The parody of NHS patients being ungrateful, ignorant and audacious in their demands is a poor reflection upon those who hold this view. It seems to be an all too common perception that NHS patients should be grateful for whatever treatment they receive. These views are evident in articles such as 'Give a Mouse a Cookie' (The Dentist, April 2012) with claims of being a tongue-in-cheek jest and an assertion of the right to freedom of expression. Views such as these are in fact plainly insulting to patients, dentists and all those who devote time and considerable skill to the profession. There seems to be a misunderstanding demonstrated by some dental professionals that NHS patients, especially those who are exempt, are not deserving of the treatment that they are entitled to.
The idea that NHS dentistry is an unwinnable struggle against oral disease is perpetuated throughout the profession. As a student, I was once told by a nurse not to pursue any interest in periodontology because "they never get better". Again, anyone with a knowledge of the disease process and has seen enough patients will know that periodontitis is often well managed in those who improve their oral hygiene. Disease rates are decreasing and dentistry is moving towards a new chapter where conditions such as tooth wear are more of a concern to an ageing population than caries. Caries is a social disease, with the majority of individuals at high caries risk being of the lower socio-economic groups. This is well-known to be due to poor diet and oral hygiene routines. Caries will most likely be prevalent at higher levels in these patient groups for many more years, but advances in the public's health knowledge and interventions such as fluoride toothpaste go a long way to reducing these inequalities. The idea that the festering mouth is related to social deprivation has not always been so; in comparatively recent times it was a sign of affluence as sugar was a luxury commodity, that only the rich could afford to consume with the frequency required to develop caries.
So called 'exempt' patients are seen by some as uneducated and under-appreciative of the services that we provide. On what authority is this acceptable? The mind boggles considering the twisted logic that would state that patients are entitled to help in paying for dental treatment, but are not entitled to the basic right of being respected in receiving this care. The forum of The Dentist (www.the-dentist.co.uk/forum.php) has seen individuals post such opinions, one such example states: "I am referring to the group of exempt patients who do not pay taxes, and thus do not pay for dental treatment directly or indirectly, and so to say they are entitled to look for the best value for their money is irrelevant; I feel they should be grateful for any treatment they receive (which should not be negligent or of a poor quality either)."
This individual is perpetuating the same prejudice towards those exempt patients that the author of 'Give the mouse a cookie' put to paper in his article. The spirit in which this individual might provide treatment is highlighted by their castigation of negligent treatment being present seemingly as an afterthought.
The reason we became dentists (for most) was to have a rewarding career with both ample financial and social benefits with great opportunity to help people. The financial reward is not something I feel an excuse should ever be made for; we as dentists work hard and sacrifice much to do our jobs well. The issue arises when we stop caring why we do what we do and instead focus upon the monetary aspects of our profession. We are not in a commercial line of business; whether it be NHS or private; we dentists have a fiduciary relationship with our patients. That is why they are patients, not clients. We do not work on a system of 'buyer beware'- we help our patients decide what is right for their treatment needs without unconditionally recommending the option that will make the most money. The word 'patient' derives from the Latin 'pati', and the subsequent French 'pacient' both meaning 'suffering' or 'sick'. The term client is again from the Anglo-French 'clyent' meaning person who is dependent upon. Our patients come to us for relief of suffering to be provided in a way in which we as the provider are on equal terms with them. To see patients as clients, even those who are not in pain is to invoke undercurrents of paternalism and power which are unethical and unproductive in treating patients.
The theory of a liberal, free-market economy and with it a free-market healthcare system might suggest that patients are responsible for their choices. These choices include whether to either work or play, spend or save, invest or enjoy. The disparities in affluence that arise over time as a result of these actions are of our own making and therefore fair. Any duty or requirement for dentists to act in a preferential way towards any group in this system regarding cost will upset this free-market. The concept is fairly straightforward; you get what dental care you can pay for. This seems to be the system that some subscribe to as it is the model upon which private dental care is based. Whilst acceptable alongside NHS dental care, the free-market model would not promote equality nor would it help redress oral health disparities if it were the sole source of dental care in this country. This is why, although not perfect, we need to cherish and celebrate the NHS dental care (and healthcare in general) system we are so lucky to have. The perception of fairness in the free-market model could only be truly coined if individuals were all born into the same circumstances. In reality, we are all born to parents who have different means, different fortunes and different ideals. To ignore the fact that most dentists tend to be from upper or middle class backgrounds would be a mistake. Some dentists lose sight of this, leading to judgemental attitudes and prejudice against those who live different lifestyles and the socio-economic disparities between themselves and the patient.
The US philosopher John Rawls stated that it is impossible to consider questions of healthcare allocation without being biased to one's own circumstances. This is not an approach deserving of too much criticism in itself but it should be noted that this bias exists. Rawls states that the only way to remove this bias is to look at any situation from "behind a veil of ignorance". This serves to prompt that individual to engage in the answering the question of what they might think or feel if they had no concept of the individual circumstances and characteristics that cause this intrinsic bias. This concept relates well to the observation that if I were to compare two individuals from different socio-economic groups, once the disparities in circumstance (education, financial wealth, emotional situation and upbringing and so on) there would be little difference between them.
It is so important not to forget our duty in addressing the oral health inequalities created by social injustice in our society. The provision of NHS dental care is one of the ways as a profession we can carry this out. We are well rewarded for the work we provide, perhaps not as well as years gone by; but I don't think there are too many dentists on the bread-line just yet. This prosperity needs to promote the social responsibility that so many dentists already demonstrate but some have perhaps forgotten.
I hope that in doing this an environment where such resentment towards NHS patients is present cannot exist. It is only through the extirpation of such misguided attitudes that the oral health inequalities in our society will be reduced.
References available on request.