Sitting on a plastic chair under the bright lights of the waiting area, a young man is crying. The palm of one hand is glued to his jaw as he stares longingly across the corridor at a closed door. Behind it, Andrew Matheson, a dentist for close to 25 years, is almost ready for him.
Pain relief is Matheson's bread and butter. For the past two years, he has extracted, filled and prescribed in a surgery converted from a ward in St Austell community hospital in Cornwall. It is one of more than 60 "dental access centres" established by the government since 1998.
The job, he says, has granted him his own personal relief - escape from the treadmill of being a general dental practitioner (GDP). After 20 years in his own practice in Huddersfield, the job became unbearable. "It was just a slog to keep as many patients on my books as possible," Matheson says. "There weren't enough hours in the day."
Disenchantment has become endemic among GDPs working for the health service. Contract reforms brought in by the Conservative government in the early 1990s amounted to a pay cut, say leaders of the profession, and accelerated the exodus of dentists from the NHS into mixed or wholly private practice. Patients have found themselves unable to get NHS treatment or dropped from state dentists' lists.
The poorest have been hit hardest. Children are entitled to free NHS dental care, but an audit commission report last year found that levels of tooth decay in youngsters in deprived areas were as high as they were 15 years previously.
In his own words, Tony Blair has been "minded" to tackle the problem. In 1999, he promised that by October 2001 anyone would be able to find an NHS dentist by calling the NHS Direct telephone service. Dental access centres were promised in areas where NHS provision was particularly poor, notably in the south and south-west. With a chain of more than 60 walk-in centres now around the country, the promise has arguably been met. There are almost five times more NHS emergency dental sessions in England and Wales than there were a decade ago.
For dentists, the benefit of a salary, rather than piecework payments, and the offloading of management responsibilities make the centres attractive places in which to work. Matheson is one of 17 dentists working in Cornwall's network of access clinics. The work, says Peter Knibbs, clinical director of the county's personal dental service, is "dictated by the absence of access to a GDP".
Cornwall had lost so many NHS practices to private care that massive ground needed to be made up. The absence of a dental training centre, coupled with a lack of highly populated towns to attract dentists, have made exclusion from services a particularly acute problem. Fewer than half of the county's 450,000 residents are registered with a state dentist and an extra 170 GDPs would need to be appointed to make up the shortfall.
Faced with such a huge recruitment challenge, the county's three primary care trusts (PCTs) commissioned the personal dental service in order to offer urgent appointments, within a reasonable waiting time and travel distance. From an office in a community health centre in St Austell, a call centre allocates patients to one of the 22 access venues around Cornwall. The most pressured centres are in those very areas where registering is most difficult. The patients are often from the most hard-to-reach groups, with mouths showing the effects of years of neglect.
"We're fulfilling the emergency role very well," says Knibbs. "But it's still not ideal. Some people would really like to register with a routine dentist. But the nightmare is that no one's taking new patients on."
As a result of this, some of the access clinics have begun providing routine care. "We can't just do a temporary dressing and suggest they go and find someone to do the permanent work," Knibbs explains. "That's not an option in Cornwall." So, despite the prime minister's promise, there is still no comprehensive service.
Access centres, say their fans and detractors alike, are quick fixes rather than a means of providing preventive care. Critics also point to the high cost of contact with a centre: up to £200 or more a visit, including the centre's start-up costs, compared to about £28 at a general surgery. Moreover, the estimated £60m invested in the centres over the past five years has stirred resentment among GDPs, who argue that nothing has been spent on addressing the problems they are working under.
In a bid to rescue the comprehensive service, the most radical changes to dentistry for more than 50 years are now being drawn up. These measures are aimed at changing the way dentists are paid, how services are commissioned and the kind of treatment patients receive.
The health and social care bill, discussion of which has been largely dominated by the row over foundation hospitals, would make a reality of the government's blueprint. Some 100 trials are under way around the country to determine how best to modernise the system. A discussion document, NHS Dentistry: Options for Change, published last year, sets out three main themes for reform: local commissioning and funding through PCTs by 2005; new methods of payment for dentists; and plans for dentists to have a public health role, carrying out oral assessments that focus on preventive care.
Health service dentists are currently commissioned through a national contract, via a laborious and complex fee scale. The bill proposes ending this link between the charges that patients pay and the fees received by dentists. Services would be funded and determined by PCTs and tailored to meet an area's particular dental needs. There are also plans for the replacement of the unpopular piecemeal payments with new methods. The proposals include salaries, as for GPs, block contracts, a simpler fee-per-item system, remuneration according to the number of patients registered, a pre-paid system and session payments. Options for Change proposes that practices should be much larger - with growth possibly funded through the NHS local improvement finance trusts (Lifts) - in order to accommodate other complementary professionals and dentists with specialist skills.
Experts say that these measures would bring dentistry squarely back into the NHS fold, meet the needs of patients, address health inequalities better and end the treadmill that state dentistry has become. What is unclear, however, is whether the proposals would woo back those dentists who have gone wholly private.
"Once they've had a taste of life in the private sector, they're not going to be minded to come back to the NHS for the third-rate fees they left for," says John Renshaw, chairman of the executive board of the British Dental Association (BDA), which opens its annual conference tomorrow in Manchester. "We may find new ways of working, but if the money remains poor, nobody is going to come back."
However, the extent of the flight to private practice is often exaggerated: only 2% of the country's 11,000 dental practices do no NHS work and some 60% of GDPs continue to earn at least three-quarters of their income from the health service. "What we want is everyone to do a little bit more NHS work," says Renshaw. "If one dentist takes on 100 patients, and then another, before you know it you have reduced a local waiting list."
Ultimately, modernisation is dependent on having enough dentists in place. The BDA estimates that there needs to be a 25% increase in training places - from 800 a year to 1,000 - to close the gap between delivery and demand. Attracting potential trainees is not a problem, Renshaw says, but the government would need to increase the number of dental schools from the current total of 13.
The government is expected next month to publish its long-awaited workforce review into exactly how many dentists are needed. Ministers' responses to it will prove crucial in rebuilding bridges with the profession. Big hopes are pinned on the government agreeing to boost recruitment. Renshaw says: "If, after all that we've been through, they say: 'We can't afford more dentists', then we'll go on the backburner and be forgotten for another 10 years."
Cost drives many people from care
Dentists perform more than 300 types of treatments on NHS patients. After they see a patient, practitioners complete a form to claim payment. Forms are assessed by the dental practice board as to whether they match the rules of the general dental service and, if so, a fee is sent.
Fees are intended to take into account the overhead costs of running a practice: premises, staff, equipment and materials. Extra government funding in the form of grants to buy equipment is also available.
Patients pay about 30% of the total cost of the general dental service. For all children under 18, and adults on income support, care is free. There is no income sliding scale and working people on low incomes and pensioners are not automatically exempt from most charges. Those near the threshold for free treatment may be able to get help with the cost, however. Patient surveys frequently cite cost as a reason for not visiting a dentist.
In England, most adults pay 80% of the cost of examinations and treatments, up to a maximum of £366 for one course. In Wales, however, examinations are free for people under 25 and those over 60, with the maximum cost frozen at £354. The dentist is responsible for collecting the money.
