Kevin Lewis – whatever happened to NHS dentistry?

As dentists leave NHS dentistry and switch to private, Kevin Lewis asks if the government will try other tactics to bolster the NHS workforce.

As dentists leave NHS dentistry and switch to private, Kevin Lewis asks if the government will try other tactics to bolster the NHS workforce.

Here in the UK we appear to have more dentists than ever before. But tens of thousands of patients report that they cannot access dentistry.

Not routine NHS dentistry anyway, and in many cases not emergency pain relief either.

They have looked in most of the usual places but have found that the cupboard is bare.

I know that the same is said to be true of medical GP services. Unfortunately, when I tried ringing to check that out for myself, I couldn’t get through.

Apparently I was number 84 in the triage queue. Maybe all those dental patients had got in ahead of me, in search of some stronger painkillers.

Unless I prepared to spend my next two birthdays hanging on the phone, I may never know for sure.

Recruiting troubles

I heard a medical GP speaking on TV recently, explaining that there was a desperate shortage of GPs. Her practice simply couldn’t recruit, try as they might.

She added that she and her colleagues were, as a result, incredibly busy and working long hours, albeit working in different ways and doing different things.

And in a sense she was speaking for dentistry too, perhaps without realising it.

Many dentists – young and older, but perhaps for different reasons – no longer feel inspired by the ‘bread and butter’ procedures that have long comprised the central core of primary care dentistry (based upon need).

They are spending more of their time promoting and doing the kinds of procedures that are private (based upon wants).

In some cases, the nature of the procedures attracts them. In other cases, it’s the scale of the fees on offer.

But we would be deluding ourselves to believe that this is an entirely new phenomenon. 

I too turned my back on the bits of dentistry that I didn’t like, and/or which I found unprofitable.

Rock and roll

Early in my career, many highly-gifted clinicians tried in vain to teach me how to make complete dentures. However, I eventually concluded (as they did) that I was missing a critical component – ability.

The dentures I constructed did eventually stay put, but only when their owner dropped them into a glass of water by their bedside.

Then they generally (but not always) stayed put until they were retrieved in the morning.

Other than that, they were in a state of perpetual motion; the era of rock and roll never ended in my practice nor in the mouths of my edentulous patients.

So, I hit upon the cunning plan of giving the patients their money back before I started, thereby saving on laboratory costs for at least one remake.

You may be starting to realise why I never developed any great affinity for anything acrylic and couldn’t afford to spend too much of my time making complete dentures – and certainly not lower ones.

Low morale for NHS dentistry

But we cannot separate the progressive exodus of a generation of dentists from mainstream dentistry towards richer, greener pastures from the growing body of research amongst dentists of all ages, demonstrating the plummeting levels of morale, wellbeing, motivation, job satisfaction and confidence in the future.

The parlous state of NHS dentistry accounts for a lot of that. Even the NHS’s own research confirms that morale falls in direct proportion to time spent working within the NHS.  

Nor can we separate it from an undercurrent of task shifting that will form an inevitable thread running through any substantive contract reform, whenever that finally materialises.

The art, science and rounded professionalism of dentistry in its fullest sense, needs a high entry point and advanced, extended, expensive university training.

But some of the individual tasks and procedures within dentistry don’t, which fuels a ‘scope of practice’ debate, drawing in the GDC.


Stephen Hancocks may or may not have felt inspired by the proximity of US Independence Day in early July when he wrote a very wise and insightful editorial in a recent issue of the BDJ, of which he is editor-in-chief.

He suggests (and I agree) that the GDC’s supposed ‘independence’ is illusory in all senses except for the most immediate, practical one.

The GDC is wholly dependent upon the ARF income that its minority constituency (registered dentists) mostly pay. Perversely enough, they no longer have any say in who serves on the GDC in their name.

They aren’t (nor do they intend to be) representatives of the profession. But they serve as proxies for that in perception terms. Token stakeholder involvement, if you like, but self-regulation it certainly ain’t.

Stephen further echoes my view that too close a relationship between the government and healthcare regulators (like the GDC) is unhealthy. I would also add that if it’s anything less than transparent, it’s positively dangerous.

Heading in the wrong direction

Not unlike the seeds of a McNamara-esque fallacy (upon which subject Martin Kelleher has recently published several elegant masterclasses), if the government wants to encourage more non-dentists (ie people who can be trained more cheaply and more quickly, paid much less money and be more easily manipulated and controlled) to deliver care, then the GDC’s statutory role in approving the undergraduate dental curriculum and other training courses, and inspecting dental/DCP schools, is critical. 

While all healthcare regulators have the sword of Damocles poised overhead and several fear for their future, it’s easy to see how and why an unofficial covert cabal could establish itself. Genuinely important skills could become dumbed down and deemed non-essential over time, by stealth. Meanwhile, undue emphasis is placed on other more accessible and easily acquired skills which underpin a rather different agenda.

The dental profession would ignore such a direction of travel at its peril, but now we’re unwittingly making it likelier.

Return on investment

But with the regional dearth of dentists and the dental care backlog filling its line of sight, the recent parliamentary debates enquiring about NHS dentistry being AWOL fresh in its ears, and even (a first perhaps?) media reports that lost access to NHS dentistry was a hotter topic than ‘partygate’ on the doorsteps during the campaigning for the recent Tiverton and Honiton by-election, the government must be questioning the end-value it is getting from its monumental investment into training dental students in all of the UK’s dental schools.

Notwithstanding the offset provided by the relatively recent imposition of tuition charges – which is painful for those who pay it, but ultimately modest in the scheme of things and in the context of the overall costs involved in the training – the return on investment is more palpable if it delivers a workforce that contributes to the delivery of NHS dentistry.

I’m not convinced that the government would be keen to invest on this scale, simply to deliver a workforce that catches the first available bus into the private sector to carry out elective cosmetic dentistry and facial aesthetics.

No reward

Like it or not, we’ve become familiar with the notion of student debt. Other countries have pursued the option of having graduating students repay some or all of that training debt in kind. For example, working in an NHS position for an agreed period after graduation, instead of paying back hard cash. 

A generation ago, graduating dentists honed their diagnostic and clinical treatment skills by doing NHS dentistry on NHS patients. They took these well-practised skills into the rest of their career as a platform for their ongoing professional development.

But NHS was paying them for what amounted to hands-on postgraduate training. That’s very different to the situation now where a lot of that NHS dentistry would attract derisory fees or – in many cases – no fees at all.

The government has threatened to announce details of some kind of marginal quickfix to the current NHS contract by the end of this month.

But you can confidently expect that they would design these measures to take the pressure off the government with the parliamentary recess looming, not to relieve the pressure on besieged practitioners or to address the underlying deep malaise. 

Catch previous Kevin Lewis columns

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