29.02.2024

Decay fast and furious

At great human cost NHS dentistry has been driven almost to the point of extinction. A similar outcome threatens health services in general, writes Ian Spencer

On February 5, St Paul’s dental practice in Bristol opened its doors to new National Health Service patients. But the queues were so huge that police had to be called to control the crowds.

In England alone, there are 12 million adults and five million children who do not have access to an NHS dentist.¹ Last year more than 26,000 children were admitted to hospital to have dental extractions under general anaesthetic due to preventable decay.² Nearly 80,000 Scots are without an NHS dentist. Patients with acute dental pain have little recourse other than accident and emergency departments or DIY dentistry. In 2020-21, there were 83,000 attendances at A&E for dental issues.

Against this backdrop, on February 7 the government published its ‘dentistry recovery plan’ - no doubt with one eye on the forthcoming general election. So far, the Labour Party response has been to propose the introduction of “supervised tooth brushing” in primary schools - Aneurin Bevan would be so proud!

From the inception of the NHS, dentists, like general practitioners, remained independent contractors - albeit paid for their services out of taxation rather than fees. But today the steady destruction of dentistry is a model for how the rest of the NHS will become a ‘safety net’ service, offering basic treatment for some, providing it is possible to find an NHS practitioner. If unchallenged, the NHS will go out with a whimper, rather than a bang, as underpaid professionals take more lucrative jobs in private practice or outside healthcare altogether.

The current dental contracts mean that few newly qualified dentists intend to work in the NHS. The British Dental Association - the nearest thing most dentists have to a union - has argued that the “government is failing to address the root cause of the crisis in NHS dentistry”.³ The BDA points out that a record number of dentists are registered to practice with the General Dental Council (GDC), but that the number of dentists undertaking NHS work has fallen to historic lows.

Familiar mess

‘Faster, simpler and fairer’ is the government’s plan to “recover and reform NHS dentistry”, which is described by the BDA as “unworthy of the name”. It serves up a familiar mess of pottage. Its foreword, by Victoria Atkins, secretary of state for health and social care, states that “dentistry is a priority for government”, which leaves one wondering what the hell would happen to something which was not! The promised “significant expansion of access” appears to amount to the introduction of ‘dental vans’ that can bring a peripatetic service to areas which are already an NHS ‘dentistry desert’, such as rural Lincolnshire, where Ms Atkins’ constituency is to be found.

The “significant incentive” to be offered to dentists is, apparently, £15 for each patient and £50 for those with higher needs. I do not think that will cut it, do you? Neither does the BDA, which argues that the current rates, even with the new incentives, effectively mean that dental practices will be making a loss. And this is not confined to dentistry, of course. Similar complaints have been put forward by community pharmacists, who, the government hopes, will step in to supply services that GPs are already failing to adequately provide, in no small part because they are leaving the NHS in droves.

Other government measures proposed, include ‘golden hellos’ to attract dentists into “areas in need” (for this, read areas which are unprofitable). Dentistry, reduced to commodity production - and the dentists, reduced to petty-bourgeois hucksters - will go where the profits go. Surely that is among the things implied by Margaret Thatcher, when she sagely asserted that you “can’t buck the markets”.

‘Faster, simpler, fairer’ also includes something that is now standard, when it comes to dealing with the ‘professions’ - an increase in the number of “dental therapists and other dental care professionals”, through a 40% increase in the number of training places for dental technicians, hygienists and dental nurses (assuming, of course, that these too will not be better off working privately. They certainly will not be able to afford the capital expenditure to set up as an alternative - or even to supplement registered dentists. Indeed, many will not even be able to afford dental care themselves!

The Joseph Rowntree Foundation has suggested a minimum income standard - not just to survive, but to live with dignity. For a single person in 2022, this was £25,500 and for a single parent with two young children £38,400.⁴ By contrast a recent salary review by the Association for Dental Nurses reported that 73% of dental nurses earned under £20,000, which contrasts with £21,460 for a sales assistant in Lidl.⁵ The pay of dental nurses, like nurses in general, has historically been pitched at a level which assumes the worker to be female and the earner of a household’s second income. Dental nurses and technicians have the additional disadvantage of working for a series of independent contractors, rather than the NHS itself and are therefore unable to exert much influence on the level of pay and conditions through trade unions (such as they are in dentistry).

Another stock response is to “make it easier for NHS practices to recruit overseas dentists who meet the UK’s highest regulatory standards”.⁶ This is notwithstanding the fact that 30% of all dentists (and 46% of recent recruits) trained overseas.⁷ Presumably, the plan is to recruit only overseas dentists who will accept a declining standard of living relative to those already based here. While the government’s proposal tentatively suggests that there will be some sort of ‘tie-in’ agreement to ensure that new entrants spend at least some time working for the NHS, I doubt that indentured labour will be attractive to many for long.

The consequence of the loss of NHS dentistry is more than rotten teeth. It is a crucial public health issue. There is growing evidence of a close relationship between dementia, heart disease, strokes and tooth decay.⁸ Chronic periodontal disease is a well-established source of inflammatory load on the body - which, in turn, is related to Alzheimer’s disease and Lewy body dementia. Vascular is the second most common form of dementia and is crucially related to arteriosclerotic disease.

Generally, good heart health is a factor ensuring good brain health. Coronary heart disease (CHD) and strokes have a well-known mutual association, with markers for inflammation shared with dental infection. Those with periodontal infections have significant elevations of plasma fibrinogen and white cell counts, which strongly suggests that periodontal infections increase the risk of CHD and stroke by inducing a “systemic proinflammatory and prothrombic state”.⁹

Good dentistry also increases the likelihood of the early detection of oropharyngeal cancer, which is crucial to improving survival rates. Currently, detection of such cancer in a premalignant state is the exception rather than the rule.¹⁰ That is likely to get worse with the collapse of NHS dentistry.

Class issue

Almost all disease shows a class gradient. The best way to live a long and healthy life is, first, to choose your parents well! The poorer you are, the less amount of control you have over your life in general and your working life in particular, and the more likely you are to suffer poor health and die younger.

This is nowhere better illustrated than in the consequences of capitalist, market-led dentistry. Particularly in the context of the current cost of living crisis, financial pressure may restrict access to basic products for dental hygiene. In a recent YouGov poll, 28% of people experiencing hygiene poverty said they had to go without toothbrushes and toothpaste.¹¹ Nutritional insecurity is usually related to a diet high in sugar and highly processed foods.

Importantly, the working class is less likely to live in an area served by an NHS dentist - and less likely to be able to afford one, if an NHS dentist can be found.¹² For many, private dentistry is out of the question - and here we are not talking about whitening or orthodontics, but simple routine dental care. Good dietary intake is also a factor in resistance to periodontal disease. It is the poorest that have to use more expensive electricity metering, for example, which in turn affects the ability to prepare fresh home-cooked food. It is - and has always been - expensive being poor.

The government admits that tooth decay is the most common oral disease affecting children and young people. Those in the most deprived 20% of areas in the country are 2.5 times as likely to have experience of tooth decay. The cost to the NHS of hospital admissions for tooth decay-related extractions in children was £50.9 million in 2021-22.¹³ As always, the ‘solution’ provided by the market is as cruel as it is inefficient.

Naturally, the Tory government’s proposals take no responsibility for the situation, despite their length of time in office. Similarly, Labour’s plan to “reform the dentists’ contract” makes no mention of an increase in pay to maintain a universal, free dental service. Perhaps this is unsurprising, as the current contracts were put in place under the Labour government of the Blair-Brown years.¹⁴

The recent, unprecedented industrial action by nurses, junior doctors and even consultants has failed to succeed even in the narrow terms of reversing years of pay cuts. The next government, barring a major shift in public opinion, is likely to be a Labour one - even if only because the Tories are guaranteed to lose it, rather than Labour winning it with any significant policy initiative.

Meanwhile, a workers’ movement without a political perspective and the strength to put forward a real alternative will become dissipated and have recourse to nothing but individual acts of resistance. In the case of dentists, that has taken the form of voting with their feet to abandon free, universal healthcare in favour of petty bourgeois interest in the private sector. It is a dress rehearsal for what is likely to happen in medicine as a whole.

The demand for free universal healthcare, including dentistry, pharmacies and ophthalmology, is a central one - not just to communists, but to any civilised society. As we move into a world where war is likely to become a generalised feature, it will be paid for at the expense of the working class by not only the reduction of pay and conditions, but a greater extraction of a surplus from workers, as free provision is lost in favour of medicine as a commodity.

The quality of that commodity will be worse for those who can least afford it, while the smiles of the rich will be as white and as wide as those on the red carpet in Hollywood.