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Published: Tuesday, 29 October 2024 09:33

Written by Peter Ingle

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It is not often that there is much in the Lancet of direct interest to GDP‘s. Founded in 1823, amongst other content, it publishes letters in its weekly editions. A recent letter cut to the very core of the current challenges in maintaining access to NHS dentistry.

Headed, ‘The politics of reform of NHS dentistry’ it‘s authors were Rebecca Harris, Gary Lowery and Stefan Listl. Dr Lowery of Bath University, has a background in Politics and International Relations, and Professor Listl is an academic with interests in quality and safety of healthcare and translational health economics. Readers may be more familiar with Professor Harris, Professor and Honorary Consultant in Dental Public Health at the University of Liverpool.

As a former Deputy Chief Dental Officer for England from 2021 -2023 and Specialist Advisor to the House of Commons Health and Social Care Select Committee inquiry into dentistry, she knows how the system works. In her own words, “My work supports the realisation of Universal Health Coverage – so that all individuals and communities can receive the health services they need without suffering financial hardship.” Perhaps most pertinently, in her time as deputy CDO she was a key player in the attempts to make progress on contract reform.

The authors start by noting the surge in interest in NHS dentistry from politicians, and its appearance on manifestos and doorsteps during the election.  They quote recent comments by leading dental public health figures that the recovery plan was out of scale with the velocity and extent to which the system is failing. There had been a call for “bold and ambitious” reform, including replacing the NHS dental contract and increasing funding. It was estimated that universal coverage would cost £4·47 billion per year compared with the currently available £3·1 billion per year. In reality NHS dentistry had experienced what they described as a “catastrophic equilibrium” for decades, where symptoms of failure are clear, but no decisive action is taken.

So, asked the letter’s authors, was transformational change a realistic proposition? They set out three fundamental issues that will have to be tackled. The first was described as an inverse care law, in that a disproportionate amount of NHS dental service is occupied by people with less need. As an example, capitation with patient registration while popular with the profession, was described as solidifying inequity between those accessing care and those who cannot. Secondly, NHS dentistry demonstrated inverse financing, with incentives and resources not directly proportional to population needs. The example of more than 50% of NHS courses of treatment being for check-ups, many of which were considered to have low clinical value, was given. Lastly, the NHS dental system has inverse governance, clinical advice is not linked to strategic planning and financial decisions. This tends to consolidate the status quo and makes ‘big bang’ reform challenging.

To overcome the longstanding policy stasis, three things needed to exist simultaneously: clarity on what the problem is, political attention to the problem, and clear options from which policy choices can be selected. In NHS dentistry that last ingredient is missing and, so the window of opportunity presented by the current political interest remains closed. Advocates for change will need to present detailed, costed, and viable alternative choices to politicians.

Then the writers began to think the until recently, unthinkable. With public finances limited, there is a tacit understanding that another £1.5 billion to close the funding gap would not be coming. Instead, the recent Nuffield report was referenced, which had offered the choices of raising user charges or limiting the NHS dental offer and introducing means-tested eligibility. Other options available include social insurance and engaging private providers.

The more radical reform options threaten Bevan’s NHS founding principles and the authors called for deliberative decision-making processes, including citizen engagement.

The letter writers also said that England, badly needs to develop a national oral health strategy to be accompanied by clear steps, timelines, and costings.

There was a sense of Professor Harris’ experience at NHS England in their concluding line: “Getting NHS dentistry to the top of the political agenda might be the easy part.”

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