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When Health Care Rationing Fails: The British and Bad Teeth

6 years ago
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Americans living in Britain have had a rough time over the past few years. Between the credit crunch, the war in Iraq and soaring greenhouse emissions, we haven't exactly been the most popular kids on the block.

Thank goodness we still have something to feel smug about: our teeth. Yes, that's right. Our clean, white teeth. I may be a champion of socialized medicine when it comes to many things, but the British dental system provides a compelling counter-example of what happens when universal health care gets it wrong.

Allow me to explain . . .

When I moved to England three years ago, I was told by just about everyone I met not to even bother trying to find a National Health System (NHS) dentist. Unlike most health care here -- which is free, accessible and reasonably hassle-free -- government dentists appeared to be in short supply. And so I felt extremely lucky when a dental practice in my neighborhood announced that it could take a limited number of NHS patients. In a city where a cup of coffee can easily set you back five bucks, I leapt at the opportunity to save some money and immediately signed up.

The experience was sobering. I come from a country -- America -- where your standard teeth-cleaning can last upwards of an hour and entails all sorts of extensive prodding, soaking and polishing. In the U.K., in contrast -- at least with the NHS -- you're in and out of a standard check-up in under 20 minutes. For kids, it takes less than five.

"That's it?" I asked my dentist, a middle-aged Indian gentleman with Einstein-like hair and a wry sense of humor, as he lowered my chair to the floor. "You're done?"

"What were you expecting -- massage and facial?" he retorted.

"But that was like . . . 10 minutes!" I said in disbelief. "What about the teeth-cleaning?"

"Your teeth are perfectly clean," he replied. "And where they weren't, I gave them a scrub. Don't let those American dentists fool you. They don't need to spend all that time on you. They just have to justify their existence to the insurance companies."

My disappointment must have been evident, because he then said, "Look, if you're really concerned, why don't you just pay the extra 50 pounds and go private? Then I'll check every tooth for decay and clean them all if you like. Plus we can talk some more. Because if you're paying extra, I figure you deserve a good chat."

"But I don't need a therapist!" I wanted to cry. "I just want a dentist!"

We did get to chatting, however, and what he revealed startled me. According to him, one in three new patients he sees needs a non-cosmetic teeth-cleaning. Sure, that number goes down to one in five once his patients have returned a few times. But he caters to an affluent, well-educated population that pays attention when he explains dental hygiene. He estimates that for an industrialized country like the U.K., the number should really be more on the order of one in 10. (Cross-national data on this point are impossible to obtain.)

My immediate thought was: "Well! Maybe if you spent more time with your patients, their teeth would be healthier!"

And that's where I got a real education. Like most things, my dentist explained, it's a question of incentives. NHS dental contracts aren't designed in a way to warrant spending more than a few minutes on each patient (see below). And so dentists don't have the time to explain the basic measures, like flossing regularly, that go a long way towards ensuring healthy teeth. As a result, many of the patients he sees simply don't know how to clean their teeth properly because they've never been told how. He only bothers because he can afford to cross-subsidize his NHS patients with payments from his private clients. The kicker: He doesn't floss himself! (What was next, I wondered? The pulmonologist who smokes?)

My curiosity piqued, I began to do some research. The heart of the problem appears to be the system of dental reforms introduced by the British government in 2006. Under the old contract system (in place since 1948), dentists were paid by the government for every NHS treatment carried out. The criticism of this system was that it encouraged a "drill and fill" culture in which dentists did a lot of purely cosmetic (non-clinical) work, with no emphasis on preventative care. After all, more treatments meant more money. Dentists could also choose where to set up their practices and to exclude NHS patients entirely.

As of April 2006, everything changed. Contracts are now agreed upon with the local PCTs (primary care trusts), which have responsibility for overseeing NHS dental care in their area and guaranteeing access. The PCTs are allocated money each year by the government that must be spent on NHS dentistry, which is then divided up among dentists willing to carry out NHS work. And unlike the previous fee-per-treatment system, dentists are now paid a flat rate covering the amount of work they are contracted to do each year, which is measured in UDAs (units of dental activity). In theory, at least, there is both greater guarantee of access (by virtue of PCT oversight) as well as more emphasis on clinical and preventative dentistry (you are paid the same amount for one filling as for six).

Crucially, the new contract also simplified the complex pay structure for dentistry (unlike other areas of the public health system, you do pay a nominal fee to see an NHS dentist). The previously highly complex payment structure of more than 400 charges is now divided into three bands: roughly 16 pounds ($27) for a check-up or minor treatment, 44 pounds ($75) for fillings, root canal work or extractions and 198 pounds ($336) for crowns, dentures or bridges.

So far, so good. Right?

Well, actually not. While these reforms were supposed to increase access to NHS dentists, in practice, they've had the opposite effect. NHS estimates suggest that nearly 1 million fewer people have access to an NHS dentist than they did three years ago. According to a citizen's advice survey carried out in early 2008, approximately 7.4 million people hadn't been to an NHS dentist since April 2006 because of difficulties in finding one. In light of these access problems, many Brits simply do without a dentist or go abroad for treatments. (The NHS acknowledges that there is an access problem, but argues that it is closing the gap.)

Not surprisingly, the new system also makes NHS work less attractive for dentists. Before Tony Blair became prime minister in 1997, only 6 percent of dentists' income came from private patients. By 2006, it was 58 percent. The first month that the new contract went into effect, some 2,000 dentists (about 10 percent) refused to sign the new contracts and left the NHS altogether, while many more signed "in protest." Many of the dentists I've talked to informally have complained about the "assembly line" feel of the new target-driven system. There are reports of dentists who were forced to close their NHS practice as soon as they had completed all their allocated treatments, while others were forced to pay back money to the PCTs for failing to reach their target.

The incentives set up by the new system also mean that dentists are more likely to "under-treat," i.e., to
fail to provide complex (and costly) treatment, even if it's clinically necessary. After all, they are now paid the same to perform a root canal as they are to pull a tooth. Not surprisingly, the number of complex procedures has dropped precipitously in the last few years.

I witnessed this dilemma personally when I was in need of a root canal myself. My dentist told me that I had the choice of pulling the (otherwise healthy) tooth for the flat NHS rate of $76 or going private and paying 650 pounds (roughly $1,070) to do a root canal. He wasn't willing to run the risk of doing the root canal himself for the NHS fee. As he put it starkly, why risk a lawsuit doing a root canal that takes several hours to do properly when you could just pull the tooth and be done with it? I went private.

The government would argue that as oral health increases, the need for complex procedures diminishes. Maybe so, but the figures don't really bear that out. According to a recent study in the British Dental Journal, 30,000 children a year go to the hospital for emergency dental treatments due to tooth decay. And in a particularly disturbing trend, more and more people are opting for DIY dentistry. According to the Daily Telegraph, some people have resorted to using pliers to pull out bad teeth.

Not surprisingly, dentistry is shaping up as a political issue. The opposition Conservative party is promising that, if elected to power, it will restore NHS dental care to the million patients who can't currently register with a health service practice. For its part, the current Labour government is promising a shift in the dental contract to calculate dentists' income based on the number of patients they have registered, rather than the number of fillings. Prime Minister Gordon Brown's new language of "entitlements" also promises treatment from an NHS dentist. New data on astronomically high dentist salaries is only likely to accelerate demand for such reforms on the part of the public.

It's tempting to conclude from this analysis that the root (!) cause of the problem with NHS dentistry is one of excessive governmental intervention. There's no question that some of the worst specters of socialized medicine are on display: too much bureaucracy, too many targets, and too little emphasis on patient's rights. In short, NHS dentistry is exactly what opponents of a public health care provision in the United States fear most: the dreaded "R" word -- rationing.

But as much as this is a story of incentives, it's also a story of culture. To my mind, the real problem with NHS dentistry isn't that it's run by the government. As I've argued before, the British government manages the rest of the health care system pretty well. The problem is that the government -- and by extension, the population -- doesn't care as much about oral health as they do about other aspects of personal health. One need only look at the budget to confirm this. A National Audit Office report in November 2004 found that, since 1990-91, NHS spending on general dental services had increased by 9 percent, compared with a 75 percent increase in overall NHS spending per head of population over the same period. Things have improved since then. The 2008-09 NHS dental budget rose by 11 percent over the previous year (vs. 4 percent for the overall health budget). But it is still only 2-2.5 percent of the overall NHS budget, according to a Department of Health spokesman.

I sincerely hope that Congress is able to secure a public option for American health care in the coming months, one that enables all Americans -- regardless of income or health status -- access to some form of health insurance. This is a long overdue and sorely needed reform. But I also hope that when we do finally manage to iron out policy, we keep the British model in mind -- both its strengths and its weaknesses. I, for one, don't want to give up my pearly whites just yet.

Filed Under: Health Care, International

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