Popular Myths: Unicorns, the Tooth Fairy, and NHS Dentistry For All.

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Published: Monday, 24 June 2024 07:48
Written by Peter Ingle
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Popular Myths: Unicorns, the Tooth Fairy, and NHS Dentistry For All.

Politicians love catchy slogans and soundbites. It may be too early to know what expressions the current election will bring to a wider audience, though readers may remember “education, education, education” from 1997, and smile wistfully when they recollect the promise of “strong and stable” leadership, in 2017.

The 2017 campaign also gave us ‘the magic money tree.’ Avoiding any technicalities about the Bank of England or monetary policy, the money tree concept was understood by voters. If there was such a tree, by all accounts, and possibly stretching the analogy, not only is it deciduous, but we are stuck in a prolonged winter.

This July the incoming government will be facing a grim financial situation. The UK has high borrowings with accompanying large interest payments. There are demands on public services and funds coming from all directions. It may be a benefit of having a large lead in the polls, but there have been many comments about how modest Labour’s spending pledges are.

Even so, promises have been made. They are, of course always “fully costed,” but experience suggests that like budgets for building work, somehow those costings will turn out to be somewhat optimistic. The six pledges announced by Keir Starmer may have underwhelmed some voters, but all come with significant costs. Setting up a publicly owned clean energy company will not come cheap, and will likely make the promised 6,500 new teachers, another of his pledges, look like small change.

It was the now almost forgotten Amber Rudd, standing in for Theresa May during a televised debate, who used the magic money tree line in 2017. Rachel Reeves, the Shadow Chancellor, who has spoken of her commitment to “balance the books” whether at home or in No 11, will be acutely aware of another of Amber Rudd’s comments in 2017: “It’s very easy to think about how you spend money, It’s much harder to think about how you raise money.”  As Chancellor she will be bombarded with demands from Ministers for more cash.

Labour may not appear to have too many worries during this election but are very much on the defensive when it comes to accusations that they will raise taxes. Here too, promises have been made. No increase in income tax, NI or VAT for five years. There are only so many times the money delivered by removing non-dom status can be spent. Other imaginative taxes might suggest themselves, but as the new Chancellor looks at a list of possibilities she will see that many have already been spotted and taxed.

What has this got to do with dentistry let alone GDP’s? Because so many political figures, as well as the profession, at all levels, remain determined to ignore the evidence all around them about what sort of NHS dental provision we can expect. Some fundamentals, like the nations finances, apply whichever party is in power, or whoever the health minister may be.

Talk remains cheap, and making promises that never have to be delivered is an easy crowd pleaser.

The Liberal Democrat manifesto for the election makes some specific promises. If elected they will, “Guarantee access to an NHS dentist for everyone needing urgent and emergency care.” They explain how they will do this, by:

Bringing dentists back to the NHS from the private sector by fixing the broken NHS dental contract and using flexible commissioning to meet patient needs.

Guarantee access to an NHS dentist for everyone needing urgent and emergency care by:

Bringing dentists back to the NHS from the private sector by fixing the broken NHS dental contract and using flexible commissioning to meet patient needs.

Introducing an emergency scheme to guarantee access to free NHS dental check-ups for those already eligible: children, new mothers, those who are pregnant and those on low incomes.

Guaranteeing appointments for all those who need a dental check before commencing surgery, chemotherapy or transplant.
Take action to prevent tooth decay by:

Providing supervised tooth brushing training for children in nurseries and schools.

Scrapping VAT on children’s toothbrushes and toothpaste.

Fortunately for Daisy Cooper, the Liberal Democrat health spokesperson, she will never have to find the funds, premises, or workforce, to deliver these promises.

Magical thinking is not restricted to those making offers. The six demands from the Toothless in England campaign are:

  • An NHS dentist for everyone: Ensuring dental care availability.
  • Reforms to the NHS dental contract: Encouraging dentists to provide NHS treatments.
  • Revenue to cover the unfunded population: Supporting 50% of people not currently funded by the government.
  • Free NHS dental treatments: Making them accessible at the point of use.
  • Prioritizing people over shareholder dividends: No more privatization.
  • Ending the two-tier system: Hygienists, check-ups, and preventive treatments as core NHS functions.

The founders of Toothless do not say much about how their ambitions would be funded, although they have the political hinterland that would probably be required to make their proposals stick.

In contract to the grass roots activists at Toothless, Jacob Lant operates at the more refined end of the spectrum. A former policy chief at Healthwatch he is now Chief Executive of National Voices, “a coalition of over 200 health and social care charities in England.” His response to Andrea Leadsom’s suggestion that NHS patients pay a monthly extra sum for their dental care was to go in the opposite direction and “urge for a significant expansion of eligibility for free NHS dental care.”

For many years the BDA has kept to a simple message, that the UDA contract is unfit for purpose and funding is inadequate. Inadequate, that is if it is to provide general dental care to the typical 50% of the population that sought it, and emergency treatment to the rest. That funding was inadequate years ago and inflation, staged and capped DDRB awards, public expectations, and the one way direction of travel in litigation and compliance, have made matters worse each year.

There may be members of remote Amazonian tribes who are unaware of the pressures on the UK economy. They would also be bemused by a set of practice accounts. But the rest of us; dental professionals, regulators, health service managers, the general public and even politicians, should be able to understand the basics. The expression ‘champagne tastes and a lemonade budget’ comes to mind.

Despite this there still seems to be a good deal of effort to try and maintain the illusion of a comprehensive service that will provide 21st century dental care to anyone who would like it, delivered at an artificially fixed price, often by self employed entrepreneurs. That would be enough to put many providers off but the challenges of running  business in 2024, avoiding unwelcome letters from the GDC or DLP, medical inflation rates, and an undersized workforce, will put off many of the remaining potential NHS dental providers.

There is a trap here that many dental leaders want to avoid. The “greedy dentist” narrative is never far away and will always appeal to a manager or politician asked why they cannot provide NHS access. If the profession, or its negotiators, start talking about a core service, or restrictions to the range of treatments,

they worry that they will then be portrayed as the ones that killed off  the dream of comprehensive universal dental care, provided at low or no cost to patients.

The dilemma is that until these difficult issues are raised and discussed, we are all doomed to have conversations based on fantasy economics and impossible promises. It is notable that both the Conservatives and Labour are talking of some extra appointments targeting urgent care, emergencies, and priority groups in their manifestos. There are no firm promises of a return to the general availability of NHS care. The widely available more advanced treatments of past times, and even annual check-ups are not mentioned. Despite these omissions, the implication is that somehow the clock can be turned back to a supposed former golden age of NHS dentistry.

The BDA remain cautious. A recent posting of theirs on X lists key demands for the next administration. Specifically mentioned are prevention, better access and valuing the workforce. The first step is “fixing a broken contract.” What the BDA avoid is saying how that contract might be fixed, and what it will be fixed with, in the absence of extra cash being made available.

The new government will not just have dentistry or even the NHS to deal with. Commenting on X about the perilous state of higher education, one expert summed up the challenges in his sector: “Labour will have to decide how much money to spend, how much to raise tuition fees in England, which universities to close and which to merge. They’ll have to drink all the poison, I’m afraid.”

The prospects facing the new Secretary of State for Health, as well as the profession’s negotiators, will be no more appealing. Not so much a case of who blinks first, as who drinks first.

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