Dentistry at a tipping point
The Scottish Government must support the training of more hygienists, therapists and dentists
I read a book1 recently which discussed poverty, its roots in the class divide and the effects which are felt in those who experience the worst our society has to offer. It was interesting on many levels, not least the eloquence with which the complexity of our ‘eco-system’ was explored. It gave some perspective to my somewhat one-sided, middle-class, privileged experience of treating, for more than a quarter of a century, those who live in a deprived area.
In our few cities, the juxtaposition is amplified by the cheek by jowl nature of city living. Finer neighbourhoods can easily be seen from housing schemes with wildly different life experiences. The principal topic discussed was stress and the uncertainty caused by living with little money, poor education and unfortunate family circumstances.
In healthcare, it is well documented that poor socio-economic conditions relate strongly to poor (dental) health. This creates demand for our services but also further stress in the form of discomfort, pain, reduced capacity to function normally, care for others, participate in education and countless other side-effects, not least serious and life-threatening infections.
This is nothing new to you or our policy providers. Is it worsening? Honestly, I don’t know and I’m not the public health expert to tell you. Being in the one place for decades, my patient list has filtered itself to regular attenders interested enough to come back to benefit from my wisdom (no better or more informed than any other dentist, except by experience). Those patients are much more likely to be better educated, in stable living and possibly working conditions. The children I see are much more likely to be well looked after by parents, guardians or carers who bring them to the dentist regularly, thereby exposing themselves to my boring and repetitive ministrations on toothbrushing, diet and regular attendance. Judging by their repeated but reluctant return (everybody hates the dentist), somehow the message is getting through. They still might need the odd filling, scaling, crown etc. but they return. We get a chance to intervene and, possibly, help prevent the decay.
This leads me to my three points. Firstly, those with the greatest need and highest inequalities for health very often don’t attend, interact with services or go to school to see the Childsmile nurses. The more deprived, the harder your life, the less likely you are to avail yourself of the services (stretched, underfunded and with long waiting times: but there). You are less likely to get treatment or, more importantly, intervention and education to prevent you needing care. This is awful, sad and the worst of our society. I recognise that Childsmile is seen as a brilliant success in the reduction of dental disease. My own personal feeling (and I have no evidence for this) is that the regular intervention and education in brushing for children and their enthusiasm to influence their parents is more important than the fluoride placement. However, if the fluoride is the most important effect, then surely water fluoridation is even more helpful for addressing inequalities across the board?
Secondly, dentistry seems to be shifting in its response to the market. Young professionals and influencers on Instagram, TikTok etc. have little or no reference to building a patient base, regular care or prevention in dentistry. It’s all about treatments, in particular, aesthetic treatments. This message pervades all else, pushing the profession away from ‘old-fashioned’, high street dentistry with frequent visits to build relationships, reinforce self-care and create an expectation of reliable supervision. Determination 1 exam funding jeopardises this, relying on GDPs to take a hit to see patients six monthly. The Scottish Government argues an extensive exam in a 12-month period is the same value as two, old six-month exams. We should work to our conscience and not worry about fees. If someone needs or wants to be seen six monthly, just do it.
We must not lose sight of our unique role as guardians of our patients’ oral and general health and create relationships built on a solid foundation of regular intervention, be that observation, prevention or treatment. We must not spiral into the abyss of one-off treatments to satisfy the aesthetic desires of patients. This is not the path to better healthcare, professionalism or a Ferrari. This is a derogation of our professional responsibilities in search of an economic prerogative.
Thirdly, and perhaps most importantly, is the recognition that ‘transforming’ healthcare and the health of individuals is not simple. Change within a system so large and complex is like trying to change the direction of supertanker. It requires small direction changes to keep the vector of better health moving without rocking the boat, losing precious cargo or simply going the wrong way. If we try to make wholesale changes, we will be so far along another path before we notice it’s right or wrong and fuel for that change will have run out.
Ropey metaphor aside, realising we have a system which works pretty well for the majority of people the majority of the time is a first step to improvement. Constant, small improvements are much more easily implemented, funded and assessed and, in my view, much more likely to be successful. NHS dentistry is at a tipping point. The Scottish Government must address this with the training of more hygienists, therapists and dentists to ensure that NHS care is viable within our dento-financial eco-system. Continue
to train, better understand our workforce planning issues and incentivise the care of those most at need.
1 Poverty Safari: Understanding the Anger of Britain’s Underclass by Darren McGarvey.
Arthur Dent is a practising NHS dentist in Scotland
Got a comment or question for Arthur? Email arthurdent@sdmag.co.uk