Pulling teeth: can NHS dentistry be fixed?

Posted by Nick Carter at Fri, 05/03/2010 - 12:54pm in Health Mandate commentary

As the end of the 2005-2010 Parliament approaches, and the political classes gear themselves up for the general election, each of the political parties' health teams will be looking to prove that they have the big ideas to take the NHS forward in a period of tight public finance but escalating public expectation.

In this short series of opinion pieces, Health Mandate's team of expert health policy consultants look at some of the big issues that will shape the political and the NHS landscape in the next parliament. Today's piece sees our specialists examine dentistry.

Pulling teeth: can NHS dentistry be fixed?

In 1999, Tony Blair told us that everyone would have access to an NHS dentist within two years. It was an easy promise to make, but the problem of access to NHS dentistry has seemed curiously intractable - curious in particular given the context of the huge increases in the NHS budget overall which have increased the NHS workforce substantially.

Thankfully. Election 2010 will give us an opportunity to hear all parties tell us their version of why the issue has been difficult in the past, but will not be so in the future. And we will hear about it: the media fascination with all things dentistry virtually guarantees coverage of any policy announcements, interesting stats - or even photo (remember those people queuing around the corner to register with a new dentist?).

Charities are also all too willing to pepper the debate with vivid individual examples of service failure. A 2008 Help the Aged policy paper on the oral health of older people noted that one pensioner pulled out two of her own teeth because she could not find an NHS dentist in her local area.

Throw into the mix the fact that this is an area on which the Government is weak - people still have difficulties finding an NHS dentist, despite multiple efforts to make the system work - and dentistry is an issue on which all political parties have good cause to enter the fray.

The issue for policy makers

There are many issues for policymakers to tackle in relation to NHS dentistry: the fact that preventative care tends to be deprioritised, that domiciliary dentistry services (for older and vulnerable people) are a rarity, that rural areas tend to have fewer dentists per head of population - and that many Strategic Health Authority areas do not call on their water companies to fluoridate their water supply.

But all of these issues pale into comparison in politicians' minds because there is one issue which really, really, exercises them: people being unable to register with an NHS dentist.

What politicians fear most during an election campaign are voters - and particularly being challenged by a voter either on the doorstep or on Question Time by an individual who can't get access to an NHS dentist, and demanding to know what are you going to do about it? This is the question that all politicians know they will face at some point over the next two months - and they need an answer.

The causes of poor access to NHS dentistry are deep-rooted, and years old. The problem stems from a dental contract introduced by the last Conservative Government in 1990, underpinned by fair terms and sound aims. But it was expensive, and it was introduced at about the same time that German reunification straitjacketed Britain into one of her worst recessions in post-war history.

After the 1992 General Election, the Government was faced with public finances in such a dire state and with a need to make such deep cuts in public spending (sound familiar?), that they thrashed around for options for saving money and ultimately settled on dentistry. And they imposed a unilateral cut in the fees dentists could earn under the 1990 contract of 7%.

The '92 fee cut made the opportunity cost for a dentist working in the NHS rather than in the private sector 7% higher overnight, and caused a mass stampede out of the NHS by dentists seeking shelter from the recession (and higher earnings) in private practice.

The stampede shot to pieces the Government's assumptions about how many dentists the NHS needed to train for the future. So in a rather unhappy coincidence, the Government closed the UCL and Edinburgh dental schools at precisely the point when we needed to increase, rather than reduce, the number of dentists in training

And this is the crux of the issue: we are [now] training the right number of dentists for a developed country of our size (about 600 new dentists a year) - but we are training them up to do relatively more private work and relatively less NHS work.

So the problems with NHS dentistry had emerged long before Tony Blair stood up at the Labour Party Conference and announced that everyone would have access to an NHS dentist. But expect to hear this from the opposition - again, and again, and again - in Election 2010.

What can we do?

Short of the mass renationalisation of private sector dentistry, or (conversely) the wholesale privatisation of NHS dentistry - neither of which will happen - all solutions available are expensive. What is needed is, essentially, to make NHS practice as rewarding as private practice.

But this won't happen either. The public finances are in no fit state to offer extravagant pay rises to the public sector, and in any case the electorate will flinch at the prospect of paying even more taxpayers' money to healthcare professionals who they believe are already well remunerated.

So, without money to splash, we need some element of coercion to keep our dentists working predominantly for the NHS. But people don't like being coerced, so they need to be persuaded. And even without money to spend, this is not as hard as people think: because access problems are easy to pinpoint, they are relatively easy to solve. This access issue is about a lack of dentists working in the NHS, so one policy solution, for example, might be to charge higher tuition fees for undergraduate dental course - unless students commit to working exclusively for the NHS for, say, 10 years after registration.

What next?

It is a shame that, when dentistry flares up as an election issue, the story will only be about access - because there are so many other important issues in dentistry which are more deserving of consideration. Detailed, innovative policy work in this area has stalled over the last 20 years - and the appetite amongst politicians to take this work forward has been lost - because the debate has focused disproportionately elsewhere.

The issue of 'improving the oral health of the population' - just like 'improving the physical health of the population' - is a classic public health policy area, and oral health care is an issue crying out for a public education campaign. We are taught as primary school children how to brush our teeth properly, and we are taught about the dangers of consuming too much sugar. We are all taught once and then we all promptly forget.

As a result, very few people are able to brush their teeth properly (and fewer still regularly enough) and very many people consume too much sugar. But there are obvious and immense political risks in taking the step of launching a campaign, with taxpayers' money, which 'tells us how to brush our teeth'.  Although it is what is needed, it is a front page headline - and not a good one.

It is particularly unfortunate because 'technologies' - it may seem rather bizarre to call them that, but that is what they are - such as better toothpaste and better mouthwash are continually being developed, but they are useless if we do not use them effectively.

And in addition to a public health campaign, there is a very important debate to be had in Parliament about whether the entire country should fluoridate its water supply.

This is classic free vote territory - fluoridating water constitutes mass medication after all, and there are important arguments to the contrary (such as the risk of fluorosis) - but it is a vote which needs to happen in the next Parliament because current policy is confused and unworkable. At the moment, it is the responsibility of a Strategic Health Authority (SHAs) to decide whether to fluoridate its region's water supply. This policy is confused because it is not entirely clear why SHAs have this responsibility (the reason appears to be because they have 'health' in their names, but beyond this they don't really have any other major public health functions). It is also unworkable because the pipes which carry our water deep below our feet predate the creation of SHAs and, as a result, don't respect their boundaries. Only one in ten of us, therefore, receive fluoridated water.

Dentistry is a frustrating policy area, because whilst the debate focuses on access - which is the easiest thing to solve - more important debates are not given the airtime they deserve. And as a result, there have been dozens of reports which seek to solve the 'access' issue over the years - most recently last year's Steele review - but they (and politicians) fail to give sufficient recognition to the important policy work which does need to be done.

Ultimately, policy on dental care and oral health over the last 20 years has not been unlike a trip to the dentist. It has been all too easy to leave things as they are, and disregard a problem entirely - but ultimately the problem will not go away, and the treatment required will end up being very painful and very expensive.

Tagged with: NHS