Lying Through Their Teeth

What the government has done to NHS Dentistry is what it wants to do to the rest of our public services.

By George Monbiot, published in the Guardian 2nd March 2023

Every child in the UK is entitled to free treatment by a nonexistent dentist. Some people on benefits, pregnant women and those who have recently given birth also have free and full access to an imaginary service. Your rights are guaranteed, up to the point at which you seek to exercise them.

For a government that wants to destroy public services, NHS dentistry provides a useful template. Rather than inciting public fury by announcing a change of policy, you stoutly proclaim your undying commitment to the service while starving it of funds until it collapses. Then people grumble and unwisely gnash their teeth, but they don’t rise up. The state of our mouths reflects the state of the nation.

A few months ago we moved house, after which we discovered that we are living in one of the UK’s many dental deserts: regions where there are no dentists accepting children as new NHS patients. A BBC survey last year found that a tenth of local authority areas do not contain a single dental practice that is prepared to do so. Overall, 80% of practices in the UK are no longer taking on new child NHS patients, and about 90% are refusing new adult patients.

Even this does not capture the full extent of the collapse: some of the remaining practices sustain the pretence of a waiting list, but the lists are often so long that it would be more honest to admit they are no longer offering the service. By the time your child is able to register, they may be too old to qualify.

We have responded as most parents do in these circumstances: frantically seeking an alternative. As we are already struggling with the deficiencies of education and other public services that have been starved of funds, even the thought of joining another campaign is exhausting. I have sent a complaint via the NHS page but otherwise, like almost everyone else, we have tried to solve our own problem. Which is just what the government wants.

There’s no mystery about why the service is vanishing: if dentists treat patients on the NHS, they lose money, because the state funding package does not cover their costs. Since 2006, dentists have worked for the NHS under a contract so ridiculous that it seems designed to fail. They are paid, in classic New Labour-speak, according to “units of dental activity” (UDA), which bear no relation to the costs of treatment. For instance, until last year dentists received the same remuneration from the NHS for a patient who required 10 fillings as for a patient who required one. Treating a patient earned you three points, regardless of the length and expense of the procedure. Every practice has to meet an annual UDA target. There is no incentive to practise preventive dentistry, and every incentive to exclude the patients with the greatest needs.

Nor is there any encouragement for dentists to seek further training and qualifications: they are paid at the UDA rate, regardless of skills and experience. So, if you work for the NHS, you can kiss goodbye to career progression.

These disincentives are exacerbated by vicious cuts. The NHS as a whole has fallen behind because, while modern health systems require real-terms funding improvements of about 4% a year to keep pace with an ageing population and technological change, it receives 1.2% in real terms. But funding for NHS dental services has been cut in real terms by 4% a year. Dental inflation, driven by the rising costs of lab bills, energy, wages and materials, is about 11% a year. Dentists working for the NHS cannot stay in business unless they use income from private practice to subsidise their public practice.

As parliament’s health and social committee noted in 2008: “it is extraordinary that the [health] department did not pilot or test the UDA payment system before it was introduced.” But since then, successive governments have only tinkered with a system that was broken before it launched. Last year, the government introduced what it called a “reformed” contract in England, to permit “better access to NHS dental services”. While there was a slight easing of the UDA formula, as the British Dental Association predicted it did nothing to stop the slide, as dentists still lose money by treating NHS patients.

In January this year, Rishi Sunak told parliament that “there are now more NHS dentists across the UK with more funding, making sure people can get the treatment they need”. In reality, the number of NHS dentists is lower than it was before the pandemic, there is no new funding and millions remain without the treatment they need.

Thanks to an entirely unsurprising recruitment crisis, many dental practices have been unable to fulfil their NHS contracts. If they deliver fewer than 96% of the UDAs for which they are contracted, they are effectively fined by the government. It looks as if they will take a record hit on 1 April, when the financial year ends, being forced to pay back as much as £400m from a total English budget of £3bn. This is likely to terminate NHS dentistry in many of the remaining practices.

So, mission accomplished. To an even greater extent than in other public services, the government has created a hostile environment for practitioners. Dentists continue to offer NHS services because they feel a moral compulsion to do so, despite the money they lose and the stress and overwork inflicted by the stupid contract. But there is only so much they can take. Though a few services may stagger on for a while, we are witnessing the end of NHS dentistry.

The result, in one of the richest nations on Earth, is that people are extracting their own teeth, making their own fillings, improvising dentures and sticking them to their gums with superglue, and overdosing on painkillers.

The policies that brought us to this point are so perverse that they can only be deliberate. Those who can afford to pay for treatment will do so; those who cannot face pain and misery. It seems extraordinary that any government would pursue this outcome, but the spirit of this government is extraordinary cruelty. What we see happening in dentistry is what it wishes on the rest of the NHS and the rest of our public services.

While ministers have their teeth fixed and whitened, the better to beguile us, across the nation they claim to govern, the rot is spreading.