When Lucy finally found a dentist that would accept NHS patients, she asked if she could join with her family. She lives in Devon with her husband and two children and none have access to an NHS dentist. “They said no,” she says. “So I asked them to take my children, not me or my husband, but they said they couldn’t take the children without an adult.” But they weren’t taking new adult patients, either.
Routine private checkups are too expensive, so they opt only for urgent care, and only to the level they can afford. She has just paid £400 to have a tooth pulled – she could have had a filling, but that would have cost £500 and she couldn’t justify the extra expense. “My children not having a dentist really worries me. I nag them a lot to brush their teeth. What’s the alternative?”
Lucy is right to worry. Tooth decay is the biggest primary cause of NHS hospital admissions for children in England aged between five and 17, as 40% of children no longer have access to regular dental appointments. Between April 2022 and May 2023, 30,000 children and more than 70,000 adults in England were admitted to A&E with tooth decay. As Matthew Taylor, chief executive of the NHS Confederation, said last year: “Accident and emergency departments are overflowing with people in severe dental distress.”
Paul was admitted to Exeter A&E in 2022 after an impacted molar had become infected, causing terrible pain and swelling. He spent five hours in the waiting room in agony. “I went through triage, had an X-ray and that’s when I met the dental surgeon,” he says. “By then it was evening. At one point, they tried to access the tooth and remove it, but they couldn’t. So they said I would have an operation under general anaesthetic the next morning.” Paul was in hospital for two nights.
The next time he wanted to see his dentist, he found that the practice had closed down. There are no others taking NHS patients in his area. He is now planning to join a dental plan that will cost just shy of £20 a month to try to avoid needing urgent care again, because “even the private practices around here are not accepting new patients”, he says.
When my elderly aunt had a fall and knocked her tooth half out at the end of 2022, she was also forced to go to A&E. I waited with her for four hours while her face got more and more swollen. Ordinarily, this kind of accident would have been treated by a dentist. But my aunt doesn’t have a dentist, as her dental surgery closed down during the pandemic and the NHS dentists in her area are not taking on new patients. Ultimately, she was in A&E for one reason: because she couldn’t afford to go private.
Like my aunt, most of the patients with dental problems who end up in overstretched A&E departments shouldn’t be there – they are supposed to be treated by a local dentist and have regular checkups to prevent such severe situations. But with 90% of dentists across the UK not taking on new NHS adult patients – according to the BBC and the British Dental Association (BDA) – and many refusing to see a child unless a parent is signed up as a private patient, it’s no wonder people are turning up to A&E in their tens of thousands.
A 2023 survey of school nurses and dentists found that nearly four out of five had seen higher rates of tooth decay. Huge parts of the UK are now “dental deserts”, where 100% of dentists are not taking on new patients, including Devon and Cornwall, Norfolk, Cumbria and much of Wales. One junior doctor posted on X recently that she had seen a 13-year-old in A&E who had grown up in the “dental desert” of the south-west of England and had never seen a dentist before. “Is this just the ‘new normal’ we are expecting now?” she wrote. As a result, say dental campaigners, oral cancer, which is usually picked up during routine checkups, has risen by a staggering 46% in the past decade. It has also led to worrying reports about “DIY dentistry”.
Danny Smith, 43, says he dreams about pulling his teeth out. He has researched dental pliers online, desperate to put an end to the pain he has as a consequence of his lupus: jaw aches, teeth grinding and chronic mouth ulcers from the steroids he is prescribed. Smith’s NHS dentist removed him from their lists during the pandemic “because I hadn’t been for two years”, despite the lockdowns making that impossible. There are no other dentists accepting NHS patients where he lives. He can’t afford to go private – he’s is unable to work due to ill health – and so he is left to his own devices, using painkillers mostly. He filled some cavities himself using a compound he found on Amazon.
But it is his family he is most worried about. He has a partner and two daughters, aged six and 14, both of whom are autistic. None of them have an NHS dentist. His elder is due braces and already struggles to trust people enough to be near her, let alone look at her mouth.
“The nearest NHS dentist that would take the children is about an hour’s drive away. But they make you register in person, then you have to wait another week before they will see you for an appointment,” he says. “To have two autistic children who experience travel anxiety going back and forth to a place that they don’t want to go, both children overstimulated and kicking off in a car, it’s dangerous,” he says.
Meanwhile, his partner is putting up with a recurring abscess. When we speak, Smith says they are considering heading to A&E.
“Dental pain is terrible for patients,” says Tamara, an A&E doctor in London. “But we are limited in what we can do. I usually offer advice on pain reduction or, if there is an infection, prescribe antibiotics.” She has known people to have overdosed on painkillers because their dental pain is so bad – “and then you’ve got to start treating them for drug toxicity” as well as their teeth.
A&E doctors are not trained for dentistry, she says. Some hospitals have oral or maxillofacial surgeons and specialists on site to whom A&E staff can refer patients, but “only for certain things. We can’t make referrals for standard dental issues, because that’s not what [the surgeons] are there to do.
“The failure to provide any decent preventive measures means the costs end up more expensive, too,” she says. “I would expect it’s more expensive to bring kids in and remove their teeth in hospital than it is to provide basic dentistry services and stop them having terrible decay in the first place.”
There have been warnings for years. In 2017, the BDA said: “Ministers keep underestimating how much their indifference to dentistry has knock-on effects across the health service.” It suggested that, due to “systematic under-reporting”, the official statistics of 14,500 people attending England’s A&Es with dental problems was far too low and gave a “conservative” estimate of closer to 135,000 patients. Visits are higher on the weekend, with out-of-hours private dentist charges probably playing a role, as patients take their chances with the free A&E. It is the same for GPs: a 2018 study found GPs were seeing 380,000 dental cases a year. Like A&E staff, GPs are not trained to deal with dental problems.
Why is our dentistry system so broken? For Nye Bevan, the founding father of the NHS, the original sin may have been the 1951 introduction of dental charges. He considered it such a serious breach of NHS principles that he resigned over it. But despite dental charges being in place for nearly as long as the NHS itself, how NHS dentistry has been delivered has changed over time. Its current iteration, the 2006 standard general dental services contract known as “the contract”, has repeatedly been found to be failing patients. A 2008 health select committee said it was not fit for purpose; a scathing report from the same committee in 2023 echoed this conclusion. The BDA has been campaigning for reform for years.
All dentists in the UK are private contractors. About three-quarters of these have a contract with the NHS to deliver a certain number of services, quantified in units of dental activity. Any UK citizen can have NHS dental services – it is free if you are pregnant, on low-income benefits or under 18, otherwise you pay according to three bands of charges – ranging from £25.80 for a checkup to £306.80 for more complex treatments such as crowns and dentures. The system is a raw deal for patients as well as dentists.
For the dentists, roughly speaking, units of dental activity work in the same way as the price bands. Band one is one unit of activity, band two is two and band three is 12. It doesn’t matter how many treatments a patient needs in a band; they only pay the one band fee – so if you need one filling, or three and perhaps an extraction (fillings and extractions fall into band two), it will be £70.70 regardless, even though it will have taken the dentist much more time. This can leave dentists struggling to fulfil their NHS commitments, which is enormously stressful. According to the BDA, 87% of dentists have experienced burnout and other mental health issues.
From a patient’s perspective, charges inevitably lead to those who are financially struggling avoiding checkups and refusing expensive treatments they might need. By the time they end up at the dentist, if they do at all, they are in serious pain and need multiple treatments that take time, which exacerbates the problems on the dentist’s side.
The government’s answer has been to increase patient charges so that the units of dental activity are worth more, rather than to fix a fundamentally broken model. Funding is an enormous part of that. NHS dentistry is not funded for everyone – it is funded to provide basic services for half of the population, under the assumption that the rest will go private. According to Bupa, the UK has the lowest per capita spending on oral health in the G7.
Since the beginning of the pandemic, at least 2,000 dentists have left the profession, bringing the number of available NHS dentists to its lowest number in a decade. Nearly half have reduced their commitment to NHS treatment. With private patients, dentists can simply charge for all the work they have done. Is it any wonder, then, that so many dentists are prioritising private patients and choosing to reduce their NHS commitment if not going fully private?
What is unfolding is a two-tier oral-health system, where a healthy smile might soon be the preserve of only those who can afford it. As politicians call for patient charges in other parts of the NHS, with the former health secretary Sajid Javid suggesting that patients should pay for A&E and GP visits, we would do well to remember dentistry as an example of how badly that system can work. Charging those who can afford to pay for dentistry has not made the system any better for those who cannot.
Mark Jones is the co-founder of Toothless in England, a campaign group demanding an NHS dentist for everyone. It started in Leiston, Suffolk, in 2020 when the last dental practice closed down. “We thought we’d start a petition,” he says. “We set up a table outside the Co-op in the town centre. Even before we had finished setting-up, we had a queue forming: “I’d never seen anything like it. People were incandescent.” The campaign has since expanded to all of England. “I’ve spoken to dentists who have had to leave the profession because they were forced to go private,” he says. “I’ve had people tell me they have had to travel to Scotland to see a dentist.”
He remembers a woman telling him the compulsory face masks in the pandemic were the best thing to happen to her, “because for the first time she was able to have a chat with her neighbours and not feel as if she was being judged for her teeth”.
But despite the efforts of campaigners such as Jones, little has been done. He recalls attending a roundtable with various politicians and the conversation getting stuck on minimum service levels. “I’m thinking: ‘What are you talking about, minimum?’ It’s the word embedded in the culture of these politicians, to get away with as little as possible. It’s the wrong way of looking at it,” he says. “People are in agony from abscesses, dying from oral cancer, and they’re talking about how to get away with as little as possible.”
In July, the then health secretary, Steve Barclay, promised parliament that the government would set out plans for a dentistry rescue plan “shortly”. It is yet to arrive. Labour has promised that it will reform the dentistry contract and provide 700,000 more appointments if it wins power. It will also roll out preventive measures such as supervised toothbrushing in schools for three- to five-year-olds, focusing on the areas with the highest childhood tooth decay.
My aunt was lucky – the doctors at A&E were able to help her in the short term and, after a number of relatives joined the search effort, she did eventually find an NHS dentist to continue her care. But thousands have not and will not have the same good fortune. Instead, they will be left to hope and pray that nothing goes wrong.
Some names and details have been changed
