I recently met with some dentists from different parts of England, some of these dentists work for emergency dental services and others work in other parts of the NHS but also involved in unscheduled care. Until now, I was unaware of the scale of the post code lottery in accessing out-of-hours dentistry. The story of patients contacting dentists in pain is not unfamiliar. However, there seems to be a general lack of recognition within the NHS that there are still some gaps in service provision when it comes to unscheduled dental care.
Unscheduled care in dentistry is often made up of a hybrid of walk-in dental services, ‘in-hours’ urgent dental care, out-of-hours dental care, dental triage services and emergency dental services often supported by hospital oral surgery or maxillofacial teams. In some areas, access slots also exist in general dental practice. Having so many different options, it would be hard to imagine that there are still gaps in services as it would appear as if dentistry has comprehensive cover.
Prior to 2006, local dentists often organised their own out-of-hours arrangements within a primary care trust area. Some practices would manage their own out-of-hours provisions and others work as a network across a geographic area. Patients would often be able to speak with a dentist who could assess the urgency of a case and then determine whether or not NHS out-of-hours intervention was necessary. Since 2006, the responsibility for out-of-hours provision passed to PCTs and that responsibility has now been inherited by NHS England. The out-of-hours dental services that have been inherited by NHS England are largely historic and based on allocations defined during the test period between 2004 and 2005. A few areas in England had supplemented the national allocations with local funding. Some former PCTs have entered arrangements with dental assessment services that are often operated by dental nurses to triage clinical need.
The reality is that there are still actual gaps in services. There is firstly a difference in acceptance criteria between hospital based services and non-hospital based services. There is also the gap in opening times for non-hospital based services. For those services that are accessible via hospital A&E departments, there is often continuous provision and therefore the most serious of dental emergency can always be treated, however those patients with dental conditions that do not meet hospital criteria can find it very difficult to access services. For example, those patients that have severe pulpitis on a Saturday night could continue to take pain killers, however where those pain killers no longer having any effect they do need to see a dentist. They may not be suitable for treatment in a hospital setting so they are often left in severe pain waiting for a service to become available. The other challenge is that some services are still restricted by old PCT boundaries, so a service may be available but is restricted by postcode or is only available to residents of a particular local authority area.
A common myth within the healthcare community is that GPs can see and treat patients that are presenting with a dental condition. The diagnosis and management of a dental condition is unlikely to be defined as anything other than the practice of dentistry and therefore it would seem inappropriate to expect GPs to manage these cases. Also, it would seem more appropriate for a patient to receive advice from a clinician who is actually trained to diagnose and manage an oral condition. There are still people in society who feel they cannot afford to pay NHS dental charges and in order to access an NHS prescription for either antibiotics or for pain killers they elect to consult a GP rather than a dentist.
In my view, access to unscheduled dental care in the NHS in England needs to be made more accessible in those areas where an artificial postcode lottery exists and commissioners need to work towards co-ordinating services so that they cover a greater period of the out-of-hours time interval.