Still crazy after all these years

I,¹ and other commentators,^2,3 have expressed anxieties about the viability of NHS Dentistry in recent times. Indeed, I first spelt out the problems with the 2006 ‘new’ contract 2 years before it arrived.⁴ Nothing much has changed. The UDA payment system has been tweaked to make molar root canal fillings more attractive (perhaps not the correct word – perhaps less bankrupting fits better), but, the question must be asked – why has it taken all these 16 years to realize that, as the letter from NHS England states (written by Ali Sparke, Director for Dentistry, Community Pharmacy and Optometry NHS England and Sara Hurley, CDO England⁵) – ‘the provision of molar endodontic care to permanent teeth….can be more time consuming’. Any realist who has ever carried out a molar root canal filling would change ‘can be’ to ‘is’, which perhaps goes to show how out of touch those at the top of NHS Dentistry are with the world of general dentistry.

Notwithstanding the proposed changes, has irreparable damage to the system been done and how easy will it be to repair what obviously is a breakdown in trust? The poor morale of many NHS dentists and the knock-on effect that many are retiring (early, in some cases) or simply leaving the profession, has seen no sign of changing, and recent figures from the NHS annual dental statistics show that 16.4 million adults in England saw a dentist in the 24 months to 31 December 2021. This is a drop of 1.7 million compared to the same data from a year previously, possibly caused by the exodus of clinicians. This may have been ‘explained’ by Steve Barclay, Secretary of State for Health from July to September 2022, when he stated ‘One of the issues is dental practices not using funding to its full capacity – the use of wider staff (dental therapists and hygienists) will make dental practices run more efficiently and free up time for dentists to perform more complex treatment’. Out of touch? Perhaps he should have visited an NHS dental practice to see for himself that, in general, dental practices are arguably among the most efficient parts of the NHS. They have to be to survive!

At last, thanks to the BDA and others, the press have caught on to the predicament of NHS dentistry, with a wide variety of newspaper and television pieces, and the new Secretary of State for Health and Social Care in England, having something to say about the problem, even if there weren't any well-thought-out solutions in evidence. What remains clear is that the system needs fixing, but how easy will that be in a cash-limited system? I titled this brief editorial after the famous 1975 song by Paul Simon. While its title might be appropriate to NHS dentistry's present state, I had hoped to quote some of the words of the song, but, unfortunately none of the lyrics are apposite. However, an interpretation of the song⁶ might fit the current situation better: namely, that the lyrics acknowledge a nostalgia for the past (a pre-UDA fee system perhaps?), but also subtly suggest that once the nostalgia is gone, it may be replaced by bitterness (dentists leaving the system?).

This brief resume of how I see the current crisis in NHS dentistry in England serves as an introduction to a Guest Editorial by Richards and colleagues who provide a view on how Wales has responded to the COVID-19 pandemic, with the authors putting forward a solution to developing Welsh services for the future, recognizing the need to change from one paradigm to another in order to address changes in disease prevalence.

PS. Thanks are due to the team in Manchester who have contributed to the excellent TMD series which ends in this issue: it has improved our knowledge of a potentially difficult subject in a readily understood way. And, may I draw readers' attention to the new series on Psychiatry and its relevance to dentistry – again, all clearly presented as case-based discussions of conditions that we might all encounter.