After decades of neglect, could this year finally mark a turning point for NHS dentistry? A dental recovery plan is expected imminently, the government are reportedly considering a Budget boost for rural dentistry, the Labour party has made dentistry a repeated feature of its election health platform, and newspaper front pages and campaigns have recently been devoted to the issue.
Not before time. As an HSJ reporter recently explained, “it is hard to find an example of a public service that is so obviously broken”. There are horrifying stories of people extracting their teeth with pliers, people waiting several years to see an NHS dentist and whole areas of the country where getting an NHS dentist is as elusive as finding the proverbial hen’s teeth (excuse the pun).
So what could 2024 have in store for this neglected public service?
1. The dental recovery plan: will promised contract changes be enough?
The 2006 dental contract is almost universally despised. Dentists say its structure around paying for set amounts of dental activity makes carrying out NHS work financially unviable, reducing it to an unrewarding set of transactions rather than a fulfilling career.
Policy-makers point out it disincentivises work on prevention, and the public remain largely unaware that even if they’re lucky enough to have an NHS dentist, their dentist has no contractual list of NHS patients, hence no obligation to continue to treat them beyond completing a course of treatment once started.
The government have hinted that further changes to the contract may come in their long-awaited dental recovery plan to tackle some of these issues, but remain firmly opposed to wholesale contract reform. The Health Select Committee has called for a shift – which we backed in our recent report – to a list-based payment model where dentists are reimbursed for caring for a particular set of people, with payments weighted according to need. The Labour party has indicated its support for reform to the contract.
But will the government’s dental recovery plan contain enough to allay calls for wholesale change or is something more fundamental needed? We think the latter, but will examine the dental recovery plan with interest.
2. NHS planning guidance: will the ringfence survive?
A feature of the broken dental contract is that, despite significant unmet need for NHS dentistry, the NHS has consistently failed to spend its full budget on dentistry every year apart from one year during the pandemic. Underspends happen because money is clawed back from practices if activity is not delivered or there are no contractors to deliver it.
As part of their guidance to integrated care boards, last year NHS England applied a ringfence to dental allocations, meaning that no ICB could divert funds away from NHS dentistry: the idea being that underspends should be ploughed back into wider dental services. The government has said this should be made permanent. But barely had the ink dried on this guidance that this ringfence was breached, with ICBs told in November they could retain any underspend to balance the books of wider NHS services in the face of a growing black hole.
The HSJ has kept a close eye on this, identifying a dozen ICB areas where underspends have been used for wider NHS services. Some clarity on this issue will come when the delayed NHS planning guidance is published. But one thing is clear: when you combine a service with such a dysfunctional contracting regime with a wider NHS in dire need of financial support, the result is potentially disastrous. And with the latest figures detailing a further real-terms cut in dental spending last year, it’s little wonder that the service is in dire straits.
3. Election pledges to restore access: watch the fine print
In our recent report, we concluded that even with contract reform and a huge boost to the workforce, universal access to NHS dentistry has likely gone for good. We are only commissioning enough to cover half the population, and restoring access for those that pay privately is probably unaffordable – an inconvenient truth for politicians hoping to diffuse the issue with £100 million or so extra.
We say it might be time to stringently means test NHS dentistry: the most in need get everything up to fillings and extractions fully covered; those who can – and often already do – go private receive accessible NHS check-ups but pay full price for treatment. This is controversial to say the least. It erodes one of the NHS’s fundamental principles and opens up concerns about a “slippery slope”. But in reality, we have a terribly unfair three-tier system already: those who can afford to go private; those lucky enough to have an NHS dentist; and everyone else.
Though they might never admit it, it could be that both main political parties have reached similar conclusions. They both talk of their aspiration that “NHS dentistry should be accessible and available for all those who need it” (Conservatives) and “in the long term, everyone who needs NHS dentistry can access it” (Labour). The word “need” is doing a lot of work in these statements. We know that under our three-tier system at the moment, it’s often the most needy who are going without care. NHS dentists are most elusive in poor, remote and rural communities, and the poor are least able to travel for care.
So as the manifestos emerge, watch closely on this issue. A system with further means testing would be one way to achieve the aspiration of access for those who need it most. But will they be brave enough to say it?
A policy area whose time has come?
There are a whole array of other issues in NHS dentistry worthy of entire blogs themselves – from the paucity of data on the NHS dental workforce, to the gradual drift to the private sector. But 2024 looks set to be an important year for dental policy, and the Nuffield Trust will be keeping a close eye on how things develop.
Merry L (2024) “What could 2024 mean for NHS dentistry?”, Nuffield Trust blog