22nd March 2021
Dear Sir Stevens,
RE: Fighting inequality by improving NHS dental and oral care
The COVID-19 pandemic brought the discourse on health back to the heart of society. I personally cannot remember ever talking about health and illness prevention more than during the previous 12 months. Given your long list of recent media appearances, I believe you must feel the same. However, my anthropology modules at University College London taught me to always question why certain issues are not talked about and whose voices are silenced. Therefore, I wish to ask you: why is oral and dental care so often overlooked when it comes to the provision of care by the NHS England?
On the 17th of March 2020, you urged the chairs of all NHS trusts to cease medical face-to-face appointments wherever possible (1). This effectively made the ongoing provision of dental care impossible. The emergency care which was later offered has been heavily criticised for flying “in the face of the standard of care expected for patients at any other time” (2). In February this year, Healthwatch England has warned of a dental health crisis as a result of the COVID-19 pandemic which has “exacerbated the human impact of years of structural issues in NHS dentistry and is now pushing it to crisis point” (3). Furthermore, the NHS England’s 10-year plan does not include any major improvements with regards to dental health (4). To me, this suggests that the NHS England systematically prioritises physical over dental health.
Dental care also takes an outsider role in terms of accessibility as it is the only NHS service with user fees (5). As a result, we can already see how current NHS dental care provision reinforces social inequalities and I am afraid that this is indicative of larger trends within the NHS. Especially worrying is the increasing unequal access to dental care and the current form of risk management. To improve health across the UK population, I urge you to:
- Discontinue dental charges for patients and restructure the NHS dental care compensation scheme to encourage dentists to provide more public services.
- Remove conditionality from all NHS services.
Dental health divides our society
I volunteer with an older people’s group in my local community centre in the heart of London. As a non-UK citizen, I was shocked to learn that bad teeth are visible markers of poverty and old age in the UK. Some may now argue that actually oral and dental health improved significantly over the recent decades (6). However, some groups seem to be systematically excluded from this achievement.
A survey found that costs influence the choice of dental treatment of 25% of adults and lead to delayed treatment for 20% of adults in the UK (6). Ethnographies from the United States illustrate the effects of poverty on oral health. The anthropologist Nolan Kline describes the oral health syndemic among migrant farmworkers in Florida (7). The biosocial concept of “syndemics” refers to the idea that multiple diseases and contextual factors can interact synergistically (8). Their combined adverse effect is greater than the sum of their individual effects. Poverty influences access to dental care and nutrition choices which in turn influence oral health (7). However, poor oral health (e.g., pain while chewing) may also encourage less nutritious food choices. These negative effects are further mediated by other illnesses such as diabetes and affect health more systemically. It is likely that we will see clustering of these health issues in the UK. It is known that those who attend dental check-ups frequently have better dental health, but also receive preventative health advice more often (9). Consequently, it should be acknowledged that the burden of poor dental health is experienced unevenly in the UK.
Dental health inequalities can also further deepen social inequalities beyond health. Already one in seven British children has severe tooth decay (6). Poor dental health in children has been described to create “stigmatised biologies” (10). These children are set up for poor dental health in adulthood. Bad teeth are clear markers of marginalisation and decline upward social mobility. Also, residents of care homes suffer from the social effects of poor oral health. The Care Quality Commission criticised insufficient oral care in care homes which results in high rates of caries and edentulism (11,12). Poor oral health in old age is perceived as an indicator of a dysfunctional body (13). In a society which promotes healthy ageing, older adults struggle to reframe their dentures, and missing teeth impact their social behaviour as well as their identity.
In summary, the NHS clearly fails to deliver on its promise of providing equitable care to all (14). Improving dental care is fundamental to create a more just society.
Improving access to dental and oral healthcare
The previous examples demonstrate that cost is a significant barrier to accessing dental care. Therefore, I urge you to drop the dental charges for NHS users. While there are many other barriers (15), I think it is crucial to make the provision of public services more attractive to dental and oral care providers.
Since the 1990s, UK dentists have increasingly provided more private and less public services. This shift has often been explained by financial reasons. Also, dentists name better quality of care (e.g., more time and innovative treatment) and greater autonomy as important motives (16). Ethnographies among dentists in the US showed that the healthcare system can reproduce existing social inequalities (10). For the same treatment, California’s dental Medicaid insurance programme Denti-Cal pays dentists 60-70% less than medical insurances. To remain financially viable, dentists either limit the number of Denti-Cal patients (restrict access) or try to economise time. Therefore, they are more likely to offer extraction than restoration and treat young Denti-Cal patients in “an assembly-line manner” (10). If offering NHS dental services does not become more attractive, similar trends are likely to occur in the UK and dental care could increasingly become a two-tier system.
Restructuring compensation schemes is also crucial to create equal access across regions. In Northumberland, two villages have been without a NHS dentists for over a year as a result of the complex bidding systems for dental NHS contracts (4). Lock and Kaufert describe how different social and physical conditions across societies can create “local biologies” (17). Local variation in dental health can be the result of e.g., differences in culture, environment or diet (10). However, local variation should never be the result of a badly designed compensation scheme.
Lastly, I think it is dangerous that the NHS embraces conditionality as part of their dental service provision. The well-known anthropologists Rylko-Bauer and Farmer convincingly argue that neo-liberal reforms which shift responsibility from the state to the individual are incompatible with the principles of justice and social good which should underly healthcare systems (18). Introducing conditionality threatens the NHS core values as it constraints access to care (14).
In 2011, a conditional health policy was trialled in NHS dentistry and is now planned to be rolled out nationwide (19,20). This traffic light system classifies patients according to their oral health status. Patients with poor oral health only receive limited access to restorative treatment until they reduce their risk by investing into preventive care (19). For a long time now, it has been well-established that non-compliant patients are also those who are the least able to comply (18). The traffic light policy has been criticised for reinforcing social inequalities (19). Therefore, how can you promote its application?
Furthermore, dentists must communicate risk to their patients as part of this programme. Policy makers seem to think that a risk score (based on the traffic light system) will encourage patients to engage in preventative efforts (20). However, fieldwork showed that dentists often translate risk in implicit ways (21). Instead of using the term “risk”, they present risk talk as an administrative obligation and express risk by outlining possible future outcomes. Furthermore, patients respond best to personal and detailed verbal advice and prefer it over abstract risk scores (20). In conclusion, promoting prevention is strongly needed and the traffic light system tries to do that. However, it fails to communicate risk in a meaningful way to patients and its conditional nature makes it unlikely that it will benefit those who need it most.
Why should you act right now?
I understand that it seems as if the NHS faces bigger challenges than dental health right now. However, I also know that discussions about you leaving your post are underway (22). Improving dental health services would make a perfect last project to set the right tone for the future development of the NHS. During the past months, the public has called loudly for the protection of our NHS. There is great support for the core values of the NHS. Now is the time to show that these are at the heart of the NHS by restructuring dental care services.
1. Stevens S, Pritchard A. Simon Stevens and Amanda Pritchard to the chief executives of all NHS trusts and foundation trusts: ‘IMPORTANT AND URGENT – NEXT STEPS ON NHS RESPONSE TO COVID-19’. [Online] London; p. 1–17. Available from: https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/03/urgent-next-steps-on-nhs-response-to-covid-19-letter-simon-stevens.pdf [Accessed: 20th March 2021]
2. British Association of Private Dentistry. BAPD takes vote of no confidence in Office of Chief Dental Officer. The Dentist. [Online] Middlesex; 2020; Available from: https://www.the-dentist.co.uk/content/news/bapd-takes-vote-of-no-confidence-in-office-of-chief-dental-officer [Accessed: 20th March 2021]
3. Francis R. Warnings of dentistry crisis as public concerns continue Healthwatch. [Online] Healthwatch. Available from: https://www.healthwatch.co.uk/news/2021-02-08/warnings-dentistry-crisis-public-concerns-continue [Accessed: 20th March 2021]
4. Watson M. NHS England’s 10-year plan. Dentistry. [Online] 2019; Available from: https://dentistry.co.uk/2019/01/09/nhs-englands-10-year-plan/ [Accessed: 20th March 2021]
5. NHS. How much will I pay for NHS dental treatment ?. [Online] Available from: https://www.nhs.uk/common-health-questions/dental-health/how-much-will-i-pay-for-nhs-dental-treatment/ [Accessed: 20th March 2021]
6. Appleby J. Dentistry: Should it be in the NHS at all? British Medical Journal. [Online] 2016;355: 1–4. Available from: doi:https://doi.org/10.1136/bmj.i5986
7. Kline N. ‘There’s nowhere I can go to get help, and I have tooth pain right now’: The oral helath syndemic among migrnat farmworkers in Florida. Annals of Anthropological Practice. [Online] 2013;36(2): 387–401. Available from: doi:https://doi.org/10.1111/napa.12010
8. Singer M, Bulled N, Ostrach B, Mendenhall E. Syndemics and the biosocial conception of health. The Lancet. [Online] Elsevier Ltd; 2017;389: 941–950. Available from: doi:https://doi.org/10.1016/S0140-6736(17)30003-X
9. Hill KB, Chadwick B, Freeman R, O’Sullivan I, Murray JJ. Adult Dental Health Survey 2009: Relationships between dental attendance patterns, oral health behaviour and the current barriers to dental care. British Dental Journal. [Online] Nature Publishing Group; 2013;214(1): 25–32. Available from: doi:https://doi.org/10.1038/sj.bdj.2012.1176
10. Horton S, Barker JC. Stigmatized biologies: Examining the cumulative effects of oral health disparities for Mexican American farmworker children. Medical Anthropology Quarterly. [Online] 2010;24(2): 199–219. Available from: doi:https://doi.org/10.1111/j.1548-1387.2010.01097.x
11. British Dental Association. Oral healthcare for older people. [Online] Available from: https://bda.org/about-the-bda/campaigns/oralhealth/Pages/oral-healthcare-older.aspx [Accessed: 22nd July 2021]
12. Moore D. What is Known About the Oral Health of Older People in England and Wales A review of oral health surveys of older people. [Online] Public Health England. 2015. Available from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/489756/What_is_known_about_the_oral_health_of_older_people.pdf
13. Warren L, Kettle JE, Gibson BJ, Walls A, Robinson PG. ‘I’ve got lots of gaps, but i want to hang on to the ones that i have’: The ageing body, oral health and stories of the mouth. Ageing and Society. [Online] 2020;40(6): 1244–1266. Available from: doi:https://doi.org/10.1017/S0144686X18001605
14. Delamothe T. NHS at 60: Founding Principles. British Medical Journal. [Online] 2008;336(7655): 1216–1218. Available from: doi:https://doi.org/10.1136/bmj.39582.501192.94
15. Scheppers E, van Dongen E, Dekker J, Geertzen J, Dekker J. Potential barriers to the use of health services among ethnic minorities: a review. Family practice. [Online] 2006;23(3): 325–348. Available from: doi:https://doi.org/10.1093/fampra/cmi113
16. Calnan M, Silvester S, Manley G, Taylor-Gooby P. Doing business in the NHS: Exploring dentists’ decisions to practise in the public and private sectors. Sociology of Health and Illness. [Online] 2000;22(6): 742–764. Available from: doi:https://doi.org/10.1111/1467-9566.00229
17. Lock M, Kaufert P. Menopause, local biologies, and cultures of aging. American Journal of Human Biology. [Online] 2001;13(4): 494–504. Available from: doi:https://doi.org/10.1002/ajhb.1081
18. Rylko-Bauer B, Farmer P. Managed Care or Managed Inequality? A Call for Critiques of Market-Based Medicine. Medical Anthropology Quarterly. [Online] 2002;16(4): 476–502. Available from: doi:https://doi.org/10.1525/maq.2002.16.4.476
19. Laverty L, Harris R. Can conditional health policies be justified? A policy analysis of the new NHS dental contract reforms. Social Science and Medicine. [Online] Elsevier; 2018;207: 46–54. Available from: doi:https://doi.org/10.1016/j.socscimed.2018.04.041
20. Harris R, Vernazza C, Laverty L, Lowers V, Burnside G, Brown S, et al. Presenting patients with information on their oral health risk: the PREFER three-arm RCT and ethnography. Health Services and Delivery Research. [Online] 2020;8(3): 1–126. Available from: doi:https://doi.org/10.3310/hsdr08030
21. Laverty L, Harris R. Risk work in dental practices: an ethnographic study of how risk is managed in NHS dental appointments. Sociology of Health and Illness. [Online] 2020;42(7): 1673–1688. Available from: doi:https://doi.org/10.1111/1467-9566.13154
22. Owne G. Sir Simon Stevens is poised to step down as NHS chief executive Daily Mail Online. The Mail on Sunday. [Online] 2020; Available from: https://www.dailymail.co.uk/news/article-8751191/Sir-Simon-Stevens-poised-step-NHS-chief-executive.html