Pulling teeth: why have successive governments failed dentistry?

After a BBC investigation this week reported that nine in 10 NHS dental practices across the UK are not accepting new adult patients for treatment under the health service, Nigel Edwards describes some of the problems in the sector and how they could provide a warning for the unfolding crisis in GP services.

Blog post

Published: 12/08/2022

Long waits for health and care services are now commonplace. There is a huge backlog of treatment to be carried out and many patients face once unthinkable waits in ambulances, A&E departments and hospital corridors.

There is also a crisis unfolding within GP services, with recent surveys showing an alarming collapse in public satisfaction. More and more people are now abandoning their attempts to get GP appointments or avoiding making one altogether.

You do not need to look far to see what could unfold. There is an area of health care that we hear much less about but which provides a chilling premonition of what could be around the corner if we fail to grapple with the crisis affecting GP services – and that area is NHS dentistry.

A crisis that’s been years in the making

A BBC investigation has confirmed the scale of the problem. Only one in 10 NHS dental practices across the UK are accepting new adult patients for treatment. People are left with unpalatable options between the high costs of going private or months of agonising waits. The growing number of people forced to carry out their own fillings or pull their own teeth illustrates the stark failure of NHS dentistry in its current and neglected form.

A near-total dental shutdown during the height of the pandemic has made a bad situation a lot worse. But the foundations of this crisis are years in the making. Three decades of overlooking this vital area of people's health and wellbeing, and a short-term approach left unchecked, have left NHS dentistry in a precarious situation.

Firstly, not enough has been done to train new dentists and then keep them. Furthermore, many new dentists finishing training and entering the profession will now do so working privately. This will not ease pressure on diminished NHS dentistry appointments.

It has been hard for rural and coastal communities to attract and retain dentists. Children in deprived areas, who continue to have markedly poorer oral health, are disproportionally the biggest victims of dental care deserts. Urgent dental care is the most common admission to hospital for children visiting A&E.

Since the 1990s, a broken contract has meant the money behind NHS dentistry is in the wrong place. While the model has seen minor tweaks over time, the way that NHS dentists are paid and reimbursed for the work that they carry out is out of kilter.

The government is now trying to make some changes to the way NHS dentists are paid to resolve the problem that the system often fails to provide the right incentives. The problem is that this centralised one-size-fits-all approach tends to be based to the lowest common denominator and blocks innovation.

This system has actively encouraged dentists into the private sector. There are very few incentives to draw dentists back to the NHS. Working privately, dentists are less burdened by bureaucracy. The payment model is far simpler and more direct.

The Treasury has found itself in a policy dead-end. There will now be a substantial cost to make the kind of radical changes needed to outweigh years of disincentives and ensure a sustainable model for dentistry in the NHS. They are likely to take the view that patients returning from the private sector represent an additional cost for little overall benefit. 

If we are not alert to it, it is entirely feasible we could see a similar divide open within general practice too. There has been a swell in demand for private GPs, with more private practices being set up. As with dentistry, general practice suffers from an all-too-familiar workforce crunch and a squeeze on appointments.

Lessons must be learned quickly

Some dental patients are now being shut out of NHS care completely. The risks that similar could happen in general practice are very real.

For policy-makers, years of avoidance mean NHS dentistry has been a problem hidden from view. That is no longer the case. The harrowing stories of dental disasters are growing by the day. The public and politicians are becoming more aware. Lessons must be learned quickly, and radical change is needed, to escape the deep dental ditch we have dug ourselves into.

*The Nuffield Trust is engaged in a project analysing the policy challenges for NHS dentistry and what changes are needed in the future, which is due to be published this winter.