Tribalism is such an unhealthy character trait. More often than not we see it in the sporting arena - particularly football - where it's considered a badge of honour to support a team no matter what. There's plenty of research that suggests tribalism is the root of hooliganism, which to me is just bonkers. It's only a game.

This belief of an entrenched viewpoint, no matter what, has made its ugly way into society we live in today. How often do we have considered, challenging and fruitful conversations and debate and agree to disagree, yet come away wiser having listened to views that challenge our own? It's always been prevalent in politics, but it's impossible to say it hasn't increased in recent years; rhetoric that has the power to divide us will always do that. It has led to what I call 'political hooliganism' - and yes, it is bonkers.

It is one of these potentially divisive political questions I want to take a closer look at: is NHS dentistry - as part of the wider NHS - being privatised by stealth?

figure 1

Wider concerns and commentary

For some, your answer to that question and subsequent interpretation of these data will be - in the main - dependent on your political allegiance. In reality, the answer has at least 50 shades of grey and a lifetime away from being black and white. In February 2021, The Guardian reported some NHS dental patients were being asked to pay for private appointments to get treatment while others faced two-year waits to be seen.

They reported that Healthwatch England had been 'contacted by hundreds of people between October and December 2020 complaining about dentistry issues in the health service, with one patient told their odds of successful treatment would increase substantially if they paid for private care. Another patient was offered a procedure for £1,700 which was £60 on the NHS'.

Sir Robert Francis QC, chair of Healthwatch England, said the pandemic had 'exacerbated the human impact of years of structural issues in NHS dentistry and is now pushing it to crisis point'. The Healthwatch England document went on to say: 'A lack of NHS dentist appointments remains the most common issue that people have told us about. People have indicated that dentists have prioritised private care or asked them to pay private fees if they wanted any treatment'.1

This is a classic example of why such questions are not black and white in nature. The BDA estimates over 19 million appointments have been delayed since lockdown, so of course there are going to be a lack of NHS appointments - the numbers just do not add up. The article failed to mention the impact fallow time had, nor the arbitrary targets imposed on NHS contract holders upon resumption of dental services in June 2020. There was simply not the capacity to work through the backlog of those appointments in a manner that tallies with patient expectations. For many private practices, they were in a better position to treat patients if they wanted and needed to be seen, so it is little wonder they would have been offered this option.

' Sir Robert Francis QC, chair of Healthwatch England, said the coronavirus pandemic had 'exacerbated the human impact of years of structural issues in NHS dentistry and is now pushing it to crisis point''

In reality, the NHS has paid private providers to deliver care ever since it was founded in 1948. The Labour Health Minister and architect of the NHS, Aneurin Bevan, nationalised secondary care, but left primary care in private hands. Dentists, GPs, pharmacists and opticians are in contract with the NHS, but not part of it; they remain in the private sector. In The New Statesman, Anoosh Chakelian wrote in December 2021: 'In 2014 I interviewed Andy Burnham, who was previously health secretary under Gordon Brown and is currently the mayor of Greater Manchester, and he said of New Labour: 'The last government worked with the private sector to bring down NHS waiting lists and they came right down. And that's how I see it. I see a supporting role but not a replacement role [for private money in the NHS]'.'2

Chakelian's excellent article went on to say there is particular concern among some left-wing politicians and NHS frontline workers that the Conservative government is using the pandemic to advance marketisation of the health service, with others on social platforms suggesting the government's Health and Care Bill will allow for greater privatisation of the NHS. It was a concern Peter Dyer, Chair of the British Dental Association's Central Committee for Hospital Dental Services, highlighted in November's BDJ In Practice:

'We really need to be aware of the apparent move to privatise large areas of dentistry by stealth under the auspices of the Health and Care Bill.

'The principle of funding primary, secondary and social care together through Integrated Care Systems is in principle a good one, but smaller dental departments will eventually come under threat of closure or being swallowed up by larger Trusts covering a wide area, again affecting access.

'We'd be facing a scenario where there's an artificial divide where elective treatment is moved to private contractors and high-end groups are treated within the NHS. There's talk of training Tier 2 dentists as specialists in primary care, where the problems could be solved on the high street. The pressure would become enormous - high street dentistry is barely able to cope as it is. There are so many holes in the idea, and we will continue to voice our concerns in the strongest possible terms to ensure hospital dentists do not face these realities moving forward.'3

Perhaps it's the two-tiered system of NHS and private dentistry, but it's easy to find and read complaints about the cost of dentistry. It's not as easy to find patients quibbling about their opticians, for example. When NHS dental charges are announced for the financial year, they - alongside NHS prescription charges - are often the target of campaigners for pricing patients out of the help they need. The BDA slammed the most recent inflation-busting 5% increase in NHS dental charges in England announced in November 2020, accusing the government of erecting further barriers to care during the COVID-19 pandemic when services remained so limited and focused on dealing with an unprecedented backlog. Further changes at a time of national rising inflation may well be announced in the coming months, and it will be fascinating to see the reaction if and when that happens.

Many patients - not through their own doing - simply do not understand the system, but rage against it when it does not benefit them. To them, the NHS means free, not paid-for. During my research, I came across one post with the title 'Privatisation by stealth - dentists raking in £££', which read:

'My dentist said I needed secondary root canal treatment or lose a back lower molar. I was told this was a specialist treatment so therefore a referral to hospital would be required but then went on to say because it was a back molar and secondary treatment that I do not fit the criteria.

'It appears that the NHS yet again is rationing provisions of services that are clinically indicated.

'Another example of privatisation by stealth.

'The dentist then went on to say however we could treat you with the specialist in our clinic and that will cost you around £600-£1000!'

It wasn't limited to England, either. One letter in The Herald, entitled 'Why have we let them get away with privatising our dentists?' read:

'At every election that Nicola Sturgeon has participated in her message has been 'Vote SNP to prevent the NHS being privatised by the Tories (or anyone else who is not SNP)'. And yet today the First Minister, abetted by her serially useless Health Secretary, has effectively privatised NHS Scotland's dentistry by stealth.

'At best you might get a check-up or a wee clean but any other treatment will require you to dive deep into your pockets. On a recent visit to my previously-NHS dentist I found that a somewhat complicated filling would cost me £300-plus. I asked the dentist when NHS dentistry would be fully restored and her sharp blunt answer was 'never'.

'Dentists have written in your pages detailing this sad situation but here it was in reality. A major part of our heath service has been de facto privatised, not by common knowledge but by stealth. Our First Minister should come clean over this dreadful situation but I seriously doubt it.

'As time goes by when Ms Sturgeon waves to her adoring fans with her gleaming smile I think she will be faced by an increasingly toothless, gurning audience, not just because of a lack of another independence referendum but due to lack of a dentistry service.

'Scotland's NHS safe with the SNP? The evidence says otherwise.'4

It is this sort of narrative that dentistry works in spite of. The letter was even published after the SNP announced free dental care for 18-25-year-olds. Scotland already operates free NHS dental check-ups and BDA Scotland say official data from before the pandemic indicated Scotland had 25% higher adult participation rates compared to England, which hints at the scale of demand and the barriers posed by patient charges. This begs the question: is it viewed differently to the majority of the NHS, simply because an exchange of money is involved? Does that affect the relationship between practitioner and patient? Will any increase in costs have patients screaming 'privatisation' from the rooftops? In this very issue of BDJ In Practice, Kevin Lewis writes:

'Third parties such as the GDC, the media and the consumer lobby are ever-alert to the possibility of a dentist's decision-making being skewed by commercial motives and these suspicions do seem to be heightened in direct proportion to the amount of money involved. This unfortunate, but deeply entrenched, viewpoint leaves private dentists particularly vulnerable. So, regardless of whether patients make that same link, you can be sure that these other parties do; interestingly, the evidence further suggests that patients only tend to explore that link at all if there is a breakdown of trust and confidence in the treating clinician.'5

What do the data say?

At this juncture it's important to highlight the above are current commentaries, concerns and opinions relating to dentistry and the wider NHS. So, what do the data say?

According to Nuffield Trust, there is nothing in the Bill that would change the NHS from being a publicly funded service. Using Department of Health and Social Care accounts, published since 2009/10, they highlighted an increase in private provision happened mostly between 2012 and 2015, associated with the market-oriented Health and Social Care Act in 2012 and with the transfer of some community services in some parts of England to charities and private firms (Fig.1).

figure 2

As the authors commented, for the last six years, private provision has remained at a stable level. Many of the changes in the NHS over this period were accused of increasing privatisation at the time, but this did not happen.6

The proportion of money spent by NHS commissioners on services delivered by the private sector remained level at around 7% since before the pandemic, according to the King's Fund.7 But if you counted outsourced elective operations, voluntary sector organisations, independent social care providers, GPs and pharmacy, optician and dental services, you reach a share of 26% of expenditure on private providers for 2018/19 - a 23% increase on 2013/14 - according to research by the Centre for Health and the Public Interest.8

A detailed assessment by The King's Fund reached the same conclusion as that of Nuffield Trust, stating: 'In many cases the use of private providers to treat NHS patients reflects operational challenges within NHS providers and is a continuation of longstanding practices. Provided that patients receive care that it is timely and free at the point of use, our view is that the provider of a service is less important than the quality and efficiency of the care they deliver. The NHS can also benefit from partnerships and joint ventures with the private sector to deliver some clinical and non-clinical services.

'Overall, there is no evidence of a significant increase in spending on private providers or widespread privatisation of services in recent years.'7

What about dentistry?

The BDA has previously stated dentistry is the only part of the NHS operating on a lower budget than it received in 2010, with no effort made to keep pace with the cost of living or population growth. Prior to the pandemic, real terms net government contributions have fallen by over £650 million since 2010, while patient charge levels have increased by over 40% to plug the gap. Since lockdown the Treasury has lost nearly £600 million from the charges that are increasingly relied upon to fund services in England. While government contributions to dentistry are now at an historically high level (believed to be the highest in history in cash terms), they are as a result of the need to plug the gap caused by a lack of patient charge revenue, caused by the pandemic. It is not money for investment to tackle the recruitment crisis, the backlog of patients or access problems, it is money to cover losses. BDA analysis in Fig.2 shows patient charges have not been a 'contribution' to NHS dentistry, but a substitute for state investment, for years.

figure 3

It shows a clear pattern of dereliction, of not preventing the system from collapsing. The recent investment is nothing but the equivalent of being prescribed antibiotics for a long-standing problem that is worsening, not improving, in the hope of short-term pain relief.

The signs were there pre-pandemic. market analysts LaingBuisson's Dentistry UK Market Report,9 published in January 2019, revealed a market valued at £7.1 billion in 2017-18 - a 0.2% growth in real terms (after taking account of the Consumer Price Index) - and of this, private sector dentistry accounted for £3.6 billion, while NHS spend amounted to £3.5 billion. The report authors warned that the number of adults seen for NHS dentistry services declined for the first time in recent years, with a significant fall in NHS (UDA) activity and total UDAs completed in England not meeting contracted activity because of labour shortages in some areas.

Significantly, there has been a reduction in the number of NHS exempt patients due to a shift in welfare benefits and also a tighter monitoring of exemptions. In addition, fewer higher value treatments were being carried out through the NHS.

The report acknowledged serious recruitment difficulties in some parts of the country where NHS demand was high and said insufficient dentist hours had led to shortfalls in contracted NHS work and patients seen - a point Sir Robert Francis QC said had been made worse in his report during the pandemic. Case in point? During a meeting of West Sussex County Council's Health and Adult Social Care scrutiny committee in January 2022, councillors were informed seven dental practices in West Sussex had given up their NHS contracts since April 2020 - all but two of them as a result of financial reasons. They were informed that funding offered by the NHS was based on information logged in 2004/05, and while the amounts received by each practice had increased since then in-line with national recommendations, some still received more money than others. It prompted James Walsh (Lib Dem, Littlehampton East) to say that access to dentistry, both nationally and in West Sussex, had got 'steadily worse', adding that what we're witnessing was 'privatisation of the dental services by stealth or by the back door'.

Yes, it is foolish to link the recruitment crisis with the possible privatisation of NHS dentistry - correlation does not imply causation - but if there are fewer dentists out there doing the work leaving patients to turn elsewhere, it is churlish to think it is not a contributing factor. A recent report including Department of Health and Social Care data - analysed by the BBC - showed almost 1,000 dentists working in 2,500 roles across England and Wales left the NHS last year. Clinical Commissioning Group West Suffolk lost 21% of its dentists in the last year. The worst-affected area was NHS Portsmouth CCG, which lost 26% of its NHS dentists over 12 months. At least 10% of NHS dentists were lost in 28 other English CCGs. The news report told of one group of dental practices in Barnsley that had failed to attract a single applicant for a number of full-time and part-time NHS dental posts vacant for almost four years.10

The story in Wales was comparable to England, which lost 8.4% of dentists working in the NHS - 6% in the last year alone. None of these data show how many have handed their NHS contracts in and moved to private practice. The very premise of supply and demand mean this is not a sustainable model, so alternatives are needed.

An uncertain picture

According to the Cambridge Dictionary, stealth means 'the quality of carrying out an action secretly, so that people do not know it is happening'.11 If we go back to the very first question posed, would you say NHS dentistry is being privatised by stealth? To some observers, it's anti-stealth, and about as subtle as the proverbial bull in a China shop, but they'd also say it is being privatised. To others, it is being privatised, and indeed done so by stealth. Some will deny both - after all, the NHS is seen as a beacon and institution we should be proud of.

The truth, as always, lies somewhere in the shadows of the grey area. We cannot say with great certainty the NHS is being privatised, be it by stealth or any other method, just as we cannot say it is not. The same rings true of NHS dentistry, but there's perhaps a better case for suggesting that's the trajectory it was on. We cannot say the pandemic has solely resulted in the shift towards the privatisation of the service. We can say throughout the pandemic, and as restrictions eased, private dentistry's supply was able to meet the demand, unlike their NHS colleagues. We can say NHS dentistry has been chronically underfunded for years, causing NHS contract holders to hand theirs back and pursue a better working environment for them and for their patients.

Who knows where the profession would be if not for COVID-19. Patterns suggest we'd be in a downward spiral, but perhaps not as close to the bottom as we are today. Given the huge and significant trauma the pandemic has caused, it's impossible not to think much of the way we view dentistry today is clouded by recency bias. Data paint a picture but offer no definitive answer. And yet, for some people, their political tribalism will no doubt lean them toward believing these data offer conclusive evidence. There is no doubt in my mind all four nations need private dentistry more than ever right now - some more than others. The long-term stability of the NHS depends on the continued ability of the private sector to treat the patients it cannot. To the patient, this will likely be seen as privatisation by stealth, but it is not. There is only one way to change this narrative, to offer balance, greater options to patients and to provide a working environment conducive to better performance for both NHS and private dentists: contract reform.

And that is a topic we can all unite behind, for the greater good of the profession.