The unedifying sight of hundreds of people lined up outside the newly opened St Paul’s dental practice in Bristol desperately hoping to secure an NHS dental appointment has shone a spotlight on the ongoing crisis in NHS dentistry.
A reported 12 million people in Britain were unable to access NHS dental care last year alone, with 90 percent of dental practices no longer accepting new NHS adult patients. As a result, forty percent of Britain’s children did not receive their recommended annual check-up.
Slow death of NHS dentistry
In some parts of Britain, as our readers will be well aware, it is now practically impossible to get an NHS dental appointment. This situation is even worse in deprived areas where there is simply not enough availability to match demand. (NHS ‘dental deserts’ persist in rural and deprived communities – LGA analysis, local.gov.uk, 1 October 2022)
Working people are increasingly finding that their only option is to pay for private treatment at great expense. But with an ongoing cost of living crisis, particularly for the poorest in our society this is not an option.
And so, people neglect their oral health (which has been shown to be pivotal for other systems in the body besides the teeth), delaying treatment until it becomes an emergency and – in extreme cases – even performing dentistry on themselves. Not only is there now a plethora of DIY ‘dental kits’ available to buy online, but workers are returning to Dickensian practices such as pulling out their own teeth with pliers, and even drilling into their own mouths to try to cure their toothache.
The clear direction of travel, as with every other aspect of healthcare in Britain, is into a two-tier system. Indeed, this system seems already well established in many parts of the country, with those who are able to pay for treatment being seen at private dental practices and those who cannot simply going without.
Underfunded and unsustainable
The Department of Health and Social Care report and annual accounts for 2022/23 show that £2.899bn was spent on NHS dentistry.
According to the British Dental Association, this translates into a huge budgetary cut, with funding having fallen by more than one third in real terms since 2010. With no attempt having been made to keep pace with rampant inflation and population growth, this amounts to a devastating cut of £1bn.
In fact, the dental budget is currently underspent and being used to plug holes elsewhere in the NHS. This underspend does not reflect a lack of demand for NHS dental services but rather the fact that dental practices are no longer providing the service that is needed.
All dentists in Britain are private contractors. The NHS relies on dentists signing up to NHS contracts which subsidise the cost of treatment. Today, however, a rapidly dwindling number of dentists are providing this service for the simple reason that the present contract is underfunded and unsustainable.
Before 2006, dentists were paid for each piece of work they did for the NHS. The current dental contract, which was brought in by a Labour government, is structured in ‘blocks’ that turn out to be totally uneconomical. Contracted dentists are committed to performing a certain number of “units of dental activity” for a negotiated fee. But under this system, simple and complex treatments earn dentists the same amount of money, with no consideration for the time each treatment will take. Meaning, of course, that many treatments have to be delivered at a financial loss.
Compounding the situation, if dentists do not complete 96 percent of their contract, the value of any activity not delivered is recovered. And to further complicate matters, the total amount of NHS dentistry any dentist can deliver is capped in the contract. The net result is that more and more dentists are finding that simple maths has forced them to reduce the amount of NHS work they perform and to opt instead to enrol private patients onto their books.
Many of our readers will have watched this process at their own practices. First private patients were introduced side by side with NHS patients. Then the books were closed to new NHS patients. Then all patients were asked to either go private or find another dentist. At each stage of the process, the dentists have been at pains to tell their patients that these changes are beyond their control. They simply cannot afford to keep delivering NHS care to their communities.
The government has responded to the crisis by pledging sops in the form of £200m in extra funding. The plan offers:
- one-off £20,000 payments for dentists working in under-served areas;
- a new £15 patient premium for dentists seeing patients who haven’t had a check-up in two years;
- a £50 premium if the patient needs significant work doing; and
- a new minimum unit of dental activity (UDA) value of £28, up from £25.33.
This ‘plan’ is being heavily criticised, however, as the incentives are far too low to entice dentists back into taking on new NHS patients.
According to the British Dental Association (BDA): “The £200m pledged by the government is less than half of the underspends in the budget expected this year, leaving no new money for the promised new patient premium.” (NHS dentistry ‘recovery plan’ not worthy of the title, dentists say by Aletha Adu and Tobi Thomas, The Guardian, 7 February 2024)
The number of NHS dentists is down by more than 500 to 24,151 since the pandemic. Compounding the problem is that as more dentists ditch or vastly reduce their NHS work, those who remain are being overwhelmed.
Health inequality
Poverty is a major contributing factor in the prevalence of poor health and in difficulty accessing services at the early stages of illness. The challenges of eating healthily while living in poverty also contribute to a higher incidence of tooth decay among people in deprived areas.
A recent YouGov Poll in England found that nearly a quarter of respondents (23 percent) reported delaying or going without NHS dental treatment for reasons of cost.
NHS dentistry is not free for most people, and the charges (varying from £25.80 to £306.80) are a real barrier to those in poverty. This is demonstrated by the 47 percent fall in routine dental check-ups, and by the 14 percent rise in emergency treatments between 2018/19 and 2021/22.
As the situation stands, large numbers of workers are unlikely to be able to access an NHS appointment at all, and many of those who might be able to get an appointment will struggle to afford the fee. The grim consequence of this is reflected in the surge in ‘DIY dentistry’.
A 2023 YouGov poll found that 10 percent of respondents admitted to attempting some form of DIY dentistry. More than half (56 percent) of these had carried out such a procedure in the last year, and one in five said they had done so because they could not find an NHS dentist.
The result of the lack of access to routine care is reflected in the substantially higher prevalence of emergency hospital admission for dental causes amongst those living in deprived areas.
Young people, especially the poorest, are also suffering, despite nominally receiving ‘free’ NHS dentistry. The decay-related tooth extraction rate for children and young people living in the most deprived communities is nearly three and a half times that of those living in the most affluent communities. (Hospital tooth extractions in 0 to 19 year olds 2022, gov.uk, 23 February 2023)
Indeed, preventable tooth decay remains the most common reason for hospital admission in children between the ages of six and ten.
It’s not a bug it’s a feature – the normalisation of crisis
Commentaries in the media and talking points from healthcare think tanks all point to the conclusion that there is no future for the NHS without reform, reform and more reform – always (naturally) in the direction of further privatisation and a further decline in public healthcare provision.
The Nuffield Trust, a leading healthcare think tank (and no doubt entirely separate from the Nuffield Health chain of private clinics and hospitals), has argued that the crisis in NHS dentistry can only be resolved by reducing the numbers of people who are entitled to NHS dentistry to the very poorest – an outcome that is already taking place in practice. (NHS dentistry “gone for good” without radical action, think tank warns, 19 December 2023)
Our position, on the contrary, is that the current state of the health service is the result of deliberate vandalism. At the behest of the monopoly capitalist class, British governments have purposely set out to degrade the NHS by burdening it with disorganisation, massive bureaucracy, private contracts and sell-offs. They have made it unworkable and removed the ability of the NHS to provide services, normalising a state of dissatisfaction amongst staff and patients alike.
In order to justify the eventual removal of state-funded healthcare altogether, these mismanagers have created a system in which ‘everyone agrees’ that the NHS is in crisis and ‘something must be done’. As it currently stands, less than one in four people is satisfied with the NHS – the lowest level since records began.
This is exactly the same model that was used during the process of privatisation of our trains, post office and water companies.
Meanwhile, the most notable (and predictable) effect of the engineered crisis in the NHS is the speed at which the private healthcare market is growing, as all those frustrated and desperate Britons who have the ability to pay go private to get the treatment they need in a timely way.
Those who do not have the cash to go private are left languishing on waiting lists, many of them unable to work or enjoy their lives, impotently hoping their names will come up before their condition kills them. For all too many, this hope is unfulfilled.
According to the Economist: “More patients are paying for their medical care directly. Older people with savings are increasingly willing to stump up to avoid long waiting times. The biggest source of revenue last year at Spire, the largest private hospital group in Britain by income, came from private medical insurance, which grew by 16 percent to £307m ($390m) in the first half of 2023 compared with the same period in 2022.
“Corporate health insurance is viewed as an important perk by employees. The NHS is not seen as the only option by Gen Z, the generation that makes most use of private healthcare: four in ten 18- to 24-year olds have used the private sector for things such as appointments with doctors, scans and diagnostics.”
All of which underlines the obvious point that what is being established is a two-tier system of healthcare in which those who can afford to will pay for treatment and the poorest in our society will simply have to go without.
Solution
The solution to our healthcare crisis is not an increase in private provision but its abolition, and its replacement with properly funded health and social care services for all.
This means removing all elements of privatisation from the NHS (including pharmaceuticals) so that funding can be directed away from the corporate bloodsuckers and back to where it is needed: decent pay for NHS staff and proper provision of frontline services.
If this demand cannot be met by a bourgeois government within the present economic system, then it must be achieved via a revolutionary change of society and the institution of a socialist system of wealth creation and distribution – a system in which all economic life is planned to meet the needs of the people.
