Kevin Lewis column

Kevin Lewis discusses the announcement – and its timing – of the Department of Health’s guidelines on single-use endodontic tools.

Once is enough

Don’t you think there is something slightly magical about writing a letter and getting an instant response? If so, then Barry Cockcroft will surely be made an honorary member of the Magic Circle any day now. Now that’s what I call a response – and I bet he wished he could make himself disappear, too.

His ‘Dear Colleague’ letter on the subject of endodontic reamers and files had been a while in the making, but when it finally saw the light of day a couple of weeks after Easter it prompted an immediate, if extraordinarily diverse, reaction. There were private dentists expressing (misguided) relief that a letter from the Department of Health couldn’t possibly apply to them. There were NHS providers announcing that all their NHS endodontics will henceforth be carried out with forceps.

There were performers giving thanks that their remuneration is salaried or based solely upon the delivery of UDAs, irrespective of the associated costs, and there were practice owners bracing themselves for some heated debates about how their associates would be paid. Some were prepared to run the gauntlet of the NHS Regulations and their PCT contracts, and declare that endodontics would be offered only privately until further notice. It was less a case of them saying ‘once is enough’ and more a case of them saying ‘enough is enough’.

Some dentists were using all their ingenuity to search for ways of making this all go away – in their minds, if not in reality – while others were simply looking for ways of making NHS endodontics go away. Included in the former box was ‘This is only guidance anyway’, ‘Where’s the evidence?’ and ‘What letter?’ Included in the second box was a large pile of referral letters. But the very fact that this guidance had now been issued at all, echoing the SEAC (the Spongiform Encephalopathy Advisory Committee) recommendation of May 2006, had already changed the landscape. It had been coming for a long time and I even remember a question on the subject at a meeting as long ago as 1996.

Further reports on vCJD in 1999 and on decontamination generally in Scotland in 2004, had created a sense of inevitability about this latest DoH position. The only real surprise was that it had taken so long to reach this point.

Many (private) endodontists abandoned the re-use of endodontic reamers and files some time ago. Most manufacturers have been labelling their endodontic reamers and files as being suitable for single use only for years. The central issue is not, I think, whether or not moving to single use is a good idea, but rather who will absorb the pain of the financial consequences. NHS practitioners – and in particular the providers and/or practice owners (not necessarily the same thing) have been caught between a rock and a hard place. There is a lot of ill feeling that this announcement has come after local commissioning is safely in place and funding has become the PCTs’ problem, not that of the Department itself.

But dentists had been promised a ‘like for like’ contract, where their income for 2006-2009 was based upon their Oct 2004-Sept 2005 gross income and their activity was (allegedly) to be measured against the same benchmark. The annual uplift to take account of inflation was clearly never designed for, and nor is it remotely sufficient for, a step change like this in practice expenses.

In bygone days, with a national fee-per-item remuneration system, there was the potential ‘quick fix’ of a swift adjustment to the Statement of Dental Remuneration, which could be tightly targeted upon the treatment in question and those providing it, and in direct proportion to the amount they did. You can’t get much fairer than that. The option was rarely used, but when precious metal prices spiralled up into the stratosphere in the early 1980’s, this is exactly what happened.

Now we have the intriguing situation of an issue such as this arising in the new era of devolution. The devolved powers in respect of healthcare, coupled with the fact that fee-per-item still exists in Scotland and (by its fingernails) in Northern Ireland too, but not in Wales or England, means that very different situations exist in England, Wales, Northern Ireland and Scotland. It is worth making the point in passing that Barry

Cockcroft is the CDO for England. Scotland has been leading the way for some time where decontamination is concerned.

The fact that almost the whole monetary equivalent of three UDAs (for many practitioners) will be taken up by the direct costs of what are now effectively disposable consumables, was painful enough for NHS practitioners to endure. The fact that local ‘block’ contracting and commissioning made a quick fix almost impossible to implement fairly and consistently was not something that everyone cottoned on to quickly. It brought into the sharpest possible focus the price of no longer capturing the prescribing data that had existed for over half a century.

Since April 2006, nobody has any real idea how much endodontics is being carried out in England and Wales, nor by whom. But the palpable sense of outrage was fuelled by the fact that the recommendation has been made, first by SEAC, and now by the Department of Health, on the basis of modelling plausible, but nevertheless hypothetical, models of what might/could happen, based on animal studies.

It may well be that we have been unwittingly treating dental patients who are already carrying vCJD prions that they acquired through dietary exposure. It may equally be that if these same patients are unfortunate enough to succumb to vCJD in years to come, because of their earlier dietary exposure, someone will point out that the patient went to a dentist once or twice and had a root filling done. That does not make us responsible.

Prion-related disease is still an uncertain, very long-term threat, where the stakes are potentially terrifyingly high. It is much easier to criticise the Department of Health’s stance than to be the person having to take responsibility for it, but in reality the expert scientific community has largely been of the opinion that ‘single use’ was the only responsible and ethical position for the profession to take. It doesn’t pay the bills, of course, and it is easy to tell others to dig deeper into their pockets if one is not having to pay the bill personally.

But some of us have been around long enough to remember that the threat of HIV (and the public preoccupation with it) ‘bounced’ the profession into sharpening up its infection control act in the 1980s. As things turned out, dentists were not the arch purveyor of HIV to an unsuspecting public – indeed not a single case of dentist-to patient transmission has been reported in the UK despite more lookbacks than the winner of the London Marathon.

But you would struggle to find many dentists who would be happy to take off their gloves tomorrow and go back to boiling water ‘sterilisers’ and dry heat ovens – or to be treated themselves using instruments and equipment at yesterday’s levels of contamination. We have moved on – and we will do so again, because we want to be taken seriously as a profession.

The immediate crisis is an issue of the balance sheet, and it can so easily be fixed with money. Some dentists will no doubt subsidise their NHS endodontics by increasing their fees for private endodontics – but they should not have to, and this is hardly fair to the private patients involved. We do ourselves no favours if we scratch around for ‘wiggle room’ by pretending that it is not about money. If the CDO’s letter had arrived in an envelope stuffed with enough money to pay for it all, there would have been little questioning of the evidence or the timing. And for the DoH the timing could hardly have been worse.

If the CDO could have avoided making this announcement just before the bare-knuckle fights start over UDA delivery in year one, he would surely have leapt at the chance. This is starting to look like last chance saloon for NHS dentistry.

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