Tipping point

On a personal level, we British have never been very good with money. A cultural thing, and possibly rooted in polite Victorian society, the discussion of money is often accompanied by an awkwardness which perhaps harks back to the notion of trade compared to profession, of prices as distinct from fee scales. The act of tipping is a classic example. In the UK it is often a tentative, slightly surreptitious and curiously choreographed behaviour, as if an embarrassment not only for the giver but also for the recipient. Contrast this with the USA, for example, where tipping is standard, expected, open and quite the opposite of a closeted fumble. In some ways it is liberating. Everyone knows where they are with it.

In dentistry, the fact of cost or charge, price or fee, that which the late, great and lovely Joyce Grenfell described as the 'sordid exchange of coin', very often makes us uncomfortable in a similar way. There is again the creeping suspicion that all this is not quite nice and that the business of dentistry does not sit comfortably with the ethos of health and providing healthcare. A qualitative study that we published last year on patient-centred practice stumbled upon the same conundrum, albeit in a sample of Canadian dental practitioners in Quebec.¹ The authors noted that, 'participants also lacked skills to address other unpleasant topics with their patients, such as those related to money and payments, and were very uncomfortable to do so. Indeed, by crossing the boundaries of the biomedical realm, dentists were brought back to their human condition, with personal feelings, emotions and vulnerability'.

Although part of a wider exploration of empathy by clinicians towards their patients the analyses revealed that dentists had little interest in understanding the life and stories of their patients. Furthermore, their openness to share decision-making was limited to procedures that they considered of relatively low value and less for procedures they considered of higher value, such as indirect restorations. As one participant expressed it: 'The barrier, to me, is the internal difficulty for a dentist to deal with money and with the notion that it will cost something to the patient […] whether explicit or not, the dentist, I believe, feels a lot of guilt that his services cost something to the patient. I have a feeling this is a deep concern among many dentists'.

Could it be that being 'distanced' from a patient makes it less difficult to ask for money?

Could it be that being 'distanced' from a patient makes it less difficult to ask for money? I wonder if this is the case for NHS charges for adult patients. In a paper in this issue Shah and Wordley analyse the pattern of fee-exempt adults from 2006 to 2019, observing some fascinating contrasts and notable consistencies.² Does, effectively, saying to a patient 'well this charge is being levied by the government not by me' provide some form of absolution of guilt, a fiscal raising of the shoulders to shrug off the responsibility? By the same token do we, acting as the intermediaries for the Treasury enable them to also space themselves from the sordid exchange of health currency? Revenue generated from patient charges has increasingly become an important source of funding for NHS Dental Services and BDA projections prior to the pandemic estimated that such contributions would eventually exceed government spending on NHS Dental Services by 2032.

We have all spent time in thought, conversation as well as in print in the recent past speculating on what life will be like when we return to a form of post-pandemic normal. For me the expression creeping into use as 'building back better' feels rather empty. Yes, better for sure but different too, not being hidebound by what has gone before just because, well, just because that's how it used to be. Governments around the world will be seeking to reduce spending and increase revenues wheresoever they can and, if we are frank, we have to accept our fair share of the cost of coronavirus. But will this be recouped through health, through dentistry, through prevention? When the dam bursts on the constrained volume of 'regular' treatment how many patients will accept a similar share of responsibility for the cost, just a little bit more than before to help the national effort? And by that stage, fee-exempt adults aside, how close is building back better to building back with a free prevention service and a paid-for treatment service?

Are we likely to lose our coyness over cash in the bright light of a vaccinated new world? No. Are we though at a tipping point of less secretive and far more frank conversations? Maybe.