The Dental Laboratories Association, the professional body for lab owners, claimed last week that its members were being deprived of work because the new NHS contracts rewarded dentists for carrying out less complex procedures. Chief executive Richard Daniels said: 'The current contract is forcing dentists to make prescription decisions based on financial resources rather than clinical need. We are getting a lot of inquiries from patients, mainly the most vulnerable in society who require dentures, who just can't get them.'
A number of websites have sprung up to act as broker between people seeking treatment and clinics that see overseas patients. RevaHealth is one of them. It says those who go overseas for dental treatment can be broadly divided into two categories: people who need a lot of expensive, unavoidable work done and those who want cosmetic procedures. 'If you need something minor done the cost of the travel and accommodation is likely to outweigh the savings,' says Philip Boyle, a director at RevaHealth. 'But if you are going for crowns, veneers or implants then you could save thousands of pounds.'
Lee Mitchell, 33, runs a bar and restaurant on Guernsey and has just come back from Poland, where he spent an entire week at the dentist. 'I had seven fillings, two extractions, a root canal, some reconstruction work, a crown and some bleaching,' he says. 'I had never thought of going abroad for treatment but when I realised how much work I needed doing a couple of my waitresses suggested Poland.'
Lee contacted the BB Cracow clinic in Krakow, which he had found on RevaHealth.com, and within days had booked his flight. A representative from the clinic sorted him out with accommodation and picked him up at the airport.
'I made nine or 10 visits to the dentist over six days. I didn't go out once in Krakow and stayed in eating soup and dribbling beer down my chin, but it was worth it,' he says. Lee's dental bill came to £1,200, which he believes is about a third of what it would have cost him in the UK. His return flight was £130 and his accommodation for the week £200.
However, the British Dental Association has issued a warning. 'Anyone thinking about having dental treatment overseas must make sure they are aware of the potential risks and the hidden costs,' says a spokesman. 'Difficulties may arise if there are problems with the treatment when the patient returns home, especially if there are insufficient records of the treatment carried out.'
Boyle says all the clinics they deal with overseas must sign up to RevaHealth's terms and conditions, which include the stipulation that they be registered with their local regulatory body.
'All the clinics in our system are used to having international patients,' says Boyle. 'Both Hungary and Poland have some of the leading technology and strictest dental regulations in the world. Whole towns on the Hungarian-Austrian border have an economy almost entirely based on dentistry.'