Decades of policy neglect have left the future of NHS dental care hanging in the balance, with the result that universal NHS dentistry has most likely “gone for good”, experts warn today. The Nuffield Trust concludes that the service is at its most perilous point in its 75-year history and radical action will be needed to prevent its further decline: either through further means testing, extensive reforms to dental contracts combined with a huge boost in staffing, or a large injection of funds.
In a comprehensive analysis of routine and publicly available data on funding, activity, access and staffing, the report finds that the pandemic, austerity and the cost of living crisis have hit NHS dentistry hard. It presents data showing that nearly six million fewer courses of NHS dental treatment were provided last year than in the pre-pandemic year, funding in 2021/22 was over £500m lower in real terms than in 2014/15, and there are widespread problems in accessing a dentist, which are particularly marked for people from Black and Asian ethnic groups. Children's oral health is a particular concern, with tooth decay the most common reason for a hospital admission for children aged 6-10.
The authors highlight that the pandemic has exacerbated a “drift” to the private sector, with dentists reducing their NHS commitments and carrying out fewer NHS funded treatments. They argue that while there has been no explicit statement about this drift, successive Governments have not yet actively sought to prevent it. Despite this, the NHS Long-Term Workforce Plan relies on tempting over 7,000 dentists into NHS work.
The report sets out a series of short- and long-term actions that any future Government must consider.
In the short-term, the authors argue that action must be taken to shore up the service as it currently exists, through measures like increasing the intervals between routine check-ups to a year; tempting dental therapists into the NHS from the private sector; providing incentives for local commissioners to provide mobile clinics and targeted work in schools and care homes; and investing in preventative care in children and young people.
In the longer-term, two ways forward are set out:
- Improving the current model through a move to a fee-for-service payment model for low-volume, high-cost and complex procedures, combined with a shift to a needs-based approach like general practice through making use of patient lists following initial assessments; keeping more dentists in post through a student loans forgiveness scheme; and investment in public health including checks in schools.
- Adjusting the NHS offer either by expanding it with a huge injection of funding, which the authors note is unrealistic; or scaling back NHS dentistry to a minimum offer for patients. This offer may include universal access to emergency care, pain relief and check-ups with preventative work. Access to more extensive NHS dental services would be protected for older people and children. Coverage would be limited and means tested to ensure the service only targets those with the greatest difficulties accessing care.
The report states that “even with extensive contract reform and the full use of new groups of staff, restoring universal access would cost billions each year”, much of which would pay for care that people are currently getting privately. It calls for an urgent imperative to provide enough access for a basic core service for children, older people and those who cannot afford private care. This would mean “removing some of the rights to NHS services which people currently enjoy in theory – but usually go without in reality”, the authors add.
Nuffield Trust Chief Executive Thea Stein said:
“We need to see immediate action taken to slow the decay of NHS dentistry, but it is increasingly clear that we can no longer muddle through with an endless series of tweaks to the contract.
“Difficult and frankly unpalatable policy choices will need to be made, including how far the NHS aspires to offer a comprehensive and universal service, given that it does not do so at present. If, as seems, that the original model of NHS dentistry is gone for good, then surely the imperative is to provide enough access for a basic core service for those most in need.
“Whichever way we go, I’m afraid that NHS dentistry cannot continue without some kind of evaluation of the offer even if there are some major improvements to the way services are contracted and commissioned.”
Lead author Wilf Williams said:
“This report illustrates that continued neglect of dental policy is not a viable strategy. The result is a widening gulf between the Government’s stated aim that everyone who needs one should be able to access an NHS dentist and the dire reality of elusive and increasingly unaffordable care.
“For the wider health system, the lessons are troubling: without political honesty and a clear strategy, the same long-term slide from aspiration to reality could happen in other areas of primary care too.”