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Social Dental Service in Great Britain*
SOCIAL D E N T A L SERVICE IN GREAT B R IT A IN * By A. E. ROWLETT, Leicester, England
I N presenting this communication, I am
conscious of the honor done me as pres ident of the dental organization pri m arily responsible for the inception of public dental service in G reat Britain. I t was in the year 1891 that the British D ental Association presented its first re port on the teeth of school children, and the appalling conditions revealed in that report made clear the urgent need for the provision of some form of inspection and treatm ent by the state. A few years later, a member of the association, C unning ham, of Cambridge, was instrum ental in setting up the first treatm ent center for the teeth of school children. T h is center, opened in 1908 by voluntary assistance, was shortly taken over by the city and has from that date blazed a trail which many other authorities have followed w ith suc cess. T h e state realized the need for reg ular inspection and treatm ent and the necessary parliamentary sanction was ob tained. Up to the outbreak of w ar, the school dental service developed slowly, but w ith the close of the w ar, a rapid extension took place, and there are now some two or three areas only which fail to make provision of this nature. I t will be seen th at public dental serv ice in G reat Britain had its development in meeting the needs of school children, and it has now extended to include the *Read at the Seventy-Fifth A nnual Session of the American Dental Association in con junction with the Chicago Centennial Dental Congress, Aug. 10, 1933.
Jour. A.D.A., July, 1934
treatm ent of the preschool child, the nursing and the expectant mother, tuber culous patients and other patients under the care of public authorities. In addi tion, a large section of the working-class population receives dental treatm ent as an additional benefit under the national health insurance acts. I t w ill be convenient to consider the various aspects of the foregoing in some detail under the appropriate headings. Before doing so, it might be well to clear the ground a little by considering the departments of state responsible. In G reat Britain, cities, boroughs and county bor oughs are responsible to the inhabitants within their boundaries for the provision of adequate facilities for education and health. In country districts, county coun cils bear these responsibilities. T h e state is responsible for ensuring that the local authorities properly discharge their func tions, and moreover the state bears half the cost of these services. SCHOOL DENTAL SERVICE
Education in G reat Britain is directed centrally by the board of education, the minister having a seat in the government. T h e local councils of the various authori ties enumerated above administer educa tion locally on lines generally approved by the board of education. Parents are com pelled by act of Parliam ent to obtain a satisfactory standard of education for their children, and this they may do either through private tuition or at state schools.
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R o w le tt— Social D e n ta l S ervice in G re a t B rita in
Every child attending a state school is medically and dentally examined during its school life, but no provision is made for those children attending private schools. T h e ideal a t which the school dental service is aiming is to provide for the in spection twice a year of every child at tending state schools; but unfortunately this ideal has only proved possible of at tainm ent in certain isolated areas. T h e problem is, of course, entirely one of finance, and there is little doubt that the long looked for improvement in world economic conditions w ill be speedily re flected in the health service of G reat Britain. A ll necessary treatm ent is pro vided and, in certain areas, orthodontic treatm ent is available. T h e value of the school dental service has been proved in those districts where inspection and treatm ent have been avail able over a number of years, and the con dition of the teeth of children leaving school bears adequate testimony to the care and high standard of the treatm ent provided. U nfortunately, much of the value of this excellent work is lost, owing to the fact th a t there is a gap between school-leaving age and the age when the young adolescent becomes eligible for den tal benefit under the insurance act. T h e bridging of this gap is a problem which the dental profession has attempted to solve for a num ber of years, but w ithout success. I t is possible that the harm re sulting from “the gap period” may be lessened by an extension of the school leaving age, which was projected recently under a socialist government, and a low ering of the age of entitlement to dental benefit. HEALTH DENTAL SERVICES
T h e m inistry of health and local town councils are jointly responsible for a number of services in connection w ith
1183
which dental treatm ent is provided. In an effort to reduce infant mortality and m aternal mortality, centers were set up at which free medical advice was made available to expectant and to nursing mothers, as w ell as municipal m aternity homes and infant hospitals. T he neces sity for eradicating dental sepsis in the expectant and nursing mother led to the provision of dental treatm ent, and, as a natural extension, dental advice and, where necessary, treatm ent was made available for children under school age attending such centers. A difficulty arising in connection w ith these particular schemes lay in the fact th at any female inhabitant was entitled to attend for medical advice, and, as the advice was of a specialist nature, the at tendance was high. I t followed that pa tients who could well afford to obtain the necessary dental treatm ent at the hands of their private dental advisers might ob tain the treatm ent from the public dental clinics. T his difficulty has largely been met by consultation between the dental organizations and the state, and only those patients who are unable to afford the services of a private practitioner re ceive treatm ent in the public dental clinics. A nother difficulty lay in the fact th at dental appliances were often neces sary, and the provision of these appli ances by public bodies at fees necessarily w ithin the range of a lower working-class population has tended to reflect on the fees charged by private practitioners for similar appliances. T h e treatm ent of patients suffering from tuberculosis, venereal disease and certain fevers, and also of mental defec tives, is to a great extent a duty of health authorities, and, in connection w ith all such schemes, dental treatm ent is almost a necessity, and as such has a place therein. T his treatm ent may be carried out either by part-time dentists or by a
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T h e J o u rn a l of th e A m erican D e n ta l A ssociation
whole-time officer, who would mainly devote himself to w ork in connection with the school and m aternity dental services. From the survey given above, it might appear th at the various forms in which dental treatm ent is provided directly by the State in G reat Britain would consti tute a serious menace to the private prac titioner. I t is unfortunately tru e that, prior to the inception of such schemes, the class of the population to which they ap ply rarely, if ever, sought the services of a dental surgeon, save for the relief of pain. T h ere can be little doubt that the services in question are exercising a very valuable educative influence on the work ing-class population, and that the next generation w ill value dental treatm ent to a much greater extent than the present. T h e great mass of the w orking classes, having neglected their teeth, offer little scope for tru e preventive teaching, but the agencies are devoting much time to the teaching of oral hygiene and care of the teeth by means of diet, and are con centrating on the children and adoles cents who, as potential parents, may be trusted to inculcate sound ideas in the next generation. A n aspect which has not been dealt with concerns the expenditure of public money, and here it may be said that the annual expenditure for dental services in connection w ith the various public schemes referred to is small in compari son w ith the sums expended on health service generally. T h e practice w ith re gard to payment for treatm ent received varies considerably in different areas. In some cities, a nominal charge is made for attendance at public centers; in others, the charge more nearly approaches the economic cost of providing the treatm en t; but in no instance is poverty a bar to ob taining the treatm ent, and every scheme has provision for free treatm ent when
the patient falls w ithin the necessitous class. PUBLIC ASSISTANCE DENTAL SCHEMES
T h e maintenance of able-bodied pau pers and the enfeebled pauper class, formerly a duty laid on boards of guar dians, was, by the Local Government A ct of 1929, transferred to local councils. N ot only are large institutions main tained for the reception of this class of the population, but also hospitals and residential homes for children. As may be imagined, dental treatm ent is a neces sary provision under schemes of this na ture. T his treatm ent, as part of the func tion of local councils, is tending to be come an additional duty of the public dental officer, rather than th at of private practitioners, as was the custom under the old guardians’ administration. T h e development of the service im mediately following the W ar, w ith the many branches summarized above, has led to the creation of a definite career in the public dental service, and, at the same time, has tended to w ithdraw a certain amount of public w ork from the private practitioner. T his has clearly been recognized by the profession in G reat Britain, and, while the need for schemes of the nature described is readily conceded, and indeed the need for fur ther extension of such schemes, it would be detrim ental to the interests of the public and the profession if it were re garded by the state as the initial step to w ard a state dental service. T h e relation ship between the state and the profession is discussed in the following paragraphs, which deal w ith the provision of dental treatm ent in connection w ith the N a tional H ealth Insurance Act, and w ith the ideal scheme which has been pre pared by the B ritish D ental Association, and accepted by the dental organizations in G reat Britain.
R o w le tt— S o cia l D e n ta l S ervic e in G re a t B rita in NATIONAL HEALTH INSURANCE DENTAL SERVICE
P rio r to 1911, the working-class popu lation of G reat Britain rarely obtained medical advice and treatm ent at the hands of private practitioners except in case of urgency, or through the medium of sick clubs or friendly societies. M any of the latter had a proud record of pub lic service; so also had the medical pro fession. N o t a few physicians in w ork ing-class districts gave ungrudging atten tion in return for low fees or w ithout fee. Realization of the importance of health in industry and in the economic life of the state led the government of the day to introduce the N ational H ealth Insur ance Bill of 1909, which passed into law despite opposition from the medical pro fession, employers of labor and, to some extent, employes. T h e act provided (w ith certain excep tions) for the compulsory insurance of all employed persons between the ages of 16 and 65 in receipt of an income below a certain limit, and of all persons employed in m anual work, w ithout wage limit. T h e workers so insured were entitled to re ceive free medical attendance and treat ment and a monetary allowance while in capacitated. T h e funds to defray the cost of the scheme were obtained by weekly contributions from the employer and em ploye and a grant from the state. T h e adm inistration of the scheme was placed in the hands of the friendly societies, which for this special purpose were desig nated “approved societies,” subject to the control of a department of state. T h e funds of the approved societies were audited by government auditors every five years and, as had been antici pated, the first valuation disclosed a sur plus over the whole scheme. By the year 1921, the surpluses which had accumu lated allowed for the provision of other
1185
forms of treatm ent or benefit which were term ed “additional benefits.” I t is im portant to emphasize th at only the mem bers of societies whose accounts showed a surplus were entitled to enjoy the ad vantage of additional benefits, and also th at the rate of benefit payable varied from society to society. T h e foregoing summary of the act will serve to make clear the fundamental dif ference between the provision of medical and dental treatm ent under the act, the former, a statutory benefit, enjoyed by every insured person as a right, the latter an additional benefit open only to those fortunate enough to belong to a society having a surplus. D ental treatm ent, first introduced as an additional benefit in 1921, has under gone several modifications since that time, the present scheme having come into ef fect in 1930. T h e 1930 scheme provided for control by a statutory body, the D en tal Benefit Council, consisting of an equal number of dentists and representa tives of approved societies w ith certain officials of the ministry of health. T h e benefit is administered under regulations, a t a scale of fees negotiated by the dental profession and the approved societies and sanctioned by the state. Each society providing the benefit undertakes to pay not less than half the cost of treatm ent, the balance being paid by the insured per son; while the dentist undertaking the treatm ent agrees to make no additional charge, and to give a satisfactory degree of service. T h e scale of fees, which need not here be detailed, includes among other items: scaling, 7s 6d .; extraction per tooth w ith local anesthetic, 2s 6 d. (maximum ex traction fee for either jaw, 12s 6d ; both jaws, £ 1.2 . 6.) ; simple general anesthetic fee, 7s 6d .; prolonged anesthetic fee, £1.1 .0 .; full dentures, £5.10.0. Insured persons entitled to the benefit
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T h e J o u rn a l o f th e A m erican D e n ta l A ssociation
are provided w ith an estimate form, which is presented to the dentist of their choice. T h e treatm ent required is esti mated by the dentist at the scale of fees and is submitted to the society concerned, and, in normal cases, is approved. T h e treatm ent is completed and the account paid. T h e society may, and frequently does, refer the estimate to a second opin ion in the person of an officer appointed by the state. H is duty is to advise the society as to whether the treatm ent esti mated is, in his opinion, such as w ill se cure the dental efficiency of the patient. M achinery is provided for the settlement of differences of professional opinion and for the investigation of complaints against dentists or societies. T h e advantages of the scheme in its present form are almost entirely w ith the insured person, as far as it can be defi nitely stated that many of the workers would otherwise be unable to afford den tal treatm ent, and there has been an un doubted improvement in the dental health of th at class since the inception of the service. T h e disadvantages rest mainly, but not entirely, w ith the profession; for the pa tient must and does suffer as a result of differences of professional opinion; there is no provision for regular inspection and treatm ent, and, as many societies are u n able to provide the benefit, a large section of the insured population is ineligible. From the point of view of the profession, the standardization of fees has definitely tended to lower the fees of private prac tice, and to lead to the treatm ent’s being carried out rather from the point of view of items than as a whole. T h e fact that societies provide the benefit out of surplus funds places the profession under the vir tu al control of laymen. T h e need for some scheme which would at the same tim e satisfy the state, the public and the profession was for long
apparent to the profession, and led to the British D ental Association’s setting up a committee of experts to study the whole problem. T h e committee recently pre sented a draft report which has received the approval of the various dental organ izations and the general support of cer tain of the bodies interested in health in surance matters. T h e recommendations represent a complete change from the methods described above, the fundamen tal difference being the provision of den tal treatm ent as a statutory, instead of an additional, benefit. Such a change would at once entitle every insured person, rather than the fortunate few, to the benefit, and it would take control of the administration out of the hands of ap proved societies. T h e system of remu neration would be by a capitation fee, in return for which the dentist would pro vide annual inspection and treatm ent for each insured person on his list. T h e ad vantages of such a method are manifest, and there can be little doubt th at the freedom from bureaucratic interference, the premium on good diagnosis and the incentive to build up sound dentitions would all react to the lasting benefit of the patient. T h e application of a statutory scheme based on a capitation system is not w ith out considerable practical difficulties, not the least of which concerns the annual fee which would secure to the dentist a fair and reasonable rate of remuneration for his work, and would, at the same time, be acceptable to the state. I am hopeful that the tentative fee put for ward in the report referred to w ill prove acceptable to all parties. A difficulty which has a more immediate bearing on the application of the scheme is th at of finance. T h e present contributions paid by employer and employe are only suffi cient to meet the cost of statutory medi cal benefit, and additional funds would
N o r d — S o cia liza tio n o f D e n tis try
be required to provide the dental benefit envisaged above. T h e present state of in dustry would not appear to be such as to permit of additional burdens being im posed on either employer or employed in the near future, and the need for state economy offers little hope of assistance from th at source. Nevertheless, we con sider th at the ideal scheme is to hand and ready for application when finances per mit. CONCLUSION
If a moral is to be draw n from this survey of public dental service in G reat Britain it is tw ofold: first, that it is the duty of the dental profession to assist in the provision of dental treatm ent for every class of the community, a duty which in G reat Britain the profession has
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not been slow to realize; secondly, that the state, while rightly taking every care to supervise the treatm ent provided, must not be allowed to fetter the judgm ent of the professional man or to control the service, for as surely as the state controls, so does it destroy th at intimate contact between patient and dentist which is vital to the practice of our healing art. If it is to retain its place in the family life of the people, the dental profession must retain its individuality and do all possible to m aintain that fast vanishing type of prac titioner, “the family dentist.” Although this paper appears under my name, the whole of the credit is due to M r. W . G . Senior, dental secretary of the British D ental Association, who possesses a unique knowledge of the subject.
T H E SO CIA LIZA TIO N O F D ENTISTR Y ; ITS D A N G ER S A N D ITS POSSIBILITIES * By CHARLES F. L. NORD, D.D.S., The Hague, Holland
I F socialization of dentistry must be discussed in this country, first of all we must ask: W h y ju st now? And, as far as I can judge, the answer m ust be that the economic situation has changed to such a degree th at new means have to be sought to insure dental care for the majority of the people. O ne used to be of the opinion that, in the U nited States, those who wished to work could work, and thus were able to pay for medical and dental treatm ent for themselves and for their families and that *Read at the Seventy-Fifth Annual Session of the American Dental Association in con junction w ith the Chicago Centennial Dental Congress, Aug. 10, 1933.
Jour. A.D.A., July, 1934
the poor had to be looked after by the state, community or philanthropic institu tions: I t is to be feared th at these times have passed forever and th at one has to face circumstances such as we have known for a long time in Europe. From this point of view, we have to divide these people into tw o groups: 1. W orkm en and all those who belong to this class, w ith their families. 2. T h e lower middle-class, having an income just sufficient to pay im portant extra ex penses, such as dental bills of any im portance. I f we, before making any suggestions to help these groups and to the benefit of all concerned, take into consideration
I N presenting this communication, I am
conscious of the honor done me as pres ident of the dental organization pri m arily responsible for the inception of public dental service in G reat Britain. I t was in the year 1891 that the British D ental Association presented its first re port on the teeth of school children, and the appalling conditions revealed in that report made clear the urgent need for the provision of some form of inspection and treatm ent by the state. A few years later, a member of the association, C unning ham, of Cambridge, was instrum ental in setting up the first treatm ent center for the teeth of school children. T h is center, opened in 1908 by voluntary assistance, was shortly taken over by the city and has from that date blazed a trail which many other authorities have followed w ith suc cess. T h e state realized the need for reg ular inspection and treatm ent and the necessary parliamentary sanction was ob tained. Up to the outbreak of w ar, the school dental service developed slowly, but w ith the close of the w ar, a rapid extension took place, and there are now some two or three areas only which fail to make provision of this nature. I t will be seen th at public dental serv ice in G reat Britain had its development in meeting the needs of school children, and it has now extended to include the *Read at the Seventy-Fifth A nnual Session of the American Dental Association in con junction with the Chicago Centennial Dental Congress, Aug. 10, 1933.
Jour. A.D.A., July, 1934
treatm ent of the preschool child, the nursing and the expectant mother, tuber culous patients and other patients under the care of public authorities. In addi tion, a large section of the working-class population receives dental treatm ent as an additional benefit under the national health insurance acts. I t w ill be convenient to consider the various aspects of the foregoing in some detail under the appropriate headings. Before doing so, it might be well to clear the ground a little by considering the departments of state responsible. In G reat Britain, cities, boroughs and county bor oughs are responsible to the inhabitants within their boundaries for the provision of adequate facilities for education and health. In country districts, county coun cils bear these responsibilities. T h e state is responsible for ensuring that the local authorities properly discharge their func tions, and moreover the state bears half the cost of these services. SCHOOL DENTAL SERVICE
Education in G reat Britain is directed centrally by the board of education, the minister having a seat in the government. T h e local councils of the various authori ties enumerated above administer educa tion locally on lines generally approved by the board of education. Parents are com pelled by act of Parliam ent to obtain a satisfactory standard of education for their children, and this they may do either through private tuition or at state schools.
1182
R o w le tt— Social D e n ta l S ervice in G re a t B rita in
Every child attending a state school is medically and dentally examined during its school life, but no provision is made for those children attending private schools. T h e ideal a t which the school dental service is aiming is to provide for the in spection twice a year of every child at tending state schools; but unfortunately this ideal has only proved possible of at tainm ent in certain isolated areas. T h e problem is, of course, entirely one of finance, and there is little doubt that the long looked for improvement in world economic conditions w ill be speedily re flected in the health service of G reat Britain. A ll necessary treatm ent is pro vided and, in certain areas, orthodontic treatm ent is available. T h e value of the school dental service has been proved in those districts where inspection and treatm ent have been avail able over a number of years, and the con dition of the teeth of children leaving school bears adequate testimony to the care and high standard of the treatm ent provided. U nfortunately, much of the value of this excellent work is lost, owing to the fact th a t there is a gap between school-leaving age and the age when the young adolescent becomes eligible for den tal benefit under the insurance act. T h e bridging of this gap is a problem which the dental profession has attempted to solve for a num ber of years, but w ithout success. I t is possible that the harm re sulting from “the gap period” may be lessened by an extension of the school leaving age, which was projected recently under a socialist government, and a low ering of the age of entitlement to dental benefit. HEALTH DENTAL SERVICES
T h e m inistry of health and local town councils are jointly responsible for a number of services in connection w ith
1183
which dental treatm ent is provided. In an effort to reduce infant mortality and m aternal mortality, centers were set up at which free medical advice was made available to expectant and to nursing mothers, as w ell as municipal m aternity homes and infant hospitals. T he neces sity for eradicating dental sepsis in the expectant and nursing mother led to the provision of dental treatm ent, and, as a natural extension, dental advice and, where necessary, treatm ent was made available for children under school age attending such centers. A difficulty arising in connection w ith these particular schemes lay in the fact th at any female inhabitant was entitled to attend for medical advice, and, as the advice was of a specialist nature, the at tendance was high. I t followed that pa tients who could well afford to obtain the necessary dental treatm ent at the hands of their private dental advisers might ob tain the treatm ent from the public dental clinics. T his difficulty has largely been met by consultation between the dental organizations and the state, and only those patients who are unable to afford the services of a private practitioner re ceive treatm ent in the public dental clinics. A nother difficulty lay in the fact th at dental appliances were often neces sary, and the provision of these appli ances by public bodies at fees necessarily w ithin the range of a lower working-class population has tended to reflect on the fees charged by private practitioners for similar appliances. T h e treatm ent of patients suffering from tuberculosis, venereal disease and certain fevers, and also of mental defec tives, is to a great extent a duty of health authorities, and, in connection w ith all such schemes, dental treatm ent is almost a necessity, and as such has a place therein. T his treatm ent may be carried out either by part-time dentists or by a
1184
T h e J o u rn a l of th e A m erican D e n ta l A ssociation
whole-time officer, who would mainly devote himself to w ork in connection with the school and m aternity dental services. From the survey given above, it might appear th at the various forms in which dental treatm ent is provided directly by the State in G reat Britain would consti tute a serious menace to the private prac titioner. I t is unfortunately tru e that, prior to the inception of such schemes, the class of the population to which they ap ply rarely, if ever, sought the services of a dental surgeon, save for the relief of pain. T h ere can be little doubt that the services in question are exercising a very valuable educative influence on the work ing-class population, and that the next generation w ill value dental treatm ent to a much greater extent than the present. T h e great mass of the w orking classes, having neglected their teeth, offer little scope for tru e preventive teaching, but the agencies are devoting much time to the teaching of oral hygiene and care of the teeth by means of diet, and are con centrating on the children and adoles cents who, as potential parents, may be trusted to inculcate sound ideas in the next generation. A n aspect which has not been dealt with concerns the expenditure of public money, and here it may be said that the annual expenditure for dental services in connection w ith the various public schemes referred to is small in compari son w ith the sums expended on health service generally. T h e practice w ith re gard to payment for treatm ent received varies considerably in different areas. In some cities, a nominal charge is made for attendance at public centers; in others, the charge more nearly approaches the economic cost of providing the treatm en t; but in no instance is poverty a bar to ob taining the treatm ent, and every scheme has provision for free treatm ent when
the patient falls w ithin the necessitous class. PUBLIC ASSISTANCE DENTAL SCHEMES
T h e maintenance of able-bodied pau pers and the enfeebled pauper class, formerly a duty laid on boards of guar dians, was, by the Local Government A ct of 1929, transferred to local councils. N ot only are large institutions main tained for the reception of this class of the population, but also hospitals and residential homes for children. As may be imagined, dental treatm ent is a neces sary provision under schemes of this na ture. T his treatm ent, as part of the func tion of local councils, is tending to be come an additional duty of the public dental officer, rather than th at of private practitioners, as was the custom under the old guardians’ administration. T h e development of the service im mediately following the W ar, w ith the many branches summarized above, has led to the creation of a definite career in the public dental service, and, at the same time, has tended to w ithdraw a certain amount of public w ork from the private practitioner. T his has clearly been recognized by the profession in G reat Britain, and, while the need for schemes of the nature described is readily conceded, and indeed the need for fur ther extension of such schemes, it would be detrim ental to the interests of the public and the profession if it were re garded by the state as the initial step to w ard a state dental service. T h e relation ship between the state and the profession is discussed in the following paragraphs, which deal w ith the provision of dental treatm ent in connection w ith the N a tional H ealth Insurance Act, and w ith the ideal scheme which has been pre pared by the B ritish D ental Association, and accepted by the dental organizations in G reat Britain.
R o w le tt— S o cia l D e n ta l S ervic e in G re a t B rita in NATIONAL HEALTH INSURANCE DENTAL SERVICE
P rio r to 1911, the working-class popu lation of G reat Britain rarely obtained medical advice and treatm ent at the hands of private practitioners except in case of urgency, or through the medium of sick clubs or friendly societies. M any of the latter had a proud record of pub lic service; so also had the medical pro fession. N o t a few physicians in w ork ing-class districts gave ungrudging atten tion in return for low fees or w ithout fee. Realization of the importance of health in industry and in the economic life of the state led the government of the day to introduce the N ational H ealth Insur ance Bill of 1909, which passed into law despite opposition from the medical pro fession, employers of labor and, to some extent, employes. T h e act provided (w ith certain excep tions) for the compulsory insurance of all employed persons between the ages of 16 and 65 in receipt of an income below a certain limit, and of all persons employed in m anual work, w ithout wage limit. T h e workers so insured were entitled to re ceive free medical attendance and treat ment and a monetary allowance while in capacitated. T h e funds to defray the cost of the scheme were obtained by weekly contributions from the employer and em ploye and a grant from the state. T h e adm inistration of the scheme was placed in the hands of the friendly societies, which for this special purpose were desig nated “approved societies,” subject to the control of a department of state. T h e funds of the approved societies were audited by government auditors every five years and, as had been antici pated, the first valuation disclosed a sur plus over the whole scheme. By the year 1921, the surpluses which had accumu lated allowed for the provision of other
1185
forms of treatm ent or benefit which were term ed “additional benefits.” I t is im portant to emphasize th at only the mem bers of societies whose accounts showed a surplus were entitled to enjoy the ad vantage of additional benefits, and also th at the rate of benefit payable varied from society to society. T h e foregoing summary of the act will serve to make clear the fundamental dif ference between the provision of medical and dental treatm ent under the act, the former, a statutory benefit, enjoyed by every insured person as a right, the latter an additional benefit open only to those fortunate enough to belong to a society having a surplus. D ental treatm ent, first introduced as an additional benefit in 1921, has under gone several modifications since that time, the present scheme having come into ef fect in 1930. T h e 1930 scheme provided for control by a statutory body, the D en tal Benefit Council, consisting of an equal number of dentists and representa tives of approved societies w ith certain officials of the ministry of health. T h e benefit is administered under regulations, a t a scale of fees negotiated by the dental profession and the approved societies and sanctioned by the state. Each society providing the benefit undertakes to pay not less than half the cost of treatm ent, the balance being paid by the insured per son; while the dentist undertaking the treatm ent agrees to make no additional charge, and to give a satisfactory degree of service. T h e scale of fees, which need not here be detailed, includes among other items: scaling, 7s 6d .; extraction per tooth w ith local anesthetic, 2s 6 d. (maximum ex traction fee for either jaw, 12s 6d ; both jaws, £ 1.2 . 6.) ; simple general anesthetic fee, 7s 6d .; prolonged anesthetic fee, £1.1 .0 .; full dentures, £5.10.0. Insured persons entitled to the benefit
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T h e J o u rn a l o f th e A m erican D e n ta l A ssociation
are provided w ith an estimate form, which is presented to the dentist of their choice. T h e treatm ent required is esti mated by the dentist at the scale of fees and is submitted to the society concerned, and, in normal cases, is approved. T h e treatm ent is completed and the account paid. T h e society may, and frequently does, refer the estimate to a second opin ion in the person of an officer appointed by the state. H is duty is to advise the society as to whether the treatm ent esti mated is, in his opinion, such as w ill se cure the dental efficiency of the patient. M achinery is provided for the settlement of differences of professional opinion and for the investigation of complaints against dentists or societies. T h e advantages of the scheme in its present form are almost entirely w ith the insured person, as far as it can be defi nitely stated that many of the workers would otherwise be unable to afford den tal treatm ent, and there has been an un doubted improvement in the dental health of th at class since the inception of the service. T h e disadvantages rest mainly, but not entirely, w ith the profession; for the pa tient must and does suffer as a result of differences of professional opinion; there is no provision for regular inspection and treatm ent, and, as many societies are u n able to provide the benefit, a large section of the insured population is ineligible. From the point of view of the profession, the standardization of fees has definitely tended to lower the fees of private prac tice, and to lead to the treatm ent’s being carried out rather from the point of view of items than as a whole. T h e fact that societies provide the benefit out of surplus funds places the profession under the vir tu al control of laymen. T h e need for some scheme which would at the same tim e satisfy the state, the public and the profession was for long
apparent to the profession, and led to the British D ental Association’s setting up a committee of experts to study the whole problem. T h e committee recently pre sented a draft report which has received the approval of the various dental organ izations and the general support of cer tain of the bodies interested in health in surance matters. T h e recommendations represent a complete change from the methods described above, the fundamen tal difference being the provision of den tal treatm ent as a statutory, instead of an additional, benefit. Such a change would at once entitle every insured person, rather than the fortunate few, to the benefit, and it would take control of the administration out of the hands of ap proved societies. T h e system of remu neration would be by a capitation fee, in return for which the dentist would pro vide annual inspection and treatm ent for each insured person on his list. T h e ad vantages of such a method are manifest, and there can be little doubt th at the freedom from bureaucratic interference, the premium on good diagnosis and the incentive to build up sound dentitions would all react to the lasting benefit of the patient. T h e application of a statutory scheme based on a capitation system is not w ith out considerable practical difficulties, not the least of which concerns the annual fee which would secure to the dentist a fair and reasonable rate of remuneration for his work, and would, at the same time, be acceptable to the state. I am hopeful that the tentative fee put for ward in the report referred to w ill prove acceptable to all parties. A difficulty which has a more immediate bearing on the application of the scheme is th at of finance. T h e present contributions paid by employer and employe are only suffi cient to meet the cost of statutory medi cal benefit, and additional funds would
N o r d — S o cia liza tio n o f D e n tis try
be required to provide the dental benefit envisaged above. T h e present state of in dustry would not appear to be such as to permit of additional burdens being im posed on either employer or employed in the near future, and the need for state economy offers little hope of assistance from th at source. Nevertheless, we con sider th at the ideal scheme is to hand and ready for application when finances per mit. CONCLUSION
If a moral is to be draw n from this survey of public dental service in G reat Britain it is tw ofold: first, that it is the duty of the dental profession to assist in the provision of dental treatm ent for every class of the community, a duty which in G reat Britain the profession has
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not been slow to realize; secondly, that the state, while rightly taking every care to supervise the treatm ent provided, must not be allowed to fetter the judgm ent of the professional man or to control the service, for as surely as the state controls, so does it destroy th at intimate contact between patient and dentist which is vital to the practice of our healing art. If it is to retain its place in the family life of the people, the dental profession must retain its individuality and do all possible to m aintain that fast vanishing type of prac titioner, “the family dentist.” Although this paper appears under my name, the whole of the credit is due to M r. W . G . Senior, dental secretary of the British D ental Association, who possesses a unique knowledge of the subject.
T H E SO CIA LIZA TIO N O F D ENTISTR Y ; ITS D A N G ER S A N D ITS POSSIBILITIES * By CHARLES F. L. NORD, D.D.S., The Hague, Holland
I F socialization of dentistry must be discussed in this country, first of all we must ask: W h y ju st now? And, as far as I can judge, the answer m ust be that the economic situation has changed to such a degree th at new means have to be sought to insure dental care for the majority of the people. O ne used to be of the opinion that, in the U nited States, those who wished to work could work, and thus were able to pay for medical and dental treatm ent for themselves and for their families and that *Read at the Seventy-Fifth Annual Session of the American Dental Association in con junction w ith the Chicago Centennial Dental Congress, Aug. 10, 1933.
Jour. A.D.A., July, 1934
the poor had to be looked after by the state, community or philanthropic institu tions: I t is to be feared th at these times have passed forever and th at one has to face circumstances such as we have known for a long time in Europe. From this point of view, we have to divide these people into tw o groups: 1. W orkm en and all those who belong to this class, w ith their families. 2. T h e lower middle-class, having an income just sufficient to pay im portant extra ex penses, such as dental bills of any im portance. I f we, before making any suggestions to help these groups and to the benefit of all concerned, take into consideration