In ‘no man’s land’? Dentistry and Covid-19

One of the projects I’ve been investing a lot of (belated due to several job changes) work into has been our project we did a couple of years ago into the work of dentists. Along with a colleague, we got a small amount of funding to investigate the rising levels of stress within Scottish dentistry. The profession’s key journal — the British Dental Journal — has been rife in recent years with articles showing concern and investigations into the high levels of stress and burnout in the profession. Our study attempted to investigate this problem but from a more sociological viewpoint, focusing on the experience of work and institutional arrangements within Scottish dentistry.

Our research — which is in the last stages of finally being written up — aimed to explore the reported intensification of dentists’ work, the regulation and governance of dental work, and the emotional and physical demands of their work. Obviously, a couple of years has separated our interviews and the current Covid-19 crisis. Yet, the coronavirus pandemic presents a crisis that accentuates many of the existing tensions within dentistry. Dentistry is one of the professions most exposed to the virus itself as well as one of the key professions that will fall through the cracks of the government’s provisions for workers in this country. Although this is written from the perspective of Scottish dentistry — because of its devolved payment setup — the tensions identified in dental provision during this pandemic substantially overlap with dental care more widely in the UK.

As a profession, dentistry represents an exemplary form of ‘body work’ (Cohen ,2011; Twigg et al. 2011; Wolkowitz, 2002)– a type of labour that is primarily directed on the bodies of others. Various jobs within health care more widely, the beauty industries and the care sector depend on the assessment, handling and manipulation of patients’ or customers’ bodies as part of the work. Dentists’ work is typical of the demands of ‘body work’ with their jobs demanding ‘co-presence’ — the work cannot be done away from the patient — requiring intensive one-to-one time, a great deal of face-to-face interaction — and emotional reassurance — and a form of work that requires demanding dexterous forms of labour. In our research, this work has been found to be both emotionally and physically demanding. Dentists are engaged in a form of health care that has several phobias attached to it, their work that involves a lot of physical manipulation that puts a lot of pressure on their own bodies, in addition to being subject to more ‘aesthetic’ or customer-focused demands.

Importantly, the work performed on patients by dentists deals with a lot of bodily fluids, and many of the procedures are themselves ‘aerosol’ generating — just think of the amount of fluid and suction required in many standard dental treatments. ‘Aerosol generating’ is a particular red flag in regard to the coronavirus, with the spread of the virus linked to droplets emitted from the nose and mouth. The problems with performing dentistry during this pandemic is perhaps illustrated in recent charts that showed dentists to be the most at-risk form of work for catching the coronavirus. Guidance for dentists in these times has been mixed with some dentists bemoaning the responsiveness of their governing institutions during this fast changing crisis. Dentistry has been largely treated as a non-essential form of health care and the response has generally downgraded dental treatment from the list of priorities. Dentists were advised within Scotland on the 23rd March to cease all routine dental treatment, with England’s similar guidance arriving on the 25th March. The result is that all urgent, emergency case work is now performed by the wholly salaried dental workforce within the NHS.

Yet, the problems with the pandemic for the work of dentists cannot be limited to the particularities of the dental treatment itself. One of the key themes that emerges in our research — and previous research on dentistry — is the apparent conflict between ‘knights’ and ‘knaves’ or care and commerce. This is not necessarily unique to dentistry itself, but is accentuated by the dental treatment being one of the few areas of health care not wholly covered by the NHS. Annemarie Mol’s (2008) work, which developed the notions of a ‘logic of care’ and a ‘logic of choice’ through her study of the treatment of diabetes in Holland, is particularly pertinent to the study of dentistry. Scottish dentistry — and dentistry more widely in the UK — arguably operates within a ‘logic of choice’ where the provision of dentistry is effectively ‘outsourced’ by the NHS to general practices — in Scotland this treatment is partly subsidised — and patients can be offered various private solutions that supplement the basic NHS treatments available. Most dentists regard themselves as operating from within a ‘logic of care’, where relationships with patients and developing ‘continuity of care’ is the ultimate goal of their work. Yet, as our research has found, dentists themselves feel a particular tension between this logic of choice and their own belief in a logic of care.

The relevance of our research and key problem for dentistry during this coronavirus pandemic is being stuck in between these two logics. The operation of this ‘logic of choice’ ultimately leaves dentists particularly exposed to the current crisis: not sufficiently within the ‘care’ setting to have this work protected centrally as part of the NHS and not sufficiently within the market setting to gain full protections for their work. Dentists are for the most part self-employed and with the closing down of most face-to-face business in the UK— non-essential retail jobs, beauty industry business, restaurant trade — as a result of the crisis, we’ve seen a drop in economic activity and a rise in unemployment unprecedented in both severity and speed. The response of governments worldwide has been to, quickly, work to guarantee the jobs of individuals made unemployed by the crisis. As we’ve seen from the multiple budgets and additional measures Rishi Sunak has had to create, each government response has covered numerous affected groups but left a number of others exposed to substantial drops in their income. The largest group that many felt had to wait too long for government help was the self-employed. Eventually, last Wednesday, the government announced a number of protections for the self-employees. Yet these provisions have been capped and people earning over £50,000 are not eligible to claim — even to the capped amount — leaving many dentists facing months without income, and those that are eligible will have to wait until the end of June to see these incomes.

Dentistry has been treated as something of a luxury in this time of crisis. Indeed, this belief in ‘knights’ and ‘knaves’ too has an effect — in our research, dentists sometimes felt that patients saw their advice for treatments often being seen as ‘upselling’ rather than the advice of health care professionals. It is sometimes hard to make a case to support a profession that a number of people are afraid of or are perceived as particularly well off — especially with the news that many earn above this £50,000 threshold — yet, dentists will be part of the NHS’s response to the crisis. Already public service dentists in the NHS are taking over much of the urgent dental care of those currently suffering from Covid-19 and the redeployment of these dentists into other roles within the hospital system is being discussed and implemented. General practice dentists — whose doors have largely been closed to the public and currently working without income — are already part of the triage system, with dentists answering their practices phones and assessing whether these cases need escalating to the public dental service. Soon, these general practice dentists will be asked to volunteer in the service to treat urgent cases. In Scotland, other health services which exist with similar tensions between public and private provision, such as pharmaceutical and optical services will continue to receive 100% of NHS funding. It is notable that the initial offer for dentists was to back only 90% of this funding (that is 90% of the 20% the NHS subsidise for treatments – the remaining 80% being the upfront cost for patients).

The problem is what happens after the crisis. Although many nurses and some dentists will be able to claim state support, a substantial part of the sector will not. As the BDA has noted, many of these measures will not help associate dentists or those who run practices. Within the Scottish news it has recently been reported that practice owners worry that dental provision in the country will be ‘decimated’ with many businesses potentially unable to see themselves through the crisis. Although yesterday new measures were put in place to cover up to 80% of average item and patient income in Scotland, many practices are dependent on the balance between private income to cover the public service work they perform. Our own research has found that price freezes on item lists over the past years of austerity in Scotland have led to increased intensification of dental work in order to maintain income levels — what effect this crisis and the government response has to dentists working lives and the value of dental care in our country is an urgent question.