Fixing NHS Dentistry

Arjun Sanghera assesses the crisis facing NHS dentistry, examining key causes such as the NHS dental contract, and how these can be overcome.

Dental care became free at the point of use for the first time ever with the advent of the NHS in 1948. Three years later, fees for some NHS dental charges were introduced, the first charges of any kind for NHS treatment. Since then, NHS dentistry has had a somewhat tumultuous history. It is certainly not an understatement to describe the current service as in a state of crisis, slowly drifting towards its demise. Despite the bleak picture, the good news is that there are a range of solutions to the crisis. There is a golden opportunity to fix NHS dentistry and develop a service that delivers for all.

The difficulties that people have faced in accessing NHS dental care has been well documented. A comprehensive BBC investigation found that 90% of dental practices across the UK are not accepting new adult patients for NHS treatment. In a third of UK council areas, no dentists were taking on adult NHS patients. These figures are shocking and reveal how the access crisis is truly national, affecting every nook and cranny of the UK. Such a dismal situation has led people to take drastic measures, including attempting DIY dentistry. In a recent parliamentary debate, Cat Smith, the Labour MP for Lancaster and Fleetwood, recalled the moment a constituent put some of his own teeth he had removed on a table in front of her. This horrifying story exemplifies the Dickensian conditions being faced by many in 21st century Britain.

So what are the main issues behind this crisis? It turns out there are quite a few of them. First and foremost, the current NHS dental contract is the big culprit. As Labour’s Shadow Health Secretary, Wes Streeting, has acknowledged, this contract was regrettably introduced by the last Labour government in 2006. However, the then government very quickly acknowledged that it wasn’t good enough and committed to reforming it in their 2010 manifesto. The Conservatives also committed to reform in 2010 and again in 2017, yet 12 years later this out of date contract is still in place. The contract itself provides disproportionate funding which has put pressure and strain on dental practices. Dentists are paid the same whether they do 3 fillings or 20. Furthermore, dentists are not provided with additional funding for doing extra work beyond their contracted targets. This creates perverse incentives. Finally, dentists can have their funding taken back in large chunks by the government with very limited consideration of extenuating circumstances, such as the impact of Covid restrictions.

The flaws in the current dental contract are coupled with funding issues. The detrimental impact of austerity on the NHS has become painfully evident, weakening the health service’s ability to provide timely medical care. The cuts imposed on NHS dental services were some of the most drastic: funding fell by 9% in real terms between 2010 and 2020. The British Dental Association (BDA) has estimated that it would take an extra £880 million a year to simply return to 2010 resource levels. It is quite clear then that a decade of funding cuts has had a lasting impact on the provision of dentistry in the UK. 

It would of course be remiss not to mention the considerable impact of the Covid pandemic on the dental industry. Similarly to other areas of the NHS, routine dental services had to be suspended at the onset of the pandemic. Inevitably, there were millions of patients who were unable to access appointments; nearly 40 million fewer courses of treatment were delivered. The pandemic has turbocharged the problems dental practices were facing pre-2020, particularly with vast backlogs now being faced by dentists.

What has been done to address this extraordinary crisis? The answer is very little. It is an unfortunate reality that successive governments have failed to properly act, despite making multiple electoral pledges to do so. In January, the government announced that £50 million would be injected into dental services to secure up to ‘350,000’ additional dental appointments. However, the way in which this £50 million fund was provided made it time limited and very difficult for dentists to access. As a result, only 28% of the £50 million was spent. In July, some small contractual changes were announced, including one that will only benefit around 3% of dental practices. Such changes amount to mere tinkering around the edges of a deeply flawed contract.

It is clear that NHS dentistry is not working for dentists and patients alike. So what can be done to fix the situation? The short answer is lots, but let’s focus on three main areas. The first big step is tackling contract reform. This would entail fundamental and deep reform of the contract by scrapping the current system. A few minor changes here and there won’t rectify the problem. There are other models, such as a ‘capitation’ based model as proposed by the BDA, which would fairly fund dentists on the basis of the number of patients they treat. In addition to contract reform, it is clear that NHS dentistry requires greater funding so that dentists have the necessary resources available to treat those in need. 

Finally, oral health needs a more central role within wider health strategies. For far too long, oral health has been considered an afterthought. This is having a detrimental impact on many, particularly young children. Before the pandemic, teeth extractions were the leading cause for hospital admission among 5 to 9 year olds. A useful proposal would be supervised toothbrushing in primary schools, which would be undertaken in coordination with parents and local dental authorities. This type of educational initiative is already practised in other countries, such as Sweden and Japan. It is also a great way to support a prevention strategy rather than one oriented around treatment. This is just one practical example of how to give oral hygiene a more prominent role within wider healthcare strategies. By elevating the importance of oral health and placing an emphasis on dental education at a young age, patients can be empowered in caring for a set of teeth that will last them their whole lives.

It is clear that access issues with NHS dentistry are severe and constitute one of the worst health crises that the UK is currently facing. Unless there is substantial reform, the problems will only worsen as dentists struggle to work through the pandemic backlogs. The good news is that there are a range of measures that can be taken to help make affordable and high quality NHS dental care accessible to all. As explained above, the current dental contract must be replaced. Secondly, NHS dentistry quite simply requires higher funding levels to allow it to be the top service it should be. Finally, we need to incorporate oral hygiene as a more important part of our healthcare strategies to empower both patients and dental professionals. Just like tooth decay, the sooner we address these issues, the better.

Arjun Sanghera is a Politics and IR student with interests in foreign affairs and healthcare and environmental policies. He tweets at @ArjSanghera.

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