Richard Smith: Surely time to let the private sector take over dental care completely

richard_smith_2014The NHS is primarily concerned with fending off death. It may be crazy, but it’s so. No expense is spared: heroic surgery, prolonged chemotherapy, absurdly expensive drugs, intensive care, experimental treatments, whatever—the cash-strapped NHS will find the money. As a consequence those activities little concerned with death—dentistry, mental health, social care, and even primary care—“must whistle,” in the words of Britain’s Foreign Secretary. I say “Stop messing about and hand at least dentistry to the private sector.” My experience of NHS dentistry has led me to this bleak conclusion.

Of course, it is not crazy for the NHS to concentrate on death. It may be irrational, but, as Schopenhauer explains, rationality is subject to the will—and “the will is a will to live; and its eternal enemy is death.” And the only way that the will can defeat death is through reproduction, explaining the lavish resources for obstetrics with the wonderful natural birth units, where my granddaughter was recently born: “Reproduction is the ultimate purpose of every organism, and its strongest instinct; for only so can the will conquer death.”

Dentistry is nothing to do with either death or reproduction, explaining my miserable experience.

I had intermittent toothache, so I went to my NHS dentist, where you have to pay unlike a visit to a general practitioner—albeit less than the true cost. The dentist tapped my lower left wisdom tooth, took an X-ray, and pronounced it “crumbing away.” It needed to come out, which has to be done by a specialist. He said he would refer me, warning that it would probably take a month to receive an appointment and another month for it to happen. He also gave me a prescription for antibiotics in case I began to develop an abscess. I haven’t used the prescription, but a few days after my visit the large filling in the tooth came out. I’ve been constantly brushing my teeth and have avoided much pain, although ever so often it flares up, sometimes stopping me sleeping.

I wondered if I should have the tooth pulled out privately. That’s what I did last time—because I was about to go to Bangladesh and didn’t want to find myself in Dhaka with an abscess. It cost me £195 and turned out to be rather a fun experience as the dentist who took out the tooth had worked on Damien Hirst’s diamond encrusted skull and told me of his experience.

As a baby-boomer who didn’t have to pay to go university, never experienced unemployment, owns an absurdly expensive house, has a fat pension, and—best of all—low outgoings, I could easily afford to go privately. And perhaps I should do, leaving the NHS for those who can’t afford private care. But a deep, possibly misplaced, loyalty to the NHS meant that I thought I should stick with the NHS. As I’ve argued before in The BMJ, the most likely endgame for the NHS is the desertion of the middle classes: their taxes are needed to pay for it and their sharp elbows to keep up standards.

A month after my initial appointment I was rung and given an appointment at the dental hospital for six weeks’ time. A couple of weeks later I received a letter that explained that my appointment was simply for examination not treatment: that would come later if needed. “Ring them up,” said my wife, “and tell them that you’ve had the examination and need the treatment. Tell them you’re in pain. Lay it on thick.” I didn’t—partly out of a seemingly uncharacteristic respect for authority and partly because I thought it would be useless.

I went to the hospital this morning and was well treated. A young dentist took my history, which meant explaining the mystery of why I take a statin and three anti-hypertensives when I have neither hypertension nor hyperlipidaemia. So it emerged that I was medically qualified, and perhaps because of that I was bumped up to a consultant after my X-ray. He showed me the X-ray, explained everything well, including possible adverse effects, and advised an extraction under local anaesthetic, exactly what I was expecting. He said that as the operation would be done under local anaesthetic it could probably be one soon, in not much more than two weeks. In passing he explained that dentistry unlike the rest of the hospital hadn’t switched to electronic records because their their heavy workload.

So I went upstairs to make an appointment, which I had to do at a desk that was also managing emergency treatment. There were some fairly desperate looking people. Unfortunately I couldn’t get an appointment for six weeks, until a day or two before I have to leave to go to Bangladesh. As I’m now having to take painkillers, I’ve decided that the time has come to have the operation done privately.

I ring my NHS dentist to see about being referred for a private procedure. Only the dentist who has seen me can refer me, and he won’t be in until next Wednesday (it’s a Thursday). Can he be reached? No, that’s impossible, the receptionist has no way to contact him. She does, however, tell me that if I come in I can get my records and X-ray. She also gives me the number of the private clinic, but she doesn’t think that I can refer myself. She suggests that I get my records and X-ray from the hospital as they are superior X-rays. I ring the hospital and spend about eight minutes listening to “you are in a queue and your call will be answered soon.” When I get through they tell me I must speak to somebody else and transfer me. I wait another two minutes. The person I speak to tells me that I can’t get my notes but I can get my X-ray from “information governance.” She transfers me. Information governance tells me that I can get my X-rays so long as I go to the hospital, bring proof of identity and pay £10; but, she explains, the dental x-rays are on a different system and she’ll have to make a request, which will take a day or so. I say that I’ll ring back before I come in.

Next I phone the private clinic. In two minutes I have an appointment for next week.

This whole process has wasted a lot of resources and time, mostly my time admittedly, and I’m still in pain. Would it not be sensible to cut dental services, which because of being so overstretched are providing an indifferent service to most patients, from the NHS and hand it to the private sector entirely? The rest of the NHS could be left to its unwinnable wrestle with death.

Private expenditure on dental health is already of a similar order to NHS expenditure. The NHS in England spends £3.4 billion on dental services but claws back some £600 million in charges. The only figure I could find on private expenditure was £2.35 billion for the UK in 2011. Private expenditure must be increasing with all those expensive dental procedures, so it might be around £2.5 billion for England alone now. So adding the £600 million to that and subtracting it from NHS expenditure means that public and private expenditure are roughly equal, whereas for all health care it’s about 80% public, 20% private.

I suggest that once care is handed to the private sector the middle classes are encouraged to take out insurance. The NHS could continue to pay for the poor, no doubt paying below the true cost leaving private patients to pick up the difference—just as happens with nursing home care and nursery care for children.

We should then have a better funded system providing better care for all. We would, however, have arrived with dental care at the prediction of Princeton health economist Uwe Reinhardt that all health systems will eventually become fee for service for the very rich, insurance based coverage for the middle classes, and a rump service for the poor. The danger is, of course, that the rump service for the poor provides low quality care—but that seems to be what’s happening at the moment even to a middle class person like me. The alternative is for the NHS to abandon its battle with death, but, as Schopenhauer helped us understand, that won’t happen.

Richard Smith was the editor of The BMJ until 2004.

Competing interest: None declared.