Millions denied access to dentistry in the UK

By Marcus Morgan
25 February 2008

According to a recent report published by the Citizens Advice Bureau (CAB), millions of adults in England and Wales are unable to find a publicly funded dentist to treat them and have abandoned regular check-ups. Dentistry, like many areas of the National Health Service (NHS), has been steadily privatised. It is now very difficult to get any treatment except at high costs.

The CAB has 3,000 offices across England and Wales and provides a free service to people with financial and legal problems who tend to be worse off than average, unemployed or on income support.

Based on a survey of 1,800 people by the polling company Ipsos MORI, the CAB “Gaps to Fill” report calculates that up to 7.4 million people have not been to an NHS dentist since April 2006, when the Labour government “reformed” dental services. Of these, roughly 4.7 million have resorted to private treatment whilst 2.7 million have gone without treatment altogether. These figures are in stark contrast to the official figures, which put the number of people who have failed to access NHS dentistry at only 2 million.

CAB Chief Executive David Harker commented, “These figures show the scale of the lack of access to NHS dentistry, reflecting the evidence, which bureaux across England and Wales have been reporting ever since the early 90’s. People on low incomes are particularly affected as private treatment is just not an option.”

One of those who took part in the survey summed up the exasperation felt by millions: “I am a mother of three on income support, we were very happy with our dentist but then with the new NHS changes the practice became private, so we had to find a dentist that was NHS to still get free treatment. The nearest one we could find was in the next town and the last time we went it cost me £18 in bus fares! That was just another slap in the face for the poor.”

Another respondent said, “There was no dentist closer than a 50 minute car/train ride. I now have to pay £80 for [a private] check-up and hygienist every six months. I only earn an average wage and this is a huge cost.”

Aside from transportation costs, the other common problem is long waiting lists. In one case, a pensioner on a low income needed emergency dental treatment in hospital but was told that she would have to find an NHS dentist for further treatment. The two dentists that were available both had 12-month waiting lists.

In another case, a pregnant woman on income support was faced with a bill of £1,420 for private treatment, or a wait of six months to see her local NHS dentist. In the end, the CAB found a charity that was prepared to help pay for the private treatment.

With a combination of difficult access, long waiting lists and unaffordable costs, many people are forced to go to the Accident and Emergency unit at their local hospital—putting extra strain on workers who are already under pressure.

The dental facilities of these units are far more basic than would be found in the average dental surgery, and many patients in extreme pain can only be treated with temporary palliatives such as a course of antibiotics. In other cases, they will simply be turned away because their problem does not meet the criteria of an emergency.

Increasingly, people are being forced to seek treatment in other parts of the European Union, such as Poland and Hungary, where costs are much lower. According to the agency Treatment Abroad, an estimated 43 percent of the 33,000 UK citizens who went abroad in 2006 for medical treatment did so for dental care reasons.

Help is technically available to people on low income through the NHS Low Income Scheme (LIS), but according to CAB, it is not well publicised and many dentists don’t even have the correct forms to claim free treatment. A MORI survey last year found that only 11 percent of the poorest had heard of LIS, and for many others the forms are so complicated they give up trying to claim.

The decline of NHS dentistry goes back to 1992, when the Conservative government sharply cut fees, leading to a large number of dentists taking on more private work, especially in more affluent areas. Many patients were told their dentists were no longer on the NHS, leaving them with the stark choice of either going private or going without.

As a result, the number of adults registered with a dentist in England fell from 23 million in 1994 to 17 million in 2003, and a similar decline occurred in Wales. The CAB report is especially revealing when it comes to the NHS contract that was launched in April 2006 by the Labour government, amidst a flurry of promises to reverse the trend—especially for low-income people.

Under the “reforms,” there were two major changes. Firstly, the fee-for-item payment system was replaced by a new three-tiered payment structure, ranging from a minimum of £15.50 for routine work such as check-ups to a maximum £189 for complex procedures (increased the following year to £15.90 and £194).

“The new charging system should mean it is now far easier for patients to understand,” said Dr. Nigel Carter, chief executive of the British Dental Health Foundation at the time. “But whether it is better value for money really depends on the course of treatment. Some things are less expensive, but some are more so.” For example, in the old system, a standard tooth filling was £14.

The second change involved the end of paying dentists an annual salary and paying them instead according to a target number of “Units of Dental Activity” (UDAs) allocated by their local primary care trust. However, the dentists receive the same UDAs for complex work as they would for simple procedures, thus creating a disincentive to carry out the more-costly kind of work.

Many dentists have complained that this target-driven approach has detracted from the time needed to give the necessary care. Consequently, 10 percent of dentists still have not signed the new contracts.

According to Dr. Anthony Halperin, chairman of the Patients Association, “Dentists are really unhappy about the new contract. They are worried they are going to be asked to do more work for less money. If the contract turns out to be uneconomic, they will switch more patients to private work because it is a safer option and if that happens it will lead to the collapse of NHS dentistry.”

Susie Sanderson of the British Dental Association (BDA) said, “The future of NHS dentistry is becoming increasingly fragile. We now have a reductive, target-driven system that is failing patients and dentists.”

According to the BDA, since the new contract came in, up to 1,000 dentists have left the NHS and 266,000 fewer patients have access to NHS dentistry. Last year, statistics from the NHS Information Centre reveal that the ratio between public and private dentists tipped in favour of the latter for the first time at 52 percent. Between 1999 and 2006, the proportion of the income made by dentists from NHS treatments fell by 16 percent, and the trend is even more dramatic among dentists under 35 who saw their proportion of earnings in the NHS falling 64 percent to 36 percent.

Today, millions of patients are unable to get routine NHS treatment, and the percentage has actually declined in the deprived areas the government’s reforms were supposed to target—with the south west and north west of England being the worst affected.

Other areas of the NHS have also undergone the creeping privatisation that dentistry has witnessed.

In 2003, the government invited health corporations, nationally and internationally, to bid for the running of “Independent Sector Treatment Centres” (ISTCs), under the pretext that this would help alleviate pressure on an overburdened NHS. The real motive for the ISTCs was to open a path to the wholesale privatisation of the NHS.

In June 2006, the Department of Health placed an advert in the European Union official journal that said the NHS was making a “step change from a service provider to a commissioning-led organisation” and invited multinational firms to manage services worth up to £64 billion. After reports in the press came to light and spurred protest within the NHS, the government withdrew the advert, only to replace it later with a new reworded version.

According to the NHS union Unison, the government selected seven companies to run 24 “fast-track” surgery centres in England whilst giving assurances that no staff would be recruited or transferred from within the NHS. But by 2007, the ISTC policy led to the Lymington New Forest hospital being the first in the country to be handed over wholesale to a private company.

In January 2007, the Institute for Public Policy Research, a think tank privately sponsored by commercial health interests and closely aligned to Labour, released a report entitled, “The Future Hospital: The Progressive Case for Change.” It called for hospital “reconfiguration” and was cited in a speech made by former Prime Minister Tony Blair on the future of the NHS. The report trumpeted the need to close district general hospitals, including Accident and Emergency units, in favour of more specialised units, in the interest of “patient choice.” But the report reveals most by what it does not say—namely, who will own and control these “devolved” hospitals, the public or private sector?