YES
Jimmy Steele
Professor of Oral Health Services Research at Newcastle University and
author of the review
At the moment if a restoration (a filling or crown, for example) fails within
a year the dentist can do it again and it doesn’t cost the patient anything,
which is quite right. If a restoration fails after one year, however, the
dentist can be remunerated again, because patients have to pay a
contribution and if patients are exempt the state pays.
The evidence suggests that fillings should last about eight to ten years.
Fillings should not be failing within a short space of time — if a repeat
treatment is required after two or three years I don’t think the patients or
the state should pay. There is a perverse incentive to do something that
will stay put for a couple of years knowing that “if it fails we can do it
again”.
This is a tough message but I think it’s fair. There are a lot of people
investing in what dentists are doing and it should work. Dentists should
think “the pressure is on me to make this last”. If they can’t say
confidently “we can do this to last five years”, then they should perhaps
ask themselves why they are doing it. If this proposal makes people think
about what they’re doing, I think it’s a good thing.
There are risks. For example, some dentists may start to take on only cases
where they feel certain that it’s not going to fail, a kind of
overcompensation. There should be a check and balance so that doesn’t
happen.
Some important procedures have much higher risks of early failure — we need to
find a way to take that into account and there are some things for which a
warranty system is not appropriate — when you do a treatment as a short-term
measure to nurse a patient through. We need to find a way to manage that
sort of thing.
I don’t see this as punitive. I hope that it will incentivise dentists to do
their work properly and reward people for quality. Most professional
dentists are happy to indemnify treatments for a longer period — the private
sector is used to providing guarantees.
Patients have to accept responsibility for brushing their teeth effectively
but dentists have a role in educating people to minimise their risks. If
they are not comfortable that the patient’s oral health is good enough then
it should trigger a conversation with the patient along the lines of “we’re
not ready to do the procedure yet”.
I don’t think the cost should be much at all. After all the expected lifetime
of a restoration is much more than three years. There may be some cost to a
practice and some dentists might argue that it will take longer to do the
treatment to that standard, but I think that is fair enough.
There has been a loss of confidence among dentists because of bad news stories
and problems with access. Unfortunately there is a perception that NHS
dentistry is a bit second rate compared with the private sector. If we do
the things we’re talking about, I believe that NHS dentistry could — and
should — become gold standard.
NO
Dr John Milne
Chairman, the British Dental Association General Dental Practice Committee
As consumers of any service we expect work to be of a certain standard and
last for a reasonable length of time. If I buy a television and it breaks
after three years, I expect it to be replaced. And it’s easy to see why some
may feel that this principle should be extended to dental work. As one of
the few areas of NHS work that isn’t free to patients at the point of
delivery, dentistry is judged by consumers according to criteria including
value for money. But judging the success and value for money of dental
treatment is complex.
That’s why dentists will have concerns about this proposal, which would extend
the current one-year guarantee period. Dentists want to provide quality and,
as the review points out, they do so. The number of restorations that fail
is small. In the Strategic Health Authority area that I work in only 1.1 per
cent of restorations fail prematurely.
In the small number of cases where work does fail, there can be many reasons
why. The success of restorative treatment is subject to influences including
further tooth decay caused by poor diet, a failure to maintain good oral
health and damage caused by contact sports or accidents. And we really
shouldn’t underestimate the influence of the first of these factors.
Regardless of how well crafted and placed a filling is, if a patient goes
home and chews on a sticky toffee, its chances of success will be severely
jeopardised. And in an instance such as this, I wonder whether it’s right
that a dentist should be financially penalised.
Dentists do their best to discourage such behaviour of course. We encourage
patients to engage in behaviour that gives them the best chance of good oral
health. Via regular dental check-ups dentists are one of the few health
professionals who regularly see patients who believe themselves to be
healthy. That gives us an opportunity to talk about diet, tobacco and
alcohol consumption and the importance of maintaining good oral hygiene. And
I know from my own experience of practising in West Yorkshire that many
patients act on this counselling. But I also know that some patients do not.
That doesn’t stop me trying to get those messages through but it does mean
that despite my best efforts I can’t always be successful.
Professor Steele recognises the differing behaviour of patients in his report.
He also recognises the flawed nature of a contract based on measuring what
dentists do and instead offers a vision of reform based on a contract that
encourages preventive work and focuses on the oral health outcomes of
patients. The British Dental Association is looking at the detail of the
proposals carefully so that we’re ready to engage fully with the Department
of Health and work constructively to deliver the very best arrangements for
patients and dentists alike. That engagement, along with meaningful learning
from the piloting of reforms, will be crucial to their success.
