Dental health is deteriorating and millions of people cannot find an NHS dental practice to take them on as a patient. Together with top up charges for NHS dental treatment and the high cost of private care, many are being prevented from accessing services. This is reflected by frequent reports of ‘do it yourself’ dentistry – from fillings and abscess lancing, to tooth extraction. The preventative aspect of dentistry was undermined as a consequence of an NHS dental contract that has driven thousands of dentists to quit. Despite its huge importance to wellbeing and population health, dentistry has been allowed to slip slowly away from the NHS in a process that provides a clear warning of what could happen to services as a whole now ‘public-private’ partnership has become the new government mantra. Only a commitment to provide a tax funded and comprehensive dental service free at the time of use, supportive of professionals and aiming to improve people’s health and reduce inequalities, will reverse this appalling situation.
Dentistry – a founding pillar of the NHS in 1948
Dentistry was one of the founding pillars of the NHS at its inception, and NHS dental services made a significant contribution to the improvement in the nation’s oral health. Many of us born soon after the NHS began remember our parents, aunts and uncles as relatively young adults but having full dentures (as did 75% of the adult population in 1948). As well as a crucial preventive role, dentists also have medical expertise and at check-ups are able to pick up early signs of mouth cancer and type 2 diabetes among other conditions. Most of us can agree that tooth ache is a miserable condition that severely affects quality of life. We don’t want our children or grandchildren to suffer tooth decay and we recognise the importance of dental education, oral hygiene and regular dental health checks. We would also agree that dental services should be available to all, with inability to pay not being a barrier to treatment. Some might draw the line at purely cosmetic interventions but should bear in mind these can bring important psychological benefits. In those limited parts of the country where the public health intervention of correcting fluoride deficiency in drinking water was implemented (covering only about 10% of the population), there was a massive reduction in dental caries. Fluoridation schemes must be extended.
Prior to 1990, virtually all UK dental care was NHS, with only about 500 purely private dentists, mostly working within central London. In the 1980s and early 1990s, a combination of factors effectively pushed the dental profession into the mixed NHS/private economy that we see today. The last 25 years has seen continuous growth in UK’s private dentistry sector and this trend continues to accelerate. Since 2017, more money is spent on private than NHS dentistry.
Holes in services – who suffers?
The impacts of poor oral health disproportionally affect the most vulnerable and socially disadvantaged individuals and groups in society. These differences in oral health across population groups do not occur by chance, nor are they inevitable. Oral diseases are largely preventable and therefore are avoidable. Reducing these oral health inequalities is a matter of social justice and ethical imperative. Despite modelling indicating that oral health improvement programmes for young children are very cost-effective, the Faculty of Dental Surgery at the Royal College of Surgeons is seriously concerned about the state of children’s oral health in England. Almost a third of five-year-olds are suffering from tooth decay and there are significant regional inequalities. Dental caries is the most common reason for 5–9 year olds in England to be in hospital, with over 60,000 children aged 0-19yr admitted to have teeth removed under general anaesthesia in 2015/2016. The estimated cost to the NHS of all tooth extractions in children is £50 million per year; most of these were carried out due to avoidable tooth decay.
A shocking recent report from the Association of Dental Groups documents that
eight million people in England are now waiting for an NHS dentist. Only a third of the population has seen one in the last two years, and the overall number of dentists is the lowest for a decade. Public satisfaction with NHS dental services fell from 60% in 2019 to 33% in 2021. Currently, three million people suffer from oral pain and two million have undertaken a round trip of 40 miles just to find treatment.
‘Toothless’ campaign groups around England are highlighting a dental crisis brought about by successive years of government neglect and underfunding. ‘Toothless in England’ acts as a network hub and demands ‘an NHS dentist for everyone’. Many vulnerable people aren’t registered with a dentist and live with long-term pain and infection. Among the homeless, 70% have dental problems and 15% have tried to extract their own teeth. Dentaid, an organisation that was set up to send refurbished donated dental equipment to poor countries, is now providing mobile dental units to England. These offer emergency treatment for people suffering from dental pain in areas including Kirklees and Dewsbury in West Yorkshire, and Bury St Edmunds in Suffolk.
Problems with access
While the Covid pandemic has had a negative impact on oral health, long before this, finding an NHS dentist had become increasingly difficult. A range of dental treatments were either unavailable on the NHS or required payment of top up charges. Recent newspaper articles have sounded warnings about acute shortages of dentists in counties including Lincolnshire and Norfolk. In Thurrock, Essex, just 26.1% of adults and 30.7% of children have seen a dentist in the past two years. There are stories across the UK of distressed people taking out their own teeth, lancing abscesses and inserting temporary fillings. Nine out of ten NHS dental practices are now closed to routine new patients, and in Somerset, it is almost impossible to register. Hundreds of thousands of people with severe toothache consult their GP only to be referred to A&E or back to dental services in an expensive merry-go-round. Overall, what has happened to dentistry represents a serious reduction in NHS services and significant erosion of the social wage (i.e. amenities provided within a society from public funds).
Charges are a major barrier to care
Charges for treatment were first introduced in the 1950s as a means of reducing demand. The 2011 Adult Dental Health Survey showed that cost influenced choice of treatment for a quarter of patients and almost a fifth stated that they had delayed treatment for the same reason. Healthwatch (which has a statutory duty to find out what communities want from health and social care) says many people regard dental charges as unfair, and has warned decision-makers that NHS dentistry is in desperate need of reform.
The dental contract – crying out for reform
A controversial contract based on the number of units of dental activity achieved by dentists was imposed by the Labour government in 2006. Dental practices were limited in the amount of NHS care they provided, and could be forced to turn away patients for fear of breaching their contract, while facing financial penalties if targets were not hit. Different dentists were also paid widely varying sums for delivering the same treatments. NHS dentists were forced to chase targets for remedial treatment, rather than provide vital preventive care. All this has demoralised the profession and driven many dentists out of the NHS altogether.
The public sector pay cap has hit NHS staff hard across the board, but for dentists it can make the difference between balancing the books or going bust. Unlike general practitioners, general dental practitioners don’t receive any capital investment from central government. Associates and practice owners in England and Wales saw taxable income fall by 35% in real terms over 10 years from 2006. Across the UK, there were 1,038 fewer dentists working in NHS primary care in 2020/21 than there were in 2019/20. Smaller practices are being priced out and taken over by large dental corporations. This government has ensured many dentists cannot see a future in the service. Without urgent reform and adequate funding there is little hope this exodus can be ended, with inevitable further erosion of the amount of NHS care that can be delivered.
What must be done
Nearly two thirds of practices needed to recruit a dental nurse between April-December 2021 and 80% experienced difficulty doing so; 76% of dental associates surveyed said they would not recommend a career in dentistry. Staffing shortages require a workforce plan and an increase in the number of dentists, dental nurses and hygienists being trained; meanwhile, European Union dental qualifications must continue to be recognised (due to cease at the end of 2022). The profession has argued that dentistry should be based on a capitation model with a contract that is patient-focused and preventive. Contract reforms should aim to encourage and support dentists to provide a full range of treatments on the NHS. In the future, dentists could be co-located with General Practitioners in neighbourhood health centres. A robust primary care system where the staff, including dentists, work as public servants for a public service, is the foundation around which NHS dentistry should be structured. This is in keeping with the Astana Declaration of 2018 (Global Conference on Primary Health Care) setting out goals for achieving universal healthcare..
NHS dental treatments need to be free at the point of use; people should be prioritised before shareholder dividend (no more privatisation); hygienists, routine check-ups and preventative treatments (including water fluoridation) must be core NHS functions. As Aneurin Bevan said of the NHS: “not only is it available to the whole population freely, but it is intended . . . to generalise the best health advice and treatment.” The intention was to make the same, high level of service available to all, according to need. This is what we must have for dentistry, with a contract that promotes both quality and equity. Dental services have been allowed to decay by successive governments with reliance on a market for those who can afford to pay and with disastrous consequence for those who cannot. This is a national disgrace and must be reversed.
Dr John Puntis
Co-chair Keep Our NHS Public