Kevin Lewis – NHS dentistry, I wouldn’t start from here…

Maybe NHS dentistry is part of a different NHS that the politicians forgot to tell us (and the public) about, Kevin Lewis wonders.

It would take the mother of all sticking plasters to fix the NHS – and it has been tried many times, but maybe NHS dentistry is part of a different NHS that the politicians forgot to tell us (and the public) about, Kevin Lewis wonders.

I expect we’ve all heard the joke about the traveller who gets lost and stops to ask a local passerby the best way to get to their destination. The local’s advice, served with a frown and a shake of the head, begins with the not-entirely-helpful riposte: ‘well, I wouldn’t start from here.’

Trying to salvage NHS dentistry, the NHS generally, and health and social care more widely, from its present plight, regularly evokes the same kind of riposte.

Increasingly, we’re hearing senior, experienced people suggesting that we must be ready to challenge the sacred tenets of the NHS, reject the status quo and think the unthinkable.  

This is hardly the first time in its long history that there’s been a cry for urgent NHS reform. As on previous occasions, the choice lies between incremental, progressive, evolutionary change or radical, fundamental change.

Politically (as ever), the choice lies between change that will cost votes or change that will win votes – both in the division lobbies of parliament and in the electoral ballot boxes across the nation(s) of the UK. The NHS is never far from the top of the political agenda.

The word ‘reform’ is itself regularly hijacked by those who prefer one or the other approach, but literally, it implies the re-assembling of the constituent parts of something to create something different and hopefully better.

The ‘constituent parts’ in this instance are most obviously people, infrastructure and organisational systems and processes.

A closer look

However, no reform proposals can (or should) be viewed in isolation from the incredibly complex issues of demand, need, supply and the biggest question of all – how it’s all funded. 

That, in turn, prompts a closer look at the constituent parts – which people? Doing what? In which part(s) of the NHS? Which systems? Which processes?  

At first sight, the NHS does appear to be in a state of abject crisis, involving every one of these interconnected fronts, but we mustn’t lose sight of how much incredibly good stuff is still being done all day, every day, despite all the pressures and challenges. 

Indeed, by many measures, the NHS is more successful now than on most of the (many) previous occasions when a crisis was declared and sweeping reforms were demanded.

Not only is the NHS a continually moving target operating 24/7, it is also humongously large and complex and unavoidably, it is always going to be saddled with the legacy of the past (for better or worse) while needing also to be fit for both the present and the future. 

Squaring this circle is a seemingly impossible ask at any time, let alone now, when just about every wind is a headwind making progress more difficult and rapid solutions a pipe dream.

It was in a Commons debate during a previous crisis in May 1956 that the (then) minister of health was hailed as an emerging stand-up comedian, when he announced: ‘What is most needed at the present time is the prospect of a period of stability’.  Slim chance of that then, and no chance of that now. 

Ignorance is bliss

Of course, the laughter died down some time ago, and anyway, the last thing NHS dentistry needs right now is a period of stability. The status quo is damaging both the profession and the public, and suits only the government (and especially the treasury). 

Just as happened in the 1990 and 2006 dental contract reforms, the ‘I wouldn’t start from here’ conundrum rears its ugly head.

As predicted back in 1951, when dental and certain other charges were first introduced on a limited basis and patient charge revenue started to flow in, it was only ever going to move in one direction after that, and the original purpose was conveniently and quickly forgotten.

Except by Aneurin Bevan, the ‘father’ of the NHS, who resigned over the issue. 

Successive increases in recent years have regularly outstripped inflation and allowed the government to pick the pockets of the profession and the public by stealth, so that they can silently launder this money and divert it to other parts of the NHS. It has been the clearest possible signal and statement of intent.

If NHS dentistry is part of a completely different NHS, just say so. Publicly.

Bold suggestions

Sajid Javid, himself secretary of state for health for a while, recently suggested charging patients for visits to A&E or their medical GPs, supposedly to illustrate the scale of radical thinking that might be necessary. In most circumstances, you might consider him brave or foolhardy to have gone public with such a suggestion, but he had already announced that he is stepping down as an MP when the next election is called, so it became a low-risk test of the water.  

Some ridiculed his suggestion, but others thought he had a point when describing an NHS co-payment as a well-established ‘contributory principle’ that might be ‘extended’ with the aim of restraining excessive and inappropriate demand, while also mitigating the spiralling cost of delivering the service.

‘Over my dead body’ retorted the ever-available media legend that is Wes Streeting (tempting providence I thought)… ‘An NHS free at the point of use has been its central equitable principle for 75 years. Patients should never have to worry about the bill.’  

Wes becomes the latest addition to the lengthening list of politicians who appear to be blissfully unaware that not all of the NHS is ‘free at the point of use’. He joins Nicola Sturgeon, Matt Hancock, Stephen Barclay, Jonathan Ashworth and many other eminent politicians who are awaiting their briefing on this, and other points on which they are deluded.  

Alternative universe

The briefing will need to explain that NHS dentistry sits in a different and probably unrecognisable NHS in which patients not only pay for most or all of their own treatment at the point of use, but regularly subsidise that of others in the process. 

In this parallel NHS, an independent contractor generously makes all the capital investment and carries all the risk and operating costs, often subsidised by private patients who pay 100% of their dental care costs out of their net (after-tax) income. And regularly topped up with payments out of the contractor’s own pocket. 

Contractually, the NHS enjoys all the rights, protections, power and control, leaving the contractor with all the obligations. The contractor even collects and remits money on behalf of the state (pro bono) and carries the bad debt risk.

I wonder how much of that happy arrangement (or how much of today’s patient charge revenue) Wes, or the state, will be rushing to relinquish? 


Wes has earned a reputation for seeking out populist causes to dine out on, and for choosing enemies that (he thinks) will win him friends. Ergo, he is currently best friends with the nurses and ambulance drivers, while castigating medical GPs at every opportunity and suggesting that their role as senior players and gatekeepers in primary care is unjustified and misplaced, and suggesting that they might usefully help out on the 8am switchboard when desperate patients are trying to get an appointment. 

It is no mean achievement for someone with such a strong populist agenda to find popularity so elusive. A far-left publication recently dismissed him as ‘a charlatan of the highest order’, the BMA described his suggestions as ‘barmy’, and one medic added ‘words cannot describe how ignorant you would have to be about the ‘gatekeeper’ role in the NHS to suggest patients self-referring to hospitals’ (as suggested by Wes in an article in The Times).

But the low point was probably when his own parliamentary colleague Dr Rosenna Allin-Khan (herself a medic who still works the odd shift in A&E) – a shadow health minister – resolutely wouldn’t say a word in his defence on this topic when questioned on BBC Radio 4.

What would Florence say?

The 1983 Griffiths report prompted a rapid expansion in the role of managers, the involvement of external management consultants and the application of management expertise/techniques drawn from business and industry and other fields far removed from healthcare.

It is a theme we often draw back into the mix as something to do more of, or less of.

But there is some truth in a memorable one-liner that’s in that same report: ‘If Florence Nightingale were carrying her lamp through the corridors of the NHS today, she would almost certainly be searching for the people in charge.’ 

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