It’s been said that ‘fairness’ doesn’t mean that everyone gets the same (that’s ‘equity’); it means that everyone gets what they need. Wind the clock back to early 1948, and there were around 12,000 dentists in the UK, many of whom were under-employed. Most people visited only when in pain, and the costs were significant, barring many from seeking regular care.
It was therefore understandable, in a nation just recovering from the ravages of war, for the government to argue for a universal and free service. Many dentists, of course, were initially resistant and even by the end of 1949, about 25 per cent remained wholly private.
It was a time when four out of five children had active caries (despite sugar rationing) and few adults retained their natural teeth beyond the age of 40. Something of a contrast with today, when edentulousness has fallen to around six per cent and over 70 per cent of five-year-olds are caries free.
How does all this stack up 65 years on? I ask because at a recent meeting of the Westminster Health Forum, we were told, again, that new money is not going to be available for dentistry and that in the context of the wider financial issues facing the NHS, primary dental care is not going to get to the top of the pile anytime soon.
For one thing, as the chief dental officer pointed out, access is not a current issue. Well over 90 per cent of those seeking an NHS dentist are successful in the medical GP surveys. But, the audience asked, access to what? When will the Government, Department of Health or NHS England make clear what is the ‘NHS offer’ to patients?
This is territory the CDO knows well. He advised that it is not for authority to state what is in and what is out. According to the terms of the 2006 contract, which most dentists were happy to sign, everything (including layered composite restorations) is ‘in’ if necessary to achieve or maintain dental health and if the patient agrees to it.
This always rather reminds me of those software ‘end user agreements’ that pop up when we download some new functionality. For all we know, we may have sold our children to the devil and all our possessions to Applesoft, since none of us ever reads
the small print. Thirty-love to Barry (it’s Wimbledon as I write).
He pointed out that the ‘clarity’ of distinguishing between NHS and non- NHS treatment is a job for the clinician; that the issue is about communication, and not about ‘ins’ and ‘outs’. Try telling that to Channel 4’s Dispatches (or to the GDC for that matter).
In fact, turning to one of the most hotly debated provisions, he added that it is for the clinician to tell the patient that they ‘do not need a scale and polish’ and hence the hygienist will cost £45 (please). A wearying task, akin to telling a GP to refuse a prescription for the fortieth viral infection he has seen that day... Or is it? Taken to the logical conclusion, if ‘fairness’, in today’s society really is about providing what patients need rather than the same for everyone then should we be providing heavily discounted layered composites for all? Or should we all (government and profession alike) be talking about providing essential, health-preserving, services primarily to those in the greatest need?
Means test or postcode lottery, we should all decide and do so honestly. Because we simply cannot go on as we are. We cannot continue to spread the jam (‘not tomorrow, but next week’ as the Minister recently said) more thinly across an entire public who seldom appreciate the standard of training, development, skill and investment that is primary care dentistry. A public, what’s more, which is on the whole, far more capable of choosing to afford the cost of decent preventive dental care.
Do we really value what we do and are, or are we all happy to participate in a race to the bottom? Equity or fairness? It’s been equity for 65 years, is it time that fairness came into the equation? Not, that is, that anything is really fair. As someone once said: life isn’t fair, it’s just fairer than death, that’s all.