Down in the Mouth

This article of mine, on the critical state of NHS dentistry in Britain, appears in the current edition of The New Statesman.


"We are going back to the dark ages of dentistry," says Richard Daniels, chief executive of the Dental Laboratories Association. Eighteen months on from the introduction of new NHS contracts, discontent within the dental profession is growing. The DLA says the current contract "forces dentists to make prescription decisions based on financial resources rather than clinical need" and claims there has been a 57 per cent reduction in "Band 3 treatments" such as crowns and dentures.
The British Dental Association shares DLA's concern. "The contracts are not going to provide quality oral health for the patients. We've got wonderful techniques and equipment now but we're not being encouraged to use them," says Lester Ellman, chairman of the BDA General Dental Practice Committee.

The new contracts were intended to solve an intractable problem. Before their introduction, there were more than 400 fee tariffs for NHS work, which left patients bewildered. Now there are just three and the contracts focus on providing cheap and affordable basic care, not on expensive, often unnecessary, treatments.
The old "payment by procedure" system, whereby dentists were paid for each item of work they undertook, was certainly open to abuse. An Audit Commission reported in 2002 that it gave a "perverse incentive" for dentists to carry out unnecessary work.

The NHS contracts are the latest attempt by the government to reverse years of decline in state provision - a decline triggered by the Conservative government's ill-thought out reforms of the early 1990s. These linked dentists' pay to the number of patients registered. When more patients than anticipated registered, the government reacted by cutting fees rather than increasing funding.
The result was a huge exodus of dentists to the private sector. In 1990, only 5 per cent of dentists' income came from private work; now it is more than 50 per cent.
The private dental market, virtually non-existent 20 years ago, is now worth more than £2.4bn.
Even a salary of £80,000 a year, guaranteed under the new contract, was not enough to persuade a further 2,000 dentists from leaving the NHS. Meanwhile, private chains and insurance companies are rubbing their hands in glee. In the year to April 2007, Denplan announced a 25 per cent increase in take-up of its schemes. In the same period, Oasis, Britain's largest dental chain, reported a doubling of profits.
But for the millions unable to pay to go private, the situation goes from bad to worse. Sixteen months on from the government reforms, an estimated 1.4 million additional people are thought to be without an NHS dentist.
In the sixth richest country in the world, thousands are forced to fly abroad in order to receive dental care. This year it is estimated that more than 25,000 Britons will travel to Hungary for dental treatment. An even more alarming trend is the number of children deprived of proper dental care.
Up and down the country dentists are telling parents they will no longer provide NHS treatment for their children. The long-term consequences for oral health is calamitous.

For most of the postwar period, access to an NHS dentist, paid for out of general taxation, was taken for granted. The idea that by the first decade of the 21st century, 60 per cent of Britons would not have access to an NHS dentist - and that one in five would be deterred on grounds of cost from going to the dentist - would have seemed unthinkable to a member of the public in the 1960s.

In 1999 Tony Blair promised that within two years everyone would once again have access to an NHS dentist. But the experience of the last decade shows that a flourishing private sector is incompatible with the notion of a state-financed system. We have enough dentists: the number has risen to more than 21,000 compared with 12,360 in 1977 and 15,400 in 1992. But so long as dentists can earn up to four-times more by going private, NHS provision will be threatened.