Introduction

As the COVID-19 bowling ball continues to decimate the dental industry like they are pins at an alley, I often wonder whether we're too pre-occupied with the first three pins. After all, if those are hit in just the right place, the rest will follow and you can almost turn your back to return to your chair just as the sound of all 10 come crashing down. Do we even care about the ones in the back corner?

For all the talk of abatements, support for private practitioners, challenges in the community and payments being passed down to associates, one sector has been teetering on the edge for some time now, and COVID-19 is the bowling ball that will push many within it over for good.

Dental laboratories and their technicians are reaching white rhino levels of extinction. Some feel COVID-19 could be the bullet that ends them having been tracked for some years. But is that hyperbole, accurate or somewhere in between?

figure 1

An endangered species

Steve Taylor, President of the British Association of Clinical Dental Technology (BACDT), suggested the answer was somewhere in the middle. He said: 'Prior to COVID-19 there had been a slight decrease in the amount of band 3 treatments undertaken by dentists on the NHS over the last couple of years, these were low single percentage figures though. Laboratories undertaking private work were steadily growing as a percentage.'

Steven Campbell, President of the Dental Laboratories Association (DLA), believes technicians and their labs have been in a perilous situation for some time.

'Dental technology has been in a delicate state for a number of years since the advent of 'Options for Change', he said. 'There is no doubt that the financial pressure placed on dental laboratories that provide NHS dental appliances prior to COVID-19 is exposing the financial frailty of dental laboratories post COVID-19. The low prices and increased costs for employing registered dental technicians, supermarket style contract terms with dental corporates and complying with the medical devices directive has meant that dental laboratories providing NHS services simply aren't able to build anything like the reserves needed to support themselves during a pandemic.

'Dental technology has for too long been considered external to the dental team and as such investment and recognition for the role of the dental technician, although still essential, is fundamentally dismissed by the Department of Health, indeed dental technology is considered to be a consumable by the Department of Health rather than a profession that makes custom made dental appliances for NHS patients.'

Peter Higgins, owner of P and C Dental, also believes laboratories and technicians have been on the extinction warning list long before COVID-19 arose. 'I would say we have been clinging on by a thread for 16 years', he added. 'I used to work at Acodent which was then the biggest lab in the country. It was my job to teach the kids coming through in the area of crown and bridge. I had a small unit with four school leavers and my sole purpose was to teach. Then the dental contracts changed. Overnight the industry changed. I was returned to production as it became apparent that anybody who wasn't producing work was surplus to requirements. I was told that surgeries accounts went from £8000 to £1000 per month overnight. I know of one dentist who tried to sue the government and lost his business, his health and nearly lost his home. I know of lab owners who lost everything. Shortly after I moved to manage a smaller lab only to watch as the work vanished off the shelves.

' The impact on our members lives is devastating, dental technicians are being made redundant across the UK even during the furlough period'

'I now run my own small laboratory and do not know of a single trainee being brought through in any lab since that time. It has taken me 15 years to get my lab to a position where I can take a day off and have cover with qualified staff and then COVID-19 struck. For 10 years I didn't have a day off which is the norm for most lab owners. A bonded crown is typically the same price now as it was when I started the job in 1996. Couple this with inflation, the price of gold, increasing costs of supplies and the fact we cannot claim our VAT back due to being categorised as medical and you have the perfect conditions for disaster. I know of a highly-skilled porcelain technician who has just done his HGV license as he cannot get the wages he needs in this trade. A trade which is supposed to be a cornerstone of the NHS. So yes, we were definitely in trouble before COVID-19 struck.'

Feeding off scraps

Peter's overall point about the precarious financial situation technicians and labs find themselves in is one that needs to be listened to. Like many of their private dental colleagues, they have faced great difficulty in accessing any form of government support. Have they been cast aside and made to fend for themselves during the crisis?

'As DLA President, I would 100% agree with this sentiment', Steven stressed. 'I have the pleasure of talking to dental laboratories across the UK and there are literally hundreds of DLA members who haven't been able to access any sort of funding support and whilst the language from the Office of the Chief Dental Officer is supportive, the rhetoric does not match the reality in terms of help at the coalface. The impact on our members lives is devastating, dental technicians are being made redundant across the UK even during the furlough period but aside from this there is also a huge mental health issue.

'The life of a dental laboratory owner is stressful anyway but these new stresses caused by the lack of support for dental laboratories during the COVID-19 pandemic, has seen the need for pastoral care as well as business advice significantly increase since March.'

Steve also believes labs and technicians were hung out to dry.

'The impact of the closure of dental practices was dependent upon the percentage of NHS work that the practice was commissioned to undertake. If they were 100% NHS, then the practice continued to receive 100% of its income. The government set up various schemes to help all types of businesses survive during lockdown. I can't think of any others that received 100% of their income without having to deliver their services.

'Staff wages for dental laboratory staff were covered by the Furlough scheme, but many of the business owners didn't receive any income. It seems at the very least unfair, that an abatement was applied to the money paid to NHS practices for the consumables they hadn't used, laboratory services and materials for example. This money had been intended for laboratories but was taken back, and my question is this: to whom and to where?

'Certainly, there were expectations that the practices would continue to pay their staff and associates, and there was some redeployment of the dental teams and staff members to assist the NHS in various capacities. As part of the income paid to practices who undertake NHS work there is a percentage that is anticipated will be paid through the system to dental laboratories for work they have made to the dentists' prescription.

'Sadly, within the payments this is classed as consumables. In April and May as dental practices were effectively closed, no Band 3 work was undertaken and subsequently the dental laboratories received no income at all. This was of course the same for private dental practices. It is obvious that no business can survive without income. Fixed costs still need to be paid somehow, probably from cash savings within the business or from savings from the business owners. Why were we left in the cold? It has to be different if a second wave does occur.'

For Peter, things got worse as time wore on.

'When COVID-19 first struck, I was quite calm as the measures brought in seemed fairly well thought out. My staff were furloughed, I made a promise to get them back, locked the door and sat in the sun. It then became a fight to get the £10,000 promised and it took until the measures were taken regarding sole traders to do so, almost three months into the pandemic. In this time it also became apparent that as directors my wife and I would only get 80% of the wage we draw. As we are paid a certain amount in dividends we 'fell through the cracks'. I personally took a £50,000 loan to make ends meet.

' The initial injustice of NHS laboratories not being supported could have been avoided if they were paid directly by the NHS as opposed to by the NHS practice.'

'As a smallish lab our turnover is reflected in our size, and with six staff to pay, this was potentially disastrous. Then we found out that NHS dentists were told they only needed to do 20% of UDAs until April 2021 and would still be paid. Would you rush back to work if you were getting paid for 12 months? Maybe, maybe not. As I see it, we are the only trade in the country whose customers are being paid by the government to not do any work for 12 months.

'At this point I decided to start my Facebook group, Race to the Bottom, for lab owners and technicians and we have been tirelessly campaigning for change ever since. We need politicians to recognise that our trade is separate to dentists. The common answer we received in my group when we emailed MPs was along the lines of 'we are aware of the ongoing situation for beauticians and dentists'. What do you say to that? It would be easier to say what doesn't need rectifying. If MPs don't even know what my trade is, what chance do I really have?'

Rumblings of discontent

Hearing the thoughts of Peter, Steve and Steven got me wondering. While all three were - and remain - unhappy with the lack of financial support for the sector, were they dismayed with the support - or lack thereof - of their NHS and private colleagues?

'Since lockdown was lifted and dentistry could resume, about 80% of my work is now private', Peter said. 'Before COVID-19 it was the other way around. By my calculations, if every dentist did one prep every four days, we would be back to normal and the 1,600 out of 6,500 redundancies would have been avoided. This is not a lot to ask, even taking fallow time into consideration. A simple directive from the CDO would at any time avoid any more unnecessary redundancies.

'To me, it feels like we are expected to prop up the NHS with personal loans and be ready and waiting when the phone starts to ring again. If all NHS labs closed tomorrow NHS dentistry would close with it. The irony is not lost on me that many in the profession believe that this is what the government wanted before COVID-19 anyway. NHS dentistry was part of Lord Bevan's original blueprint and was supposed to be free at the point of contact. Does £269 for a Band 3 treatment sound free to you?

'Also, if most of the income labs are receiving now comes from private clients, it is the very people who have been let down by the NHS and pay privately who are currently propping up the whole system. I'm not sure that's right - or sustainable in the long term recovery.'

'Everyone within dentistry is showing their support and acknowledging that the current situation is critical for dental laboratories but beyond supportive words, there has been no notable action to help dental laboratories', Steven added. 'Whether that is at a local level where dental practices could work with their dental laboratory, or at national level where the right instructions and parameters associated with the NHS payments during COVID-19 could save hundreds of dental labs and save thousands of jobs in dental technology, it isn't happening. And it needs to.'

Steve explained: 'The initial injustice of NHS laboratories not being supported could have been avoided if they were paid directly by the NHS as opposed to by the NHS practice. If laboratories were able to tender for NHS contracts and be commissioned directly, the choice for the dentists on which laboratory to use would be purely on quality and service.

'Going forward, bringing dental technology back to within dentistry seems the wisest choice to ensure we're not in this position ever again.'

The second wave

Rather like the Spanish flu pandemic of 1918, some experts forecast the second wave of COVID-19 could be worse than the first. For the UK, heading into the winter season, there are discussions and rumblings relating to a second national lockdown to prevent cases and deaths from spiralling out of control. For those businesses who have just about managed to survive the first wave, a second one would be catastrophic, a point Steven believes is becoming closer to being a reality.

'It is widely acknowledged that the second wave is now starting and if this is the case and no additional help for dental laboratories is forthcoming from the HM Treasury, then we will see a likely end of dental laboratories that provide a service that is led by NHS dental practices', he said. 'If the furlough period is not extended to cover the 6-month period that is now being recognised as the second wave, then November will be the month that jobs in dental technology will fall off a cliff edge. And, as it has been said many times before, once we lose these low paid, highly skilled professionals to jobs in supermarkets or delivery driving for online retailers they simply won't come back just because the demand for dental appliances has increased. It is a very perilous situation we find ourselves trying to survive in.'

For Peter, a second wave would be disastrous.

'It is a question I put to my group this morning and overwhelmingly the answer was that they will not survive' he said. 'With the promise of no more furlough, I am faced with making all of my staff redundant in November. I can't take out any more loans and even though a test case ruled in favour of COVID-19 being included in Business Interruption Insurance payouts, several companies are already turning claims down.

'We really have no other form of income and, as I have previously said, both my wife and I are reliant on the company as it is with many friends and colleagues in the industry. As I sit here writing this the country has been put to COVID-19 level 4 so I expect a drop off in the limited work we have from tomorrow. If help doesn't arrive by the end of September it is my gut feeling that 50% of labs won't see Christmas, which is a horrendous thought.'

According to Steve, should there be a second wave the industry will have a choice to make. 'If it does happen - and all signs currently point to a second wave upon us - then post-COVID-19, clinical dentistry needs to decide if it wants technical dentistry to exist for NHS patients. Without serious financial support the laboratory industry will not be able to go into suspended animation. It's a radical question to ask, but a just one, given the circumstances.'

What would a future without labs and technicians look like?

If, for a moment, their grim predictions came to fruition, how exactly would the profession cope?

Steve explained: 'Since the re-opening of dental practices in a limited capacity from 8 June, payments to dental practices are again at 100%, with an expectation of a minimum of 20% activity. This minimum of 20% activity has involved hardly any laboratory work at all. Dental laboratories who have positioned themselves to support the NHS dentists and patients have simply been left to die on the vine. No income has been passed on to them. Businesses can't survive without income and as the furlough scheme comes to a close, dental laboratories are going to have to make drastic reductions to their workforce or simply close down. It is anticipated that 85% of dental laboratories within the UK will be making staff redundant. This could easily equate to well over 1,500 dental technicians being lost to the profession. There were only around 6,000 technicians registered with the GDC, so this loss would be an enormous percentage.

' If they are made redundant, or the business they are employed in closes, these poor students are left in limbo part-way through a degree course'

'The closure of dental laboratories is also having a catastrophic impact on the workforce of tomorrow. Some of the training courses require the technician to be employed - this is how they gain the required practical skills. If they are made redundant, or the business they are employed in closes, these poor students are left in limbo part-way through a degree course unable to complete the necessary course requirements. I am aware of course lecturers being contacted in the early hours of the morning by distraught students whose chosen career has simply been taken away because dental technology hasn't been deemed worthy of support. That cannot continue.'

Steven took a slightly more upbeat view.

'We won't see a future without dental laboratories', he stated. What we will see is an experience very different to the world we are in today, as those labs that survive will have survived due to the amount of private dental practices that they have who have clients that have been open during the pandemic.

'It is therefore a logical assumption that those NHS dental practices looking for dental lab services that didn't communicate and support their dental laboratory during the phased return, will very much have to wait in the queue and expect their costs to increase to provide NHS dental appliances once service return to normal or near normal levels.'

Taking Steve's anticipated figure that 85% of dental laboratories will be forced into making redundancies, the higher the percentage of private work that the laboratory undertakes then the greater the chance that the business may survive, albeit in a reduced form. Steve explained that as most private dentists have managed to work within the restrictions of fallow time and enhanced PPE to undertake AGP procedures, this has meant that the laboratories that supply to these private practices are seeing restorative and prosthetic work return. He estimated that on average June's production was about 20% of June 2019, July up to 45-50% of July 2019 and August up to around 60% of the previous year.

'I have been told of some dentists who have taken it upon themselves to pay a retainer to the laboratories they use regularly to try to ensure they will still be in existence for when AGP restrictions are lifted further', he said. 'One can only admire this working relationship, support and respect. NHS dental laboratories need some truly creative thinking now to prevent a catastrophe.'

Prevention better than cure

Dentistry's often-used mantra, and one that firmly applies to the entire profession and industry should we face a second wave of COVID-19. What will NHS England and the offices of the four Chief Dental Officers do differently to the first time around? What lessons would be learned? I asked what measures Steve, Steven and Peter would like to see implemented to offer labs and their technicians assistance.

'I often hear Sara Hurley quoted as saying she 'wants to put the mouth back into the body', Steve said. 'I feel this should be expanded to say 'put the mouth back into the body, and dental technology back into dentistry'. In fact I would say that the powers that be from commissioners to ministers need to see and understand that dentistry in not just about clinical activity. Without technical support NHS dentists will have a greatly reduced offering to make to NHS patients, and it is apparent to all that not all patients can afford the private option.

'If NHS technology support isn't available from within the UK because the laboratories have closed or are all private, then NHS dentists will have the options of not undertaking band 3 treatments or sending work to overseas laboratories. If they don't undertake band 3 treatments they will certainly appear de-skilled compared to their private counterparts. Sending a F/F to an overseas laboratory for the 4/5 construction stages will add considerable time and cost to their consumables bill. The other option would be to send the work to private dental laboratories, again at increased cost, and again not sustainable. We need to be remembered not as the Cinderella service within dentistry, but as an integral part.'

Steven added: 'Ultimately the time has come for dental laboratories that provide services to NHS dental practices to be paid. They need money to survive - goodwill and supportive comments are nice but unless they have cash in the bank either from the practices that have continued to receive NHS contract payments or from the Government it really doesn't matter nor pay the bills. What matters is that if the money isn't forthcoming, the labs are going to close. Whilst the ultimate loser will be NHS patients, the secondary losers will be NHS dental practices that have to deal with patients that cannot access the treatment they need, particularly as we see the large backlog of patients waiting for dental treatment post lockdown. Financial support is crucial to keeping us afloat.'

' We need to be remembered not as the Cinderella service within dentistry, but as an integral part.'

Peter believes the sector may have shot itself in the foot, and putting the gun down will aid its survival.

'In the absence of a union, labs have traditionally sprung up for many years offering lower and lower prices. It is my belief that we are not regulated with any effect. We all know that a quality crown can only be made at a certain cost. You can reduce this by using inferior products, paying lower wages and spending less time. It should not be left to unscrupulous dentists to fit the cheapest crown they can find. This keeps costs at a perilously low price.

It is my belief that a minimum price should be enforced by those who have the power to do so. It is a model used to some success in Germany - the laboratory is paid a minimum price directly meaning that the surgeon then uses the best lab he can find. If you are below that price you will receive a higher fee if your work is up to standard. If not you either increase your quality or fall by the wayside. Would you go to the NHS for a false hip knowing that the surgeon has sourced the cheapest components he could find, made by a school leaver who hasn't been sufficiently trained and the work has been signed off by the qualified factory owner often without checking it due to time pressures and cost efficiency problems? I doubt it.

'I do not know of any laboratory in 24 years who have ever had somebody come in to check the quality of their work. In no other industry is this acceptable. For those who are in the position of charging more than the minimum price it will be up to them to chase up the excess. Everybody wins, especially the patient as the trade would now begin to govern itself through standards of quality. We would still be lacking the guidance such a critical trade needs but financially we would have a footing.

'As it stands during COVID-19 the money given to surgeons in UDA payments sits with them whilst we go without. There cannot be an argument that a portion of these payments is to pay lab fees. If dentists are not enforced to do the work then they should be enforced to pass this money on. If this had been the case as we entered lockdown, labs would not have needed furlough payments and we could have stimulated the economy buying supplies to stock up for the bleak future. If we have been forgotten, what about our suppliers? There is a domino effect that stretches further than patients in the practice, and we need to make that absolutely clear, otherwise there won't be a service left to support.' â—†