A SOCIALIST MEDICAL ASSOCIATION MEMORANDUM
The policy of the Socialist Medical Association is to ally itself with and to foster progressive opinion in order that the best possible health service shall be made available free to the whole population. Such a health service necessarily includes a complete dental service,
The National Health Service Act which comes into operation on July 5th 1948 is perhaps not a perfect legislative instrument, but defects found in practice can be corrected in the light of experience. The Act does at least lay the foundations for a national, a nationwide, health service; it also provides the framework for a fully comprehensive dental service.
This memorandum discusses the dental provisions of the Act.
Organisation of Dental Services
The National Health Service will include the following dental services:
1. A local health authority dental service.
2. A general practitioner service.
3. A hospital dental service.
These (and the medical and the allied services of which they form part) will be under the control of Regional Hospital Boards, local Authorities, and Local Executive Councils respectively’, Co-ordinated as the Act requires, they will constitute a comprehensive service as soon as sufficient personnel can be enlisted to staff them. It is the Minister’s declared intention that the professional staffing of the dental service shall be ‘based on registered Dental Practice ‘
Regional Hospital Boards, Local Authorities, Local Executive Councils
A word of explanation may be necessary with regard to these. For detailed consideration the reader is referred to the relevant clauses of the Act and to its third, fourth, and fifth schedules.
Briefly, England and Wales are to be divided into fourteen administrative regions, each region being based on a medical school and teaching hospital; the hospital services of each region to be controlled and co-ordinated by the Regional Hospital Board.
In the case of Local Authorities providing health services eg the School Dental Service, these will continue to operate as hitherto under the appropriate health and education committees of their respective authorities (county, borough, county borough etc.) although the pairing and, possibly, the elimination of some smaller Local authorities is likely in the near future.
Local Executive Councils
These have been created in order that the control of general practitioner service shall not be in the hands of Local Authorities, It was felt that some established family doctors and dentists might object to working under the same management, so to speak, as salaried officials of the public health service. Local Executive Councils will be directly and solely responsible for the general practitioner services of their area, the only duty of the local authorities in this connection being to provide, staff and equip health centres at which general practitioners may elect to work either whole time or part time, instead of in their private surgeries.
So much for the administration of the three dental services. Something may now be said of their executive scope.
The Hospital Dental Services
This will be, using the term in its widest sense, a specialist service. In it the consultants will be found, the teachers, the research workers, the practising specialists, all to be available as a “second opinion” to all dental practitioners. From it the junior staffs in charge of dental outpatients, the house surgeons, the resident and non-resident dental officers of non-teaching and satellite hospitals will be drawn. It is in the hospitals, where the volume of work will enable it to be used to the fullest advantage, that the more expensive and elaborate technical equipment will be installed.
This memorandum is not the place to argue as to who precisely should be recognised as dental specialists or in what they should specialise or of what their special equipment shall consist. Let it be agreed (purely as an example) that there will be a need for maxillo-facial and oral surgeons; let it be agreed that one would normally look for them to hold a medical or some additional dental qualification; let it be agreed that a fully equipped and up to date operating theatre must be at their disposal. When the importance of preservation of dental function in relation to preventive medicine is more widely appreciated, it will doubtless find expression in further suitable specialist appointments in the hospital services.
Of the Local Authority dental services
There is little new to say. The present inadequate School Dental Service will have to be much enlarged to meet its increased responsibilities consequent on the raising of the school leaving age. The Maternity and Child Welfare Dental Service (employing only the equivalent of 39 whole time officers in 1945) will need to be greatly extended, otherwise, not even the modest aim of a comprehensive dental service for the “priority” classes of nursing and expectant mothers, infants and school children has any hope of being achieved.
Adolescents have unfortunately had to be omitted from the priority classes owing to the shortage of dental personnel, but it is to be noted that the raising of the school leaving age will at least make a start in bringing this important group under treatment and, while recruitment in the Armed Forces is compulsorily maintained, the Dental Services of the Navy, Army and Air Forces will continue closing the gap from the other end. The County Colleges will also provide entitlement to dental treatment for those under-going higher education.
All this is something, but it is not enough; caries is notoriously a disease of early life, and if ideas of conserving teeth are to become anything more than pious aspirations a priority dental service for all up to the age of 21 is essential. Nevertheless, the Socialist Medical Association finds it difficult to accuse the Minister and his advisers of neglecting the dental care of Youth, when no practical and public spirited scheme has been put forward by the dental profession itself.
Later it is hoped that Local Authority services which already exist on paper or in a rudimentary form for the dental treatment of the tuberculous, the blind, the mentally ill, the aged and the chronically infirm, will be developed.
A final word. Those who work for Local Authorities have waited long for better pay and conditions of service and for some measure of autonomy under their administrative superiors. There are grounds for hoping they will not have- waited -in vain. The recent interim increase in school dental officers’ salaries has emanated from the direct intervention of the present Minister of Health. Better pay, greater administrative responsibility, more scope for preventive work; these will come, and soon, if deserved. But what is most needed in the Local Authority dental services is a new spirit of endeavour and an educative and preventive and not merely an operative dental surgeons’ approach. That only the dentists themselves can provide.
So to the General Dental Service, which any general practitioner may join. All he will have to do is have his name put on the list of his local Executive Council. Three types of service will be open to dental practitioners:
a) Whole time salaried service at a health centre;
b) Part-time salaried service at a health centre, leaving the rest of their time free for private practice;
c) Practice in their own surgeries, remuneration to be based on a scale of fees similar to but in in many respects, both administrative and pecuniary, more generous than that obtaining under National Health Insurance Dental Benefit today.
Participation in the General Dental Service will entitle the participant to benefit under a superannuation scheme. It will not be obligatory to enter the service on the “appointed day”; any practitioner who wishes to “wait and see” may do so without prejudice to his right of joining later.
From the patients point of view the service is available to all, contingent only on the patient finding a dentist who will accept him under its conditions. Equally, no patient need use the service unless he wishes; he can have treatment at his own expense from any dentist who will give it to him.
There is little in the scheme for General Dental Services to which even the most reactionary private practitioner can take exception. Admittedly it does not accept the “principle” (sic) of Grant in Aid, which some have demanded; the right to charge what they please, or, at any rate what they can get. This would be as unreasonable as it would for a Government arbitrarily to impose what Fees it pleased. As yet the scale of fees for General Dental Services remains unfixed. It is to be negotiated between the Government and the profession to the light of the independent findings of the Spens Committee. This seems a fair enough procedure. There will always be individuals loath to serve the nation at any price other than their own. So far as the National Health Service Act is concerned such individuals will be at liberty to continue in private practice.
In the view of the Socialist Medical Association, this is one of the defects of the Act. The Association believes it is more than time we ended that competition for the fees of the sick which, however camouflaged by the professional coat and manner, is an unescapable feature of private practice. Nor does the Association welcome the continuance of that itemised list of dental treatment prices which did so much to lower the status of the “panel” dentist. Health is not a commodity to be purchased in job lots. The remuneration of a healing profession should be based on appropriate annual income restated if necessary in terms of fee per hour.
A Socialised Health Service
The Socialist Medical Association considers that private practice ought to be abolished and replaced by a socialised state service. “Socialised” does not necessarily or in a party sense mean socialist; it means (Oxford Dictionary) “interdependent, co-operative, practising division of labour;” it stands for team-work as opposed to competition.
Most dentists will remember when they were students in a general hospital. Few will seriously contend that the team-work, the division of labour, the co-operation there, was not of greater service to the patient than any thing they have since been able to provide in private practice. The overheads of a modernly equipped private surgery are notoriously high. Many dentists live over their practices in order to keep expenses down, leading their private lives perpetually in the shop window. Do they really enjoy this? Do they like the “headaches” the sudden defections of secretaries or cleaners or the breakdowns of equipment cause them? There may be older private practitioners who (in retrospect) claim that this has all been part of the fun,, but it is certain the younger men and women in the profession want to do dentistry, not bookkeeping and household chores.
Here it may be appropriate to quote some recent words of the Minister of Health. Addressing a conference of the British Dental Students Association at Leeds on July 16th 1947 Mr Bevan said: “We are trying to prove that the State can make itself responsible for the provision of the physical apparatus of medicine and yet not intervene in clinical work. We conceive there is a functional link, of co-operation between the profession and the State, that in which the State provides hospitals, clinics, apparatus and drugs, and the professional man and woman steps in and uses them with perfect clinical freedom, without any intervention from lay people.”
The basic unit, the community unit, of the new health service will be the health centre. Each Health Centre will have its Dental Department. The dentist working in it will find himself something more than just a dentist; he will find himself a member of the health centre teams a link in the health service chain. Salaried, pensionable, working regular and reasonable hours, eligible for sick leave and for holidays with pay, he will also be free to attend his share of post-graduate courses without anxiety about what is to happen to his practice and free of all expense, Throughout his health centre he will not only have such facilities as X-rays, bacteriological reports, pathological, medical and dental specialist advice, but he will also keep in close touch with the medical and a dental teaching hospital in his region and with any research workers employed in investigations in which his special interests lie. It has been suggested that the Dental Departments of Health Centres will be dingy and depressing places. One of the functions, of the Local Dental Committees of the Local Executive Councils will be to see that they are planned, staffed, equipped and maintained the way a modern dentist would want them.
Dentistry requires its team of auxiliaries no less than any other branch of medicine. The dentist cannot do without the dental technician or the dental nurse (or attendant as she is now less happily styled)
The dental technician is an important member of the team, and will have every opportunity of attaining an improved status and security of tenure within a socialised dental service. The trade unions have done much to alter the chaotic condition of the craft previous to the war and have established a basis for the training and education of technicians for the future. With the active co-operation of the dental profession and of the Ministries a standard of attainment in keeping with the important part played by these craftsmen in the field of health will be assured.
Health centres will generally need to be equipped with their own dental laboratories staffed by dental technicians; it is of paramount importance that there should be personal liaison between dentist and technician if work of a high standard is to be achieved. This is fully substantiated by the Teviot Report.
There is no need to insualise technicians undertaking dental operations at present reserved to qualified and registered practitioners. Adequately paid for his services and with sound prospects of advancement in this trade, the technician is unlikely to be interested in working, “in the mouth.” In some possible future it may or may not prove desirable to recreate a dental profession along the lines envisaged in the minority reservation of the Teviot Report. Meanwhile the bogey of dilution can, so far as dental technicians are concerned, be dispelled.
The present vulgar spate of repair shops is abhorred no less by reputable technicians than by dentists; free dentistry under the Act will hit repair shops hard. The Socialist Medical Association regrets none the less, that, if only as a gesture of good faith, the Government should not have to decide to abolish these institutions.
So to dental attendants. These invaluable auxiliaries at present enjoy no recognised scale of pay. The S.M.A, admits to membership both dental technicians and attendants, and through the latter have heard of many dental attendants in private practice who receive no more than “pin money.” Dental attendants can definitely expect better conditions in the State service; neither their usefulness nor their interests have been forgotten by those who are framing the machinery of the National Health Act.
Of the vexed question of dental hygienists little can be said while the matter is still sub judice. The Socialist Medical Association favours the greatest increase possible in dental health propaganda, but as to whether hygienists shall scale teeth it seems wiser to await proof of need. This pamphlet has discussed the dental provisions of the National Health Service Act and the case for a Socialised Service. If it has done anything to arouse interest in either it has fulfilled its only purpose.