On 5 July 2023, the NHS will mark 75 years of service. This anniversary comes just after the government announced the new long term workforce plan for the NHS in England, heralded by Rishi Sunak as “one of the most significant things” he will do as Britain’s prime minister. The challenges facing the NHS are immense. Yet criticisms of the plan are coming thick and fast including the lack of detail, unworkable and unachievable aims, not least from the professions who work in the NHS. It does not resolve the immediate crisis of long waiting lists for treatment, the number of doctors, dentists and nurses leaving the NHS and the chronic shortage of staff. To take the example of NHS dentistry, or rather lack of it, let us consider its history and current situation. NHS dentistry has crumbled to naught just like a rotten tooth.
When the NHS was created in 1948, it was the first time ever that everyone was able to access dental care, free at the point of use, at least to begin with. The poor state of the nation’s teeth had been a cause of concern for a long time, highlighted by the number of recruits in the Boer War at the end of the 19th century who had to be admitted to hospital with illnesses related to dental problems. Many were also sent home, deemed unfit to serve.
When the NHS opened its dental service, just over a quarter of practising dentists signed up but more followed, often doing a mixture of private and NHS work. Many dentists had concerns about the practicability of the new service, the bureaucracy involved, and whether the funding model was sustainable.
Dentistry in demand
The public flocked to the new NHS dentists. More than 100 patients a day were seen in some surgeries and the demand for dentures was massive. In the first nine months of its existence, NHS dentists provided over 33 million artificial teeth, a figure that would rise to 65.5 million for the year 1950-1951. Such was the demand that in 1951, the first ever charges in the NHS were for dentures, with charges for other work following soon after but with exemptions for young people, pregnant women, new mothers and those on the lowest incomes.
Dentists are private contractors to the NHS, which means that as businesses they pay the capital and running costs of their surgeries. The contract between the NHS and dentists determines what work is provided for under the NHS, payments to dentists, and charges to patients. The contract is regularly revised. From 1947 dentists were paid for each filling or extraction and for other work. This led to a culture of ‘drill and fill’ because such treatment was incentivised, but preventative work was not. In 1991-92 the dental budget was overspent by £190mn and the amount paid for each item of treatment was reduced by 7%. This encouraged dentists to move away from the NHS into private work, a process which has accelerated.
A dental desert
In 2022, BBC News contacted nearly 7,000 NHS practices – believed to be almost all those offering general treatment to the public. It found that “the lack of NHS appointments has led people to drive hundreds of miles in search of treatment, pull out their own teeth without anaesthesia, resort to making their own improvised dentures and restrict their long-term diets to little more than soup”. The situation was worst in the south-west of England, Yorkshire and the Humber and the North West, where 98% of practices were not accepting new adult NHS patients. Many practices have abandoned waiting lists altogether. Not even children who are entitled to free dental care have been able to be seen.
In Gloucestershire, health chiefs are increasingly concerned at the lack of NHS dentists. In January this year, there was a significant underspend for NHS dental services of around £5mn. The reason given is difficulty in attracting dentists to the county, with a shortage of at least 31 full-time equivalent dentists.
The situation in neighbouring Oxfordshire is no better. A report from Healthwatch Oxfordshire this year included a ‘mystery shopper’ exercise which involved contacting 76 dental practices in Oxfordshire to ask staff “Are you taking on adults or children for NHS dentistry?” Of the 71 who responded, just four were accepting adult NHS patients and 17 were accepting children. Here are some of the comments from patients:
Dental contracts are commissioned, and payments received, in units of dental activity (UDAs). One of the major reasons cited for the unwillingness of dentists to come to the South West is the low UDA, as costs have risen with no proportionate increase in contract value. In recent years there has been a mass exodus to the private sector by dentists. An estimated 3,000 dentists have quit the NHS. Many claim that it is no longer viable to offer NHS treatment.
The British Dental Association calls the current system ‘dysfunctional’ for both patients and dentists. In response to the new NHS plan, it notes that plans to boost dentist numbers represents “an exercise in futility without first tackling the failed, underfunded systems driving practitioners out of the NHS”. It is not enough to train and recruit more dentists who are likely to choose private practice.
Addressing the issues?
Consistently, both the government and the Department of Health and Social Care have said that they are “committed” to addressing the issues of access to dental care as part of the ‘levelling up’ agenda. Daisy Cooper MP raised the access crisis in parliament earlier this year. She pointed out that while a one off, time-limited emergency sum of £5mn was given to fund emergency appointments, it was not very successful, failing to create a significant number of new appointments. In her own constituency, St Albans, not a single extra appointment was generated.
The prime minister, whose immaculate teeth suggest that he is a stranger to NHS dentistry, speaking at the launch of the new NHS plan, said that “one example of reform is in dentistry, where we can have people who are not dentists, where, umm, what are they called, therapists, one of the roles where we expect them to do more dental work” to much derision on Twitter. So there we have it, once again out of touch, the voice of extreme privilege with absolutely no understanding of what it is like to not be able to find a dentist or afford private health care.
Such an appalling situation is happening in England today, in a dental desert. It is the result of years of difficulties between dentists and the NHS, over the system of payments. People are driven to pay for private treatment because they have no alternative; others, who cannot pay, suffer and may even resort to DIY to ease their pain. This is dangerous. During the cost-of-living crisis when the most vulnerable are choosing between heating and eating, taking care of oral health, visiting the dentist regularly for check-ups and treatment is impossible because there are no available NHS dentists.
Was this dental desert really the kind of vision the founders of the NHS had in mind?’
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