Tackling Disparity in dental provision means reform of the system that created it

Today the Herald is reporting that the gap in dental provision in the poorest and wealthiest communities is now at 20 per cent. Finding ways to address this problem involve delving in to the fundamental problems with the modern NHS.

To understand why dental care is experiencing so many difficulties in Scotland we have to return to the introduction of the NHS internal market. Introduced by Margaret Thatcher in the 1980s it was the ideological belief that the methods of management used in the private sector were fundamentally more efficient than those used in the public sector.

Up until the 1980s most public services had been run as effectively professional practices, delivered and led by professionals. Think about the structure of a private sector professional services company like an accounting firm or a legal practice; they are not run with a private sector management regime in the way that a supermarket chain is. They are led by professionals who know their trade.

That is an analogy for how medical services used to run. It was Matron and not an HR manager who ran a ward in a hospital, and it was doctors not finance managers who allocated funding inside the system. The move to an internal market was designed to disempower professionals and empower managers to enact the will of politicians.

But it was also always something else; the architects of the internal market saw it as a first step towards privatising the NHS. If every procedure in the NHS can be given a price, then soon the actual nature of the provider becomes irrelevant and you have moved to a system where you can just procure a health service from the private sector.

The shift to an internal market was deeply ideological but has since been embraced by politicians across the political spectrum. No service has had marketisation more deeply embedded than in NHS dentistry.

The impacts of this are quickly visible in the current situation. First of all, resource is allocated not according to medical need but by spreadsheet. The number of NHS dental check-ups funded per person has dropped from two a year to one a year. Is this too much or two little? If you ask a dental professional the answer is 'yes'.

Yes, once a year is too often for some patients who have excellent dental health, excellent dental health routines and no indicators of emerging problems. Yes, once a year is nothing like often enough for someone with ongoing deterioration in their dental health.

The internal market model removes medical determination from health in favour of abstract indicators and blunt averages. But in the dental sector it also takes a 'pay the very, very minimum and require private practice to up-sell everything else' approach. Few patients won't have experienced this if they require dental treatment.

You are told that you can have a procedure done on the NHS, but that it isn't actually the right procedure or is only a stopgap or will require to be redone again because it is not permanent, and the option to upgrade to the treatment actually required will be offered – for a price.

And this offer is very often made when a patient is in a vulnerable position, in the dentist's chair and in need of attention. This incentivises dentists to target practices towards communities which are best able to pay to accept the up-selling. It actively disincentivises provision in the poorest areas. And for patients in financial duress, the fear of being told there is an additional bill to pay may easily be enough to put them off seeking early treatment or getting a check-up.

This only scratches the surface of how the internal market is failing the public provision of dentistry (the regime of dental payments is dense and opaque to most of us) and it is clearly compounded by long-term underinvestment in dental care by successive administrations.

It is unlikely that Scotland's problems with dental provision will be solved solely by reforming the internal market in NHS dentistry, but it seems highly unlikely it can be solved without reform of internal markets. The disparity of dental provision is pretty much exactly what you'd predict to see resulting for the system we have put in place.

It is hard to see how an effective dental service can be provided until Scotland returns to a professionally-led model of dental care. To find out how Common Weal would do that, read our book Sorted.