NHS dentistry is in intensive care
NHS dentistry has been in ICU for what seems like an eternity. Certainly since the pandemic publicly-funded dental services have been in woefully short supply. There are understandable reasons: Dental services were decimated by Covid. They were rightly seen as posing the highest infection risk and so appointments fell away in their millions. The knock-on effects were enormous, both for oral health and the public purse.
Hence, Government ministers and officials are deserving of sympathy and understanding. Making up the backlog is a hard enough task without a pandemic to contend with. Layer on top the need to fix a series of systemic failings that were restricting access to NHS dental services even before Covid, and you’ve got quite a challenge on your hands.
The travails of our dental system are certainly not news to any member of the public who has tried to find an NHS dentist in the past two to three years, let alone dental professionals like me. Most parts of the country are now deemed ‘dental deserts’ with virtually no access to regular or emergency services for new NHS patients.
Nor are the problems news to MPs, whose post bags are full to brimming with complaints from desperate and angry constituents. For this reason, like many in the dental profession, I have been listening intently to the Health and Social Care’s emergency inquiry into NHS dentistry, which started 6 months ago and is due to report soon.
What I want to know is: After months of rhetoric, has the Government finally grasped the nettle? Does it understand the level of reform (and funding) needed to put the service back on its feet? For me, the jury is out.
The service’s main shortcomings were amply described by dental representatives during the course of the inquiry: The difficulty recruiting and retaining dental clinicians of every type; the shift to Integrated Care Boards which are only just bedding in; and more than anything else, the much-maligned Dental Contract and Unit of Dental Care (UDA) system that disincentivises NHS dental work in preference for more lucrative private, cosmetic work.
The Government insists that reform is underway and things are improving. But are ministers doing enough, and quickly enough? At the committee’s final oral evidence session last month, Parliamentary Under-Secretary of State for Primary Care and Public Health, Neil O’Brien MP, faced a sceptical audience.
Assisted by his Chief Dental Officer, Sara Hurley, O’Brien gave a stout defence of the Government’s record. 20% more NHS patients had seen a dentist in the year to March than the previous year, he claimed, and more bands of activity and a guaranteed minimum value have been added to the UDA. “We are not into small tweaks” he assured the committee.
The problem is that’s precisely the charge being levelled at ministers: “All we’ve seen is small tweaks” the British Dental Association (BDA) had complained in the previous hearing. Professor of Oral Health at Essex University, Nick Barker, identified the root cause not being addressed: a perverse incentive baked into the dental contract that rewards high value repair work over lower reward prevention.
As a result of this, cash-strapped dental practices are disincentivised from NHS work. Unless this is reformed, the exodus of dentists, hygienists and therapists from the profession will continue; and patients, especially poorer ones, will continue to lose access and suffer. In response to these realities, Neil O’Brien’s reform measures sounded like, well, tweaks.
However agile the Government’s protestations might be, the data undermines its case. All through the session, the minister was confronted by committee members with dire reports from their own constituencies. How could he claim to be re-incentivising dentists when they are handing back dental contracts? How can he be improving access when practices are closing and wait-lists extending to 5+ years? And so on.
The minister and his officials do offer plausible and promising-sounding ideas for reform. He dismissed the BDA’s call for a capitation system that would reward dentists on the number of patients treated and talked instead of a ‘blended solution’ (part capitation, part payment by unit of activity) that could both incentivise dentists and provide effective management of complex patient cases.
There are also promising ideas in the field of prevention, which is close to my heart. The Chief Dental Officer highlighted the achievements of the Starting Well and the Dental Check By One programmes which target hard-to-reach families and have increased access to dentistry for children under the age of two by 17%.
In the absence of demonstrable or rapid improvements from the Government on access-widening and system improvement, prevention takes on a heavier workload.
There is no substitute for brushing, flossing, chewing sugar-free gum between brushes, or avoiding sugary drinks and food, as any dentist will tell you. But as a policy prescription, prevention does little for people in need of urgent, remedial care, and there are plenty of those about.
Professor Liz Kay was President of the British Dental Association from 2021-23.
