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Special ArticlesDENTISTS AND THE ACT

MINISTER AND THE BRITISH DENTAL ASSOCIATION

AFTER a meeting of its representative board on Jan. 31,the British Dental Association issued a statement sayingthat for many years it has advocated a dental healthservice available to all who need it, and that it has giventhe Ministry of Health its expert advice on the best

’. way to provide such a service. The Minister was requestedto embody in the National Health Service Act and itsregulations certain fundamental principles which are

described as follows:

PRINCIPLESClinical Freedon

In private practice, so long established as a highlysuccessful service for the public which it serves and,indeed, providing by far the greater part of the dentaltreatment given in this country, a dental practitioner isfree to give what he considers, in his professional judg-ment, to be the best possible treatment to each individualpatient, subject only to two conditions : (a) that thepatient consents to the treatment ; (b) that the fee iacceptable to both parties-i.e., a fee that the-patientconsiders reasonable and within his means and that thedentist is content to accept as a fair and just rewardfor his’skill and services. In private practice, the dentist

has complete clinical freedom, with no restriction uponhis initiative and enterprise. He is free to use whatevermethods and materials he thinks are in the best interestsof his patient.The proposed regulations of the Act confine clinical

freedom to certain items of conservative treatment (e.g.,fillings of a standard type), but for the great majority ofhis patients the practitioner would have to fill in a formof estimate for the necessary treatment and submit thisfor approval to a board, the Dental Estimates Board,before being able to commence treatment. In addition,all patients would be contractually liable to attend forexamination by a State dental officer before treatment inorder to confirm the clinical judgment of the dentist andafter treatment to confirm the standard and completionof the work.The association holds the view that this curtailment

of the clinical freedom of a dentist will operate to thedetriment of the standard of treatment given.Patient-Practitioner Relationship

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The whole basis of successful dental service lies in themutual confidence and respect of patient and practitioner.Nothing can be acceptable to the association whichweakens this relationship. In the Health Service, how-ever, the dentist, once the sole guardian of the patient’sinterests, is primarily in contract with a State-appointedexecutive council, and his relationship with his patientwill take second place.Method of Remuneration.The method proposed by the Ministry is by means of

a nationally established fixed scale of fees. For each itemof treatment there will be a fixed fee for every practitionerin the land, quite irrespective of the degree of skill, ability,experience, and effort he exhibits in his work, of theamenities and surroundings he provides in his practice orof the standard of efficiency and wages of his staff. Underno conditions will a practitioner be able to receive anextra reward for any additional professional attributehe may possess. His patient will not be permitted tosuggest that he would like to have " something betterthan panel." The patient must be content with thestandard of utility dentistry which will be provided bythis method of remuneration.The association has asked for a system of remuneration

by " grant-in-aid." This means that the Government

grant for each item of treatment would be available tothe patient whether he attends a practitioner willing towork at the standard scale fee, or a practitioner whosestandards, skill, experience and amenities enable himto provide " something better than panel " and thereforeentitle him to receive a higher reward for his work. Thissystem is in successful operation in the social-security

schemes in France, Belgium, and Norway and provisionfor it has recently been made in the Health Service forNorthern Ireland. ’ lThe fixed scale can only result in a standardised

service for all, for the good dentist will be unable toafford to maintain his higher standards of service at hnown expense. The most careful and conscientious dentistwill earn the least.

aesthetic ValuesThe association maintains that there is no indication

that, in the Health Service, proper recognition will begiven to the aesthetic side. The proposed continuationof certain conditions of present dental benefit, such asrestriction to certain types of filling material in certain teeth, restriction of the methods and materials necessaryto construct artistic dentures to improve the appearanceof the patient, lead to the conclusion that even if art indentistry is not actively discouraged in the newsservice.it will very soon die out for lack of any incentive.

Clerical WorkThe Health Service will introduce into the practices

of most dentists as a new feature a quite unnecessaryamount of form-filling and correspondence with thirdparties in relation to treatment of a patient, resulting inmuch irritation and loss of productive time. ,

It would appear to the association that this largeincrease in clerical work is only necessitated by the natureof the bureaucratic and statistical controls which arenecessary to Government departments and will not inany way increase the quality or efficiency of theservice to the patient. Indeed, it is more likely tooperate in the opposite direction.

Discipline .

The association maintains that the proposed disciplinaryregulations substitute for the system of self-disciplineand responsibility to the patient which is inherent inprivate practice, one which suggests that the integrityof the dental profession is not rated as highly by theMinistry as by patients in private practice.The association is of the opinion that as many of the

restrictive, narrowly defined disciplinary regulations aspossible should be abandoned as unnecessary for a pro-fession whose professional code.of ethics and behaviour inprivate practice has gained a reputation in the publicmind of integrity and trustworthiness.At a meeting between the’Dental Consultative Com-

mittee and the Minister of Health on Nov. 25, 1947, theabove principles were put before the Minister by memo-randum and word of mouth. " He failed to concede anysingle one of them to the profession."

THE B.D.A.’S VIEWS

The association maintains that a practitioner shouldhave the right of final appeal to the High Court, andthat, in view of the Minister’s power to determine byregulation the conditions and terms of service of officersemployed by any body constituted under the Act, thereis under the Act no security for the practitioner.The association is opposed to the idea of the general

dental services under the Act being given solely bywhole-time salaried dental officers in health centres; it

regrets that responsibility for the most important sectionof the community-namely, the children-is sharedbetween the Ministries of Health and Education ; andit states that the inclusion of adolescents in the priorityclasses was refused by the Minister on account of an

alleged shortage of dentists." The Minister’s attitude to many of the suggestions

made by the association has been affected by hisconstant emphasis upon an alleged shortage of dentists.The association is of the view that, provided theconditions of service are attractive enough to bringinto the service the full strength of the profession,there are sufficient dentists to meet any demand thatis likely to take place in the immediate future of theNational Health Service Act." -

The representative board of the B.D.A. recom.

mends all members of the association to refuse to enter

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the service " until the Act and its regulations are amendedso as to include the principles advocated by the associa-tion." It adds that the association " is prepared, in thepublic interest, to maintain, with no sense of commitment,its contact and discussions with the Minister of Healthin order that amendments may be obtained to theHealth Service Act, 1946, and its regulations whichwould ensure a satisfactory dental service for the public."

The Minister’s Statement

A memorandum sent to all dentists in England,Scotland, and Wales points out that any dentist can takepart in the service or not. When his name has been

placed on the dental list of the local executive councilhe can accept patients to whatever extent he chooses,while also retaining his right to private practice. Patientswill not be required to register on the list of any parti-cular dentist ; they will have complete freedom of choiceof dentist and will be free to consult a dentist outsidethe area in which they reside. A patient needing treat-ment will merely have to get in touch with the dentistin the same way as in private practice.

If he participates in the service the dentist willundertake to provide proper surgery and waiting-roomaccommodation and suitable equipment and instruments,to use proper-skill and attention, and to seek to securefull dental fitness. This undertaking will apply to anypatient whom the dentist may treat under the scheme,but he is in no way limited as to the number of patientshe may see, nor is he obliged to accept any patient underthe service.

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Broadly speaking, treatment falls into two maindivisions-that which may be carried out without

any prior authority and that which requires the priorauthority of the Dental Estimates Board. The DentalConsultative Committee have represented that dentistsshould -not in general be obliged to obtain prior approvalexcept for special and expensive forms of treatment ;but the Minister feels bound to retain some interest inthe cost and standard of the service and he believesthat in the following arrangements control has beenreduced to the minimum consistent with this principle.

1. Treatment not Needing any Prior Authority.-In this

category is all normal conservative treatment-i.e., prophy-laxis, fillings and root treatment, extractions for the relief of

pain or extractionsnot necessitating replacement by dentures(including any necessary anaesthetic), ordinary denture

repairs. X-ray examination for diagnosis and certain othertreatment may likewise be carried out at once, subject to aimitation, of cost which will be settled following the discussionson remuneration.On the completion of treatment the patient and the dentist

sign the estimate form, which is then sent to the DentalEstimates Board for authority for payment.

2. ’Treatment Needing Prior Authority.-In this categoryare the removpl of teeth (otherwise than in (1) above), theprovision of dentures, extensive and prolonged treatment ofthe gums, gold fillings, inlays, crowns, special appliances, andoral surgery.

With the approval of the Dental Estimates Boarda patient will be able to pay the extra cost of certain moreexpensive treatment or appliances.The Dental Consultative Committee have represented

that applicants for dental treatment should be requiredto undergo the whole of the treatment needed to makethem dentally fit-just as insured persons claimingdental benefit are at present required. The Minister,however, does not feel that it w"uld be right to deprivea person who is unwilling to undergo full treatment ofa service which is designed to be available to the whole

, community and which is provided at the expense ofpublic funds. Where a patient is not willing to undergothe whole of the treatment necessary the dentist willcarry out (or seek approval for) such treatment as hisprofessional judgment suggests and the patient will allow.

The Dental Consultative Committee have pressed fora system of remuneration by way of grant in aid ; butthe Minister considers that this would run directlycounter to the principle that full dental services underthe National Health Service shall be free of charge,except for specially expensive treatment and appliances.

Recognising the difficulties which may arise in the

provision of a service dependent upon a profession whosenumbers may prove to be too small, the Act has placedon local health authorities the duty of making available,as a priority, dental advice and treatment for all

expectant and nursing mothers and pre-school children(in addition to the arrangements made for school-childrenthrough the school health service). Patients will retainthe right to obtain treatment under the general scheme,provided they can find a dentist who will accept themfor the purpose.

CHEMOTHERAPY IN COURT

ADVANCES in chemotherapy with the sulphonamideswere reviewed by Mr. Justice Jenkins in his recent

judgment in favour of Boots Pure Drug Co. Ltd. in theirpetition for the revocation of the patent no. 533,495granted to May & Baker Ltd. and Ciba Ltd. for aninvention entitled " Manufacture of New BenzeneSulphonamido Derivatives." The hearing lasted 17 daysand evidence was given by Sir Lionel Whitby and otherauthorities on ’chemotherapeutics. The patent includesthe manufacture of sulphathiazole and the allied 4-methyl-thiazole, which is used in Continental countries ; and,subject to any reversal by the Court of Appeal, theseimportant chemicals may now be freely manufacturedby anyone in Great Britain. The respondent companies’motion to amend their patent to apply only to these twocompounds was refused because a specification as

amended would be substantially different from theinvention claimed.

Regarding the substitution products of sulphanilamide,His Lordship said that research appeared to have pro-ceeded on empirical lines and had been largely a matterof guesswork, or trial and error. Heterocyclic substitutionhad been investigated first by the two respondentcompanies, and a paper on the value of sulphapyridinehad been published by Sir Lionel Whitby in THE LANCETon May 28, 1938. In Swiss patents granted that yearthere was a reference to chemotherapeutic activity,and in no. 533,495 there was a statement that " thenew p-aminobenzene-sulphonamido-thiazoles had chemo-therapeutic activity in streptococci infections and similarillnesses." This was construed by the Judge as amountingto a suggestion that all substances produced by themethod specified and from the materials should havechemotherapeutic properties. Evidence from chemicalexperts had shown that there were 97 million possiblecompounds from the given starting materials, but it wasimpossible to predict which would be valuable in chemo-therapeutics ; sulphathiazole was an extraordinari.lyuseful drug and was described by Sir Lionel Whitby,in his evidence for the respondents, as among the bestthree sulphonamides. The proved utility of two par-ticular products out of hundreds or thousands comingwithin the terms of the unamended specification couldnot suffice, however, to provide subject matter for theinvention as claimed, and the petitioners’ objection onlack of subject matter was well founded. There was adisparity between the inventive step and the width ofthe monopoly claimed, and this also afforded goodground for objection. Inutility had also been made outby the same evidence as that used to establish lack ofsubject matter, and the patent was invalid for thesereasons.

While this action may result in a lower price to thepublic for sulphathiazole, because competing manu-facturers may now prepare this compound at cost only,manufacturers may tend to diminish the volume of theirresearch work if they feel that protection of their resultscannot be maintained. In industry research is financedfrom profits, and an immediate gain to the consumer isnot necessarily an ultimate gain.