Goodbye Lansley - Ministers to retake control of NHS

Last Friday (Feb 5) Health Policy Insight published^[i] the draft of the Government's forthcoming White Paper on Health, which was reviewed extensively in the media over the weekend. The main news in it for dentistry was that the paper included proposals to hand over control of water fluoridation to the health secretary and away from local councils. The move was widely welcomed in the profession especially by the CWF network (@network_cwf), the national organisation of dentists supporting water fluoridation.

Andrew (now Lord) Lansley’s 2012 reforms, when he was health secretary, handed control of the measure to local councils, which led, in October 2014, to a decision by Southampton City Council to scrap plans to fluoridate its water. This followed a vigorous campaign by ‘Hampshire Against Fluoridation’ and tentative plans to introduce the measure in other areas such as the North West of England and Hull were quietly dropped. Speaking in the January 14 Commons debate on dental services during Covid-19, health minister Jo Churchill said she was ‘extremely sympathetic’ towards the measure, so we may expect its revival perhaps.

In his report^[ii], the late Professor Jimmy Steele said the first priority of any NHS system should be ‘a strong, co-ordinated public health system’, something that has not been possible with it being devolved to individual local councils,

The Lansley approach, which was controversial in the Conservative/LibDem coalition, was to take power away from ministers and put it in the hands of administrators. NHS England was given ‘power without responsibility’ to quote Stanley Baldwin’s description of the press in the inter-war years^[iii].  But Ministers were still held accountable to Parliament for the NHS; ‘responsibility without power, the worst of all worlds’ as then Home Secretary David Blunkett, described it in 2002.^[iv]

Without going into any detail, the document says there will be ‘enhanced powers of direction for government’ to ensure that ‘those overseeing the health system’ are held to account. For dentistry this could mean that the focus moves from NHS England’s obsession with delivering UDAs to MPs’ demand that anyone who wants to see an NHS dentist can do so - a shift from activity to access.

Secondly the Lansley approach was to promote competition within the service, hence the over-long process of commissioning new services, typically a year or more and, arguably, the botched orthodontic recommissioning exercise.

The pandemic showed, though the commissioning of urgent dental care practices, that the NHS can move rapidly when circumstances demand and so it should be in the future.

In responding to the January 14 debate, health minister, Jo Churchill said that ‘a transformation in dentistry is necessary.’ She continued: “There is a huge opportunity to deliver a greater range of health advice monitoring and support, using dentists and their teams.”

The demise of the Lansley system could give her the opportunity to achieve this.

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^[i] http://www.healthpolicyinsight.com/?q=node%2F1699

^[ii] NHS dental services in England: An independent review led by Professor Jimmy Steele, June 2009

^[iii] ‘power without responsibility – the prerogative of the harlot throughout the ages’, Stanley Baldwin speech on newspaper proprietors March 17, 1931

^[iv] Speech by home secretary, David Blunkett to Labour local government and women’s conference Cardiff, February 2002

Last week, Pfizer and BioNTech announced a breakthrough in the fight against the SARS-CoV-2 virus. Pfizer proclaimed its initial Phase 3 data showed its vaccine is 'more than 90% effective'. The news was hungrily devoured and then regurgitated by the national press in an excited fanfare. The BBC reported Health Secretary Matt Hancock as saying the NHS will be ready from December to roll out the new coronavirus vaccine if it gets approved.

Removing a pair of latex gloves in a single movement with a “pop” is an art form and takes practice. Two deciduous teeth out, bite on this, a satisfying pop and I’m marching through to reception to take a call. “Mike Lennon here” said the voice at the end of the line. The last time I heard that voice was on the child dental health clinic at Manchester University way back in 1984.

So hop into the De Lorean for a quick spin. Mike, regional director of dental public health, was affectionately christened “Boss Hog” for his striking similarity to the character in The Dukes of Hazard and his straight talking. Fast-forward to 2012 and Mike, a Chairman of the British Fluoridation Society (BFS), had read my letter in the British Dental Journal and wanted to make contact with Hull LDC. The BFS as a Group are world experts on fluoridation and were keen to help and advise.

In 1984 Orwellian language, Mike talked in “old speak” and in 2012 he wanted to hear about my theory that CWF had indeed fallen in to a “memory hole”. Mike must have done something right at Manchester in 1984. Tom Robson leading the CWF campaign in the North East in 2019 is also one of Mike’s Manchester graduates. As Tom says – we all have the same hairstyle now.

Returning to the TV theme, the BFS are the Dental Public Health equivalent of the ‘New Tricks’ retired detective team. Not wishing to be age-ist, certainly mostly 65 plus but all of them with brains the size of planets and huge commitment. They have forgotten more about fluoridation than we have learned over the last seven years and, to be very honest, without them the towel would have gone in years ago. And boy they work hard at it. To say the BFS are inspirational is an understatement.

Mike was, however, a realist. Having been round the proverbial fluoridation block – the F-block - for many years he wanted to know if Hull LDC were in it for the long haul. I think we convinced him we were.

Alan Johnson was one of Hull’s MPs at the time and still the only Secretary of State for Health to state his clear unequivocal support for CWF so Mike suggested I contact him and try and set up a meeting in Hull to get the ball rolling. At this point in time the F-Word was not exactly a thought crime but it tended to be hidden in a “basket of measures” in new speak terms.

We were going for direct action – so we sent out a letter inviting local councilors to a meeting on Oral Health in the City to discuss how to improve the situation.

So in attendance at the Hull Ionians Rugby Club we had: a former Secretary of State for Health, several Councillors, NHSE Dental Commissioners, PHE representatives and this was the moment when Hull LDC made it’s pitch beside the pitch.

It was an important first step in bringing CWF to the attention of local Councillors who, at the end of the day, have the final say on policy. This is only right and proper. After all, targeted fluoridation is a local issue. The challenge for Hull LDC was describing the challenges we face daily, the poor oral health, the high numbers of child GAs, the very poor child dental health statistics, all in human terms and offering CWF as part of the solution because it is safe and effective. Councillors want to do the right thing but are also nervous about doing the wrong thing. It takes time and an attentive audience to provide the science and to reassure that most of the “googled” information needs to be critically evaluated. The best reassurance though existed across the Humber where parts of North Lincolnshire have a fluoridation scheme. As is often the case with CWF – the numbers speak for themselves.

The meeting went well and we knew we had Councillors who were supportive and understood the benefits fluoridation could and would bring to the City. But progress seems agonizingly slow, tedious and   frustrating for Dentists at the front line of Primary Care. In fact it is a necessary part of following the correct procedure and rightly so.

So, in the meantime, Hull LDC chose some direct action. We pledged to try and raise CWF at every opportunity and at any meeting we attended. So we quizzed Andrew Lansley at the BDA Conference and asked questions around fluoridation on every possible occasion. Hull LDC members attended an anti-fluoridation meeting in Hull and had the first of many encounters with the “Ministry of Truth” which bottomed out at CWF turning the public in to waste disposal units for the aluminum industry and boosting the profits of the Rockefeller pharmaceutical companies. By the end many of the more neutral in the audience were leaving incredulous. At first we were the “odd” ones at professional meetings but over the next few years we could sense that slowly but surely the F-word was no longer being avoided or whispered but was slowly making it’s way out of the basket of measures to become a single measure in it’s own right.

Slowly the “double speak “ of CWF being recognised as being one of the ten greatest public health achievements of the 20^thcentury ⁽¹⁾. but being too “hard” was being countered and challenged 2+2=4.

1. Centers for Disease Prevention and control: Community Water Fluoridation: A vital 21^st Century public health Measure

https://www.cdc.gov/grand-rounds/pp/2013/20131217-water-fluoridation.html
https://www.cdc.gov/mmwr/preview/mmwrhtml/00056796.htm
Ten great public health achievements - Us 1900-1999
Community water flouridation a vital 21st century public health intervention

Image credit: "retro" is licensed under CC0 1.0 

If you check out the word fortitude you get a sense of the characteristics necessary to campaign on Public Health. Resilience, endurance, perseverance, patience, tenacity, resolve, determination, grit and pluck. I wish we’d looked this up in 2012 when we started all of this – we may have decided to duck the challenge. We didn’t, and now we know why fortitude is essential, necessary, imperative, obligatory paramount, courage over a long period, plucky………

Back to 2012 then - let’s fire up the De Lorean although for the petrol heads it’s a metaphorical one as we know they stopped making them in 1983 which coincidentally was the same year that McColl v Strathclyde set a 201 day record for any legal case in Scotland over you guessed it Community Water Fluoridation. Manchester City win their first league title in 44 years, the Olympics come to London, Bruce Springsteen releases Land of Hope and Dreams and Hull LDC wake up.

Hull LDC met at the Ionians Rugby Club back then and that evening we meant business. Ionians were known for their love of democracy, philosophy the arts and pleasure. We were more in to treating our patients and staying healthy and solvent as NHS Practitioners but we did enjoy a beer. That night we were fed up as usual. Fed up with the tsunami of decay and the human consequences, the pain, the extractions the relentless tide of poor dental health. We were all very committed to prevention. We were all very committed to our patients and to the community of Hull. But we felt powerless and we knew we needed change. Hull has very poor oral health and is one of the most deprived areas in England. We understand the social health gradient now, but we were embedded in it in 2012 (as we still are) and we finally decided to do something. This isn’t surprising. People from Hull have a track record of standing up. In 1642 Hull refused the King entry to the City even though he turned up personally, endured a long siege militarily outnumbered by 2:1 and finally saw off the threat. That definitely takes pluck, grit, and fortitude.

Over a pint of bitter and a sandwich we voted to try and drive a Fluoridation agenda. We would start with a letter to the BDJ and publish an e – petition. So we did, convinced in our own minds that by the next AGM we would have cracked it.

We even developed a QR code link to the e- petition on the Petition Parliament site. Like a deluded punter down the bookies – we couldn’t lose could we?

The BDJ printed the letter and we waited for the e-petition to take off, soar,go viral. But it didn’t and in October six months after our rallying call for something to happen, it closed on 315 signatures.

So in October 2012 it seemed like Hull LDC were standing at the Fluoridation barricades alone or at least there were only 315 of us. Then the phone rang in Reception and my Nurse whispered in my ear – “there’s a Prof on the phone who wants to speak to you about your letter in the Journal.” I finished my fifth extraction on a child that morning and took the call.

To be continued...

In developing countries, oral health services are limited to regional or central hospitals in urban areas. Even where dental assistance can be found, little priority is given to preventative or restorative treatments; many African, Asian and Latin American countries solely offer pain relief or emergency services.
 

In Africa, there is a ratio of one dentist per 150,000 people – in developed countries it’s one per 2,000[1]. Sadly though, preventive dentistry is even more crucial to these remote areas of our world, because there are far fewer dentists to treat oral diseases. Dental pain is of course unpleasant for everyone but in the UK the inconvenience of booking and then attending an appointment is the main concern. However, for someone without access to dentistry, their suffering constitutes chronic pain, occupational and social limitations and can even be life threatening.
 

Most concerning is children’s oral health. Tooth decay is a widespread childhood disease, from which 60-90% of schoolchildren are suffering around the world[2]. A study across two decades from 1990 to 2010 in London, with close to 3 million subjects found that 20% of children had dental decay in their deciduous teeth[3]. In The Gambia, 86% of 5 year-olds have decay in four or five teeth and half of those clean their teeth with chewing sticks: the other half simply don’t clean their teeth at all. In Cambodia 93% of 6 year-olds average 9 teeth with cavities and 60% of mothers reported their children had suffered dental pain in the last six months.
 

Dental decay is a lifestyle-related disease that is increasing in the far reaches of the world where traditional diets are being replaced with cheaper, imported food products containing high levels of sucrose and carbohydrates. Also, junk food manufacturers vigorously campaign their products towards vulnerable groups, such as children. In the UK we have vastly improved levels of sugar consumption when compared to a country like Mexico, but it is still double the WHO recommendation of 18kg per person, per year.
 

Along with the spread of unhealthy eating habits, developing countries are contending with other exacerbating factors like lack of access to:

·      Fluoride – An average UK worker need only work for an hour to accrue enough fluoride toothpaste for a year, the average Kenyan would have to work for an entire week.

·      Dental clinicians – There are about a million practising dentists unevenly distributed around the world. They may be found in urban areas but there is a critical shortage in poor, remote areas.

·      Government healthcare funding – In some countries, government policies and the sheer number of people suffering with caries makes treatment virtually impossible. In India, the health budget is meagre for oral health and there is no fluoride policy. Moreover, preventive products like toothbrushes and toothpaste are classed as cosmetics and subject to hefty tax levies.

It’s frustrating to think that there are simple and cost-effective solutions for lifestyle change, which are not available to so many. A scheme that was introduced in Jamaica between 1987 and 1995 proved how simple a solution could be. The National Salt Foundation Program encouraged the country’s only salt provider to produce and sell only fluoridated salt. This led to an 87% decrease in schoolchildren’s dental caries, at a cost of just 6 cents per person, annually[4].
 

Benjamin Franklin’s famous quote “an ounce of prevention is worth a pound of cure”, is a mantra that Darren Weiss, dentist and founder of the Humble Smile Foundation holds close to his heart.
 

“The focus on prevention became a practice philosophy for me,” said Weiss. “I was actively lecturing dentists about the value of prevention, but I was troubled with one thought – if I truly wanted to apply my preventive expertise, why wasn’t I based where it is of the greatest value?”
 

In light of this, Weiss collaborated with local dental professionals to design an oral health outreach programme, called Planet Smile. The focus was to promote preventive dentistry in parts of the world where the need is greatest. When he visited the Humble Brush stand at the 2015 International Dental Show and learned of their sustainable, biodegradable bamboo toothbrushes, he found a like-minded organisation with an inspirational, environmental and social vision. By working together, The Humble Smile Foundation was born. Now, for every Humble Brush sold, a physical toothbrush or equivalent oral care is given to someone in need overseas.
 

The Humble Brush Foundation recently joined forces with Assyrians Without Borders, a group to which they have donated toothbrushes assisting the charity’s aid to Syrian refugees in Turkey. With more programmes in the pipeline for Iraq and Syria, the work of the Humble Smile Foundation and Humble Brush continues to reach out to global communities suffering unimaginable hardship.
 

Contact Humble Brush today, to discover how you can effect change in the far-flung reaches of the world, without even leaving your surgery.

For more information about the Humble Brush visit www.humblebrush.co.uk or to find out more about the Humble Smile Foundation’s work visit www.humblesmile.org

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1. Royal College of Surgeons report January 2015
2. Daily Telegraph letter 2014
3. Daily Telegraph letter 2015
4. Mintel market insight reports

Image acknowledgement

Running to Paradise Garden
by Nicolas Alejandro
https://www.facebook.com/nicolas.alejandro.ph  Shown under Creative Commons licence