Richard Smith: A foretaste of the end of the NHS

richard_smith_2014When the NHS began in 1948 dental care was free at the point of delivery, but charges appeared as early as 1951. My current experience with dental services gives me a foretaste of how the whole NHS may begin to crumble.

There is little left of one of my upper molars. My NHS dentist has filled it several times, telling me honestly that the filling has a 50% chance of surviving. The alternatives, he said, were some sort of complicated crowning or extraction. As my many sins do not include vanity (and anyway the tooth is not easily seen), I thought that extraction would be best; and I wish now that I hadn’t gone along with the third filling—but it’s always hard to go against a professional.

About six weeks ago while I was abroad the filling came out again. When I got home I made an appointment for about a week away, which I thought not too bad. The dentist agreed that the time had come for extraction and referred to me to an oral surgeon. “If you haven’t heard anything in three weeks contact us.” After two and a half weeks I decided to try and speed up the process. I rang the practice, got the number of the practice I’d been referred to and rang them.

They didn’t know if they’d received my referral as they hadn’t had time to go through the pile, but they would make an appointment anyway. The oral surgeon comes only on Tuesdays and is fully booked until the end of May. Unfortunately I will be abroad again and so made an appointment for the end of June, wondering if I’d make it that far.

Yesterday I developed a toothache, which despite taking regular aspirin disrupted my sleep.

When I got up this morning I set to work to discover my options. I looked at NHS Choices, and it told me that I should go to an Accident and Emergency department if you:

• “are in severe pain that is not helped by painkillers
• are bleeding a lot and it won’t stop
• trauma of the face, mouth or teeth after a recent accident or injury”

None of those applied to me. I rang NHS 111 and almost immediately got through to a pleasant woman, who explained that there didn’t seem to be a way that I could access an oral surgeon urgently. “You used to be able to just go to King’s, but it was chaos. Now you need an appointment, and it depends on where you live. Where do you live?” I said that I lived in Lambeth and Southwark and that King’s was in Lambeth and Southwark. “But that doesn’t mean you’ll qualify.” She couldn’t tell me whether I would or not but said that they didn’t do anything urgent until after 5.30 pm anyway. “If you haven’t sorted out anything by 6pm ring back, we start a triage service then.”

I asked if she could advise on a private dentist. She couldn’t.

I thought that I’d better look for a private oral surgeon myself. I searched on Google, which has many ads for emergency dentistry. I tried the first one that wasn’t an advertisement. They couldn’t help, they didn’t have an oral surgeon. The first advertised place said they could give me an appointment for 9.30. It would cost £65 for the consultation and from £250 upwards for an extraction.

Interestingly it wasn’t the cost that stopped me but worries about the quality of the service. I realised that I didn’t have confidence in dental regulation. Another worry was they’d be more interested in the money than me. Just as I never pick a plumber or builder off the internet, so I was reluctant to select a dentist.

By now it was opening hours for the dental practices. The one where I’m scheduled for an extraction couldn’t help. My own practice was sympathetic and made an appointment for me to see my dentist tomorrow. “He’ll give you some antibiotics.” Perhaps too he’ll be able to advise me on a private dentist.
Is this, I wondered, how it will be when NHS medical services go the same way as dental services? We hope, of course, that that will never happen. Why should medical services be different? The answer is “death.” Death is the making of medicine: “matters of life and death” take priority—but it’s death not life that really makes the difference. I remember an American psychiatrist saying “We psychiatrists made a mistake by not emphasising how mental illness kills” and think of a professor of psychiatry a week ago reeling off statistics on how mental illness shortens life. Lucky old cardiologists with so many deaths, and oncologist are luckiest of all in that cancer equals death in the popular mind.

Then I think of friends in the US and other countries where services are private. They would have “their dentist” who would see them this morning and solve the problem within hours, referring them if necessary. They wouldn’t anyway be waiting months for an extraction. I think too of doctor friends here who would use their networks to get care quickly. Perhaps I need sharper elbows, a greater capacity to get angry. Instead of writing a blog on my experience and reflecting on its implications, I’d be out there solving the problem.

My last thought relates to my recent reading on the breakup of empires. Mostly it’s messy. The collapse of the Roman Empire was followed by centuries of chaos. The British Empire left partition, apartheid, and the insoluble problem of Palestine. So if the NHS Empire breaks up might it be more orderly? History says not.

Richard Smith was the editor of The BMJ until 2004.