Monthly Archives: November 2016

Too much chemotherapy…. This is an area where the greatest savings and improvement in quality of life could be made.

It is early diagnosis that matters, and that means experience GPs filtering symptoms, or inexperienced nurses requesting many unnecessary tests. Given the falling numbers of doctors and nurses, the implications for further improvement are expensive either way. Informed consent in the emotional atmosphere surrounding a new cancer diagnosis is difficult and time consuming. When metastases are already present the risk/return decision becomes very hard.. We don’t have the financial  Perverse Incentives to over treat, but we seem to achieve it nevertheless, because of our unwillingness to be honest. This is an area where the greatest savings and improvement in quality of life could be made.

Fiona Goodlee comments in the BMJ editorial on 10th November 2016: Too much chemotherapy (BMJ 2016;355:i6027 )

People with cancer are living longer now than 40 years ago. This is clearly good news. But how much of this improvement can we attribute to drug treatment? Not much, concludes Peter Wise this week in an article I humbly suggest all oncologists should read (doi:10.1136/bmj.i5792). The nearly 20% improvement in five year survival over the past four decades is probably mainly due to improved early diagnosis and treatment rather than developments in cytotoxic chemotherapy, he says. And patients are being badly misled by over-enthusiastic accounts of what chemotherapy can achieve. Many expect a cure. In reality they will gain on average only a few months of extra life.

The roots of this over-enthusiasm are sadly familiar but worth recounting in the specific highly charged and intensive context of cancer. Wise, a medical ethics consultant and former consultant physician, doesn’t mince his words. Unrepresentative, industry funded trials that use surrogate endpoints are part of the problem. So too are regulatory failures, perhaps explained by regulatory capture in which “the regulator risks being regulated by the industry that it has been appointed to regulate.”

Unjustified enthusiasm for cancer drug treatments comes at huge cost, financial and personal (including treatment related deaths and reduced quality of life), and increased risk of dying in hospital rather than at home. Many patients don’t realise that opting for supportive rather than active treatment—often called “refusal”—is an option and may give them longer as well as better quality life than chemotherapy. Conflicts of interest among clinicians compound their reluctance to have tricky conversations.

If improved survival is indeed largely due to early diagnosis and treatment, how is this best achieved? Many patients visit their GP with vague or non-specific symptoms. How should these be investigated and followed up without causing unnecessary alarm or wasting precious resources? As Brian Nicholson and colleagues explain (doi:10.1136/bmj.i5515), “safety-netting” aims to ensure that patients don’t drop through the healthcare net and are monitored until symptoms can be explained. But there is little evidence on whether this works or how to do it well. In particular, how much responsibility should patients be expected to take in chasing up and understanding test results? The authors encourage a sharing of this responsibility between clinicians and patients, but also clear communication and robust systems to prevent patients falling through the net.

Wise concludes with a call for higher bars for drug approval for new and existing drugs. Ethical cancer care demands empowerment of patients, he says, with accurate, impartial information followed by genuinely informed consent. And funds and attention should shift to prevention, early detection, prompt and radical treatment of localised and regional disease, and early provision of supportive care. Only then will cancer care serve patients rather than governments and industry.

Advanced directives needed. Choice in death and dying. Lord Darzi warns of “draconian rationing”. GPs need to be involved at the interface of oncology and palliative care.


Closing hospitals can help us save the NHS

Those with the least “source force” or political clout (the soft targets) will suffer most. The distance between inpatient psychiatric care will increase. The medical care of prisoners will get worse. Despite the evidence that the public would rather have convenience than better outcomes. (Citizens prefer to die early (as a group) rather than to have services at inconveniently distant from them. ) The Utilitarian approach is needed but only after politicians have admitted we cannot have Everything for everyone for ever, and that overt rationing is needed. The obvious specialisation is in strokes where those closest to tertiary centres will get the best treatment option, and the best results..

Rachel Sylvester opines in The Times 29th November 2016: Closing hospitals can help us save the NHS – We should stop the kneejerk reactions and accept that more specialised services save money and are safer for patients (If you have time read the correspondence. Mostly from the informed city dwellers, they are in favour of closures. But those in the country and with a “community hospital” will not change their minds..)

‘You can declare war more peacefully than you can reform a healthcare system,” writes Ken Clarke in his memoir Kind of Blue. According to the former health secretary, hospital closures always provoke the bitterest battles. As soon as he embarked on a reorganisation in the 1980s he “became immersed in a constant round of demonstrations and petitions fighting to ‘save’ clapped-out institutions all over the country”.

On one occasion he had to force his way through a crowd holding placards outside a maternity hospital that was due to be shut. Although the local MP privately told him it had been a “terrible mistake” not to close the place years ago, and the senior obstetrician gave him his clinical view that it was “dangerous and unsuitable”, neither of them would back him up in public. Mr Clarke describes how a newborn baby born at the hospital was thrust into his arms as he addressed the protesters. “Clutching the baby nervously and hoping I was holding it the right way up I was then interviewed by the local television crew,” he recalls.

As affable as he is resilient, Mr Clarke relished every fight — his greatest dread was “a long, quiet, uncontroversial tenure of office in any department”. But even he was shaken by the hostility to hospital closures.

Now it will be Jeremy Hunt under fire. Having seen off the junior doctors’ strike, the health secretary is about to preside over a shake-up that will see hospitals closed, maternity units axed and A&E departments downgraded all over England. Although the details are still being finalised, it seems certain that thousands of hospital beds will disappear in the search for £22 billion of efficiency savings by 2020.

So far 33 out of 44 areas have published their “sustainability and transformation plans” and the rest must do so before Christmas. Under the proposals, which are out for consultation, one of the five acute hospitals in southwest London could close, along with three community hospitals in Leicestershire, four in Devon and three in Dorset. Other institutions will have services such as emergency stroke care removed as part of a drive to create specialist centres of excellence.

Theresa May has instructed Mr Hunt to prevent a high-profile row over hospital closures, but it’s hard to see how he can control the backlash. Even though the plans have been drawn up by local NHS bosses rather than ministers the government will still get the blame. Mass protests are inevitable as details of the changes are firmed up — indeed, 4,000 people recently marched against planned changes to Barnstaple hospital in Devon, and campaigners in Cumbria are warning that mothers and babies will die if they have to travel 40 miles from Whitehaven to Carlisle for care.

MPs, who are aware of the strength of public feeling, have already started to lobby the Department of Health to protect hospitals in their constituencies. They all remember the 18,000 parliamentary majority won by the independent candidate Richard Taylor in the Wyre Forest constituency at the 2001 election after he campaigned on the single issue of restoring the accident and emergency department at Kidderminster hospital.

Politicians are haunted by hospital closures, and the voters are fixated on protecting their local NHS, but we must all be rational rather than emotional about the provision of healthcare. There is a looming winter crisis in the health service and an impending disaster in social care as a result of local government cuts. The financial problems facing hospital trusts are matched by a growing workforce gap. Only a quarter of managers are confident they have the right mix of staff numbers, quality and skill to deliver proper healthcare, according to a survey published today by NHS Providers, which represents hospital trusts.

“However strongly people feel about their local NHS, the service cannot stand still,” says Chris Hopson, the chief executive. “There are thousands of people who are in a hospital bed who don’t need to be there.”

It is time to stop fetishising hospitals as the only way to deliver care and think about how best to allocate resources in the 21st century. It costs £400 a night to keep someone on a ward — money that could often be better spent elsewhere — but this isn’t just about cash. Nobody seriously wants to spend more time than they have to in an institution where they are at risk of infection and have no privacy. With long-term conditions such as dementia and diabetes eating up a growing proportion of the budget, money needs to be liberated from buildings and beds so that it can be redirected to looking after people at home.

In any case, the evidence — as opposed to the emotion — shows that centralising services can be the safest as well as the most efficient way to treat patients. In 2010, stroke units were closed in some London hospitals and resources concentrated in eight specialist centres. Despite the protests, almost 100 more people now survive every year as a result of the expert treatment they receive. After the centralisation of trauma care, the chances of surviving a serious accident have risen by 50 per cent.

Professor Naomi Fulop of University College London, who assessed the changes to stroke services in London, is convinced that this is a model that should be replicated around the country. “It may seem counterintuitive for an ambulance to drive a critical patient straight past the nearest hospital, but it saves lives,” she says.

In Grantham, the local hospital trust has announced that it is closing its A&E unit at night because it does not have enough doctors to run the department safely. With paramedics able to treat patients in the ambulance on the way to hospital, it may be better to have fewer A&E units but make sure those kept are properly staffed by experienced consultants.

Labour MPs who want to blame the Conservatives for hospital closures should remember that such a rationalisation was first proposed by the well-respected surgeon Lord Darzi, who became a health minister under Gordon Brown and is a Labour peer.

The crisis in health and social care means this is not a moment for local protectionism — a kind of nimbyism of the health service — nor for political short-termism from MPs who know what is needed but don’t want to admit it to their constituents. Closing hospitals may be the only way to save the NHS.

Civil unrest will be inevitable… This is the future … “Super-surgeries with 50,000 patients” – take it or leave it..

The rich get richer … and the poor get shorter lives, less choice, but more local care.

Local politics and health: Hundreds from West Wales (Pembrokeshire) to protest at the Senedd against ‘downgrading’ of Withybush Hospital

Sustainability and transformation (rationing) plans – surely STPs deserve a better acronym…

Spineless politicians should agree rationing with local communities, not behind closed doors.

Surge in twins linked to obese young mothers: UK is one of the worst places in western Europe to be pregnant and have a baby: a ‘no go’ area for a politician but we should break out of the consensus on the NHS and learn from other countries..

Making rural hospitals sustainable – It is both quality hospital doctors and GPs we are short of… Please don’t be tempted to reduce standards..

Nine health secretaries attack government for failing mentally ill –

Smitha Mundasad  for BBC news 29th November reports: Thousands ‘miss out on stroke treatment’



No thinking outside the box.. Aim at 10% excess of doctors..They want to know about the money, not about the structures..

The BMA in Wales is consulting its members at the request of the WG.

Student support funding for students ordinarily resident in Wales

What do you think of the Welsh Government’s suggested response to the findings of the Diamond Review into student funding support in Wales? Is the Welsh Government right to accept the key proposals: that all students should receive a grant of at least £1,000 a year towards their daily living costs; that extra maintenance support should be provided on a means-tested basis so that the average student receives £7,000 a year; and that the current Tuition Fee Grant should be replaced with an additional student loan? In addition, can you let us know if you are happy with the way the Welsh Government is proposing to implement these proposals?

Deadline for responses: 16 January 2017

We have to be realistic in the funding, but there are greater issues to be dealt with:

Medical Recruitment and Training needs to change radically. 

Changes need to address the gender imbalance as well as the lack of sufficient numbers.

 NHSreality has suggested that several changes are needed.

1.       Adverse selection whereby Medical Students are appointed from all over the country, and not simply from the outperforming suburban schools in richer post-codes.

2.       Graduate entry to medical school will largely address the current gender imbalance.

3.       A virtual Medical School in Wales and other areas of the UK whereby graduates are appointed into A General Practice for their training supervision, and which they address as their base. (they will then be more likely to integrate into a community)

4.       Evidence based learning / tuition delivered “on line” for the most part. Written Exams also delivered on line. Orals and Physical Examinations will need centres, but these can be distributed or centralised.

5.       Use GPs in Hospitals, especially to facilitate the interface of oncology and palliative care. The savings that could be made are fantastic. 

In addition, following the meeting GPs from pembs attended earlier this year:

6.       Exit interviews for all staff, depersonalized and summarized by an independent third party (HR) for Boards and the Minister.

7.       Changing to an open and honest culture of “overt rationing”.

8.       Depoliticize the decision making processes so that the crisis now on us, ignored for so long, never happens again.

9. At present every applicant who is good enough should be accepted into Medicine, wherever it is taught in the UK. We should be aiming at 10% excess

Update 3rd December

Caroline White reports in BMJ Careers 23rd October 2016: Just 4% of UK doctors come from working class backgrounds – Unfair education system and inequality are restricting accress to the medical profession.


NHS funding and rationing: The debate intensifies

Whilst Yorkshire men and women are renowned for their grit, they are also respected for their honesty. Mike Waites in the Yorkshire Post reports: Approved: NHS surgery ban on fat patients and smokers in Yorkshire, and if this is correct it is the first time rationing has been approved so that a whole population know what is “not available” to them. It is important because it is overtly rationing (deserts based), and will punish the poorer members of society more than the richer ones. It is pragmatic and realistic, but regressive… (it increases inequalities). This is the type of decision that needs to be made, and even more so for the high volume cheaper services. Government will hope that the media turns a blind eye to the principle: once rationing is overt we can all plan for what is not available. Is the Y Post in denial, or simply being disingenuous in it’s comment: “The NHS funding crisis is not an abstract issue; it is affecting patients’ fundamental right to treatment. If smokers and obese patients are hit this time, where will the rationing decisions …”?

Hugh Pym reports for BBC News 31st October 2016: NHS funding and rationing: The debate intensifies

It is becoming as familiar as Halloween or 5 November fireworks – a crescendo of demands for more money for the NHS ahead of the Autumn Statement. So is it any different this time and are the financial pressures more intense than before?

In 2014, ahead of the general election, George Osborne, then Chancellor of the Exchequer, conjured up an extra £1.9bn for the NHS in England for 2015-16, after warnings there had been an unbridgeable gap in the finances.

Under the usual funding formula, this became £2.2bn across the UK, on the assumption the devolved administrations spent their allocations on health.

This was unveiled with a hospital photo opportunity involving Mr Osborne, Simon Stevens, of NHS England, and the Health Secretary Jeremy Hunt and was widely welcomed by health commentators and think tanks.

The election came and went, and it was not long into the 2015-16 financial year before hospital trust bosses were warning of mounting deficits and the sums not adding up.

Fast forward to the autumn of 2015, and Mr Osborne was publishing his Spending Review for the years up to 2020.

Chart showing spending rise from 2014/15-2021/22

Once again, a photo opportunity of the chancellor in a medical setting, this time in a GP surgery, was designed to underline the government’s commitment to health service funding.

The 2015 Spending Review allocated £3.8bn above inflation to the NHS in England in 2016-17 – and annual increases beyond that, to reach £8.4bn in 2020.

Once again, this was a cue for applause from the health world, with experts noting there was a significant increase in the first year of the settlement.

A year on, however, and there are renewed warnings about the dire state of NHS finances…….

NHS England is committed to finding up to £22bn of annual efficiency savings by 2020.

NHS trusts end-of-year financial results chart

Across 44 areas of England local health and social care, leaders have been told to come up with sustainability and transformation plans (STPs), to make better use of resources and redesign services.

A poll of local commissioning groups by Health Service Journal has shone some light on the process.

Of those that responded (just under 50%), nearly half had plans to reduce hospital beds and a third intended to close or downgrade accident and emergency departments as part of their STP.

The underlying problem is the same as it always has been.

The NHS has a finite level of resources allocated by governments but has to cope with unlimited demand.

What looks like a good settlement the year before can seem more like a sticking plaster solution as the cash gets swallowed up in the face of unpredictable increases in patient numbers.

The money will be tight across the board in this Autumn Statement.

The chancellor and the prime minister may decide to leave the NHS to make better use of the above inflation increases already awarded.

But in doing so they may have to face damaging headlines as the NHS struggles to cope through this winter.

Leaderless – and a missed opportunity to tell the truth…

The leaderless health services are gutted that nobody will tell the truth. The staff understand the financial constraints but they do not recognise a sustainable system. The missed opportunity affects the really remote areas more than Oxfordshire, and they seem angry enough. The crisis can only get worse..

Sophie Grubb reports today in the Oxford Times: Hundreds take to streets for NHS day of action as Jeremy Corbyn holds talk in Oxford

About 200 people gathered in Manzil Way at 12pm to join the procession led by Keep Our NHS Public and Hands Off Our NHS.

Leading the group, which included two cardboard coffins and one donated by Cowley firm Colourful Coffins, was Oxford nurse David Bailey in full ‘undertaker’ garb.

He said: “We are now aware, because of a leak, of the sustainability and transformation plans for BOB [Buckinghamshire, Oxfordshire and Berkshire West]. It means £146m is going to be removed from the health budget for Oxfordshire, £62m of which is on staffing because we are the most expensive commodity the NHS has – but also the most vital.

“Nurses are the most numerous but I expect it will be some physios and radiographers and we may see some doctors as well. It’s going to have a devastating effect.

“We will probably see the downgrading of the Horton and community hospitals will close and that will affect services around the county.

“Our worry is that this is going to be the end of the NHS.”..

Huw Pym for the BBC reports 24th November 2016: Autumn Statement: Missed opportunity for NHS?

The NHS and social care were barely mentioned in the chancellor’s Autumn Statement, and health groups and think tanks lined up to condemn Philip Hammond within minutes of him sitting down in the Commons.

So was there a failure to resolve a looming crisis? Or did Philip Hammond simply feel that in a difficult financial climate, there were other more pressing priorities?

Warnings about cuts in social-care spending in England and the impact on the health service have become more intense in recent weeks.

There has been a steep rise in the number of patients fit to leave hospitals, but who continue to occupy beds because of problems arranging social care.

That has concentrated minds, and NHS leaders indicated they were prepared to accept there would be no new money for health as long as social care, run by local authorities, received a financial boost.

But that did not materialise. The pleas had fallen on deaf ears.

“Missed opportunity” was a verdict on the statement much repeated by health think tanks and medical profession leaders.

The Royal College of Emergency Medicine even warned government inaction would put lives at risk.

Social-care chiefs warned the chancellor’s failure to act would mean more carehomes closing and growing gaps in the market.

In response to Labour claims in the Commons that there was “looming chaos” for health and social care services in England, Mr Hammond said there was a programme of investment in the NHS being delivered.

He repeated the government line that an extra £10bn annually was being allocated to the NHS budget by the year 2020-21.

He said the government would work with service leaders to ensure the money was spent effectively, underlining his view that it was not so much about the volume of investment as how it was deployed.

The new clashes over money for the NHS came as the UK Statistics Authority called for more clarity by the government in its references to the extra investment.

The stats watchdog observed that the £10bn increase for “NHS funding” in England was over a six year period from 2014-15.

However, total health spending, including public health, which has seen cuts, has not grown as fast.

The Statistics Authority noted that, according to Treasury figures, over a four-year period up to 2019-20 it would increase by £2.9bn.

Ed Humpherson of the UK Statistics Authority, said he would ask the Treasury to present estimates for NHS England and total health spending separately.

He has urged officials to “ensure clarity around sources, time periods and what is being measured”.

The stresses and strains on NHS finances have been well documented, and the debate about how much money the government is investing to help tackle theproblems is rising up the political agenda.

A report from the National Audit Office highlighted again the financial pressures and argued that the problems were “endemic and not sustainable”.

The NAO report, unusually, confirmed the view there were tensions at the highest levels of Whitehall.

It talked of perceived differences between the government line that funding had been adequate and in line with what health service leaders asked for and NHS England itself.

There was an eye-catching conclusion: “Confronted as NHS England is by the pressures of rising demand for services, these signs of differences do not help build a confident feel about the future of the NHS.”

Those “differences” seem unlikely to fade away.

The NHS England leadership that had called for more funding for social care only to be disappointed will hardly be thrilled by the Autumn Statement.

The chancellor may find he has a lot more explaining to do.

NHS hospitals told to send patients to private sector to ease potential winter crisis · 3h ago in the Independent

We now need to sacrifice the last “sacred cow”

When I read this article “Thatcher’s NHS plans caused cabinet ‘riot’” in the Times 25th Nov 2016 (Henry Zeffman) I was interested to read that, 34 years ago, in 1982, Mrs thatcher had predicted what would become accepted as necessary. All suggestions have been wholly or partially accepted EXCEPT for the reported recommendation on the then NHS. We need a new NHS where the power of the large mutual dictates the price, choice, and standard of care. Devolution is bad for smaller mutual such as Wales.. But there is no need to abandon the Health Service as a National Institution IF we agree to ration overtly, and discuss sensibly and pragmatically the many unpalatable options.Image result for sacred cow health cartoon

Margaret Thatcher secretly fought to keep alive radical plans to dismantle the welfare state even after they caused a cabinet “riot”, according to newly released government files.

The proposals drawn up by the Central Policy Review Staff (CPRS), a government think tank, went further than any reforms Thatcher undertook during her decade in Downing Street.

They included replacing the NHS with an insurance-based service, ending the state funding of higher education, ending the link between benefit rises and inflation, charges for schooling and cuts in defence spending.

When Geoffrey Howe, the chancellor, introduced the proposals at a special cabinet meeting on September 9, 1982 it was met with fierce resistance by the moderates, or “wets”, in Mrs Thatcher’s ministerial team.

Lord Lawson of Blaby, the energy secretary who replaced Howe as chancellor the following year, recalled in his memoirs that it was “the nearest thing to a cabinet riot in the history of the Thatcher administration”.

Details of the report were leaked to The Economist, causing a public outcry.

Thatcher responded by declaring from the Conservative Party conference platform in Brighton the next month that the NHS was “safe with us”. She later claimed to have been “horrified” by the CPRS plan.

However, Treasury papers from the period released by the National Archives show that the prime minister and her chancellor continued to struggle to keep the proposals alive.

On November 26, 1982, nearly three months after the cabinet meeting, a Treasury official named P Mountfield told Howe that the prime minister had convened meetings with the key ministers whose departments were concerned by the proposals: Keith Joseph, education secretary; John Nott, defence secretary, and Norman Fowler, health secretary.

“This series of meetings is designed to soften up the three big spenders. Without their support the operation will not work,” Mr Mountfield wrote.

“Your main aim, I suggest, should be to ensure that no sacred cows are prematurely identified. Given the prime minister’s concern about the NHS, this may be difficult.”

Another Treasury official warned Howe that the opposition of the cabinet would scupper implementing the CPRS’s ideas.

GW Monger wrote: “DHSS [department of health and social security] officials say there is no chance Mr Fowler would agree to further study of this idea. I imagine that in the circumstances, and especially given the prime minister’s speech at Brighton, it is difficult to press them.”

Though Howe maintained that deep reform was needed to cut public spending, he was alarmed when the Adam Smith Institute wanted to publish the “Omega Project”, its own vision for privatisation and deregulation.

Howe wrote: “Every proposal will be seized on and hung round our neck. I see v great harm.”


One of Geoffrey Howe’s most complex tasks as chancellor was working out what to do with the Treasury wives.

In January 1982 the chancellor summoned his ministers and senior officials for a weekend discussing Britain’s economic difficulties and instructed his permanent secretary to make arrangements for the wives of those in attendance.

“The chancellor is anxious that any participant of the seminar who wishes to be accompanied by his wife should be able to do so,” wrote Sir Douglas Wass.

“The wives would join participants at meals but would otherwise ‘amuse themselves’.”

Sir Douglas issued a dress code for dinner — lounge suits for men and “short dresses for ladies”.

After the Tories’ 1979 election victory the first call Howe received was from his defeated Labour predecessor. Denis Healey passed on a message from his wife, Edna, to Howe’s wife Elspeth, warning her not to move into the flat above 11 Downing Street until the “antediluvian” kitchen was refurbished.

Thatcher was reluctant to approve this. In December 1979 a Treasury official wrote to No 10 complaining that three months after they had submitted plans, costing £4,150, there had been no response, despite three phone calls.

Sally Gainsbury released this in the FT 2012: NHS privatisation leak damages Thatcher and in retrospect this rejection must have led to FundHolding.

The full text of an internal paper that was at the heart of one of the most damaging leaks in Margaret Thatcher’s first term is laid bare in files from 1982 – the cabinet office’s Central Policy Review Staff’s review of “Longer-Term Options”.

Most controversially, these options included dismantling of the National Health Service, which would be replaced by a system of compulsory private insurance, with state funded healthcare only for the poorest or most frail.

The extension of private school education was also proposed, to be encouraged with vouchers and tax breaks, and funded by an introduction of charges for state schools.

The paper was widely leaked at the time and caused outcry, prompting Margaret Thatcher to pledge “The National Health Service is safe in our hands”.

Although ministers attempted to distance themselves from the paper at the time, the official record of the cabinet meeting at which it was discussed – alongside “disturbing” Treasury projections on public spending – shows the cabinet concluded that “much could be done to reduce the size of the public sector by privatisation in areas such as healthcare, education and many local authority functions”.

cropped-nhs-hands-safenh01.jpgIts a health financial emergency – and the Chancellor has taken no direct action.

We must think the unpalatable to stop death of NHS, say doctors



Dentistry is important – for an important sub group…

John Appleby in the BMJ opines on whether “Dentistry: should it be in the NHS at all?” (BMJ 2016;355:i5986 ) and comments “…continued inequalities in dental health (partly exacerbated by patient charges) suggest the NHS should perhaps be doing more—not less—to fulfil its fundamental mission on equal access for equal need.” So if dentistry is to be excluded for the majority it is still important for the NEETs. it could reasonably be rationed out of the local Health Service provision for those paying tax….

When the NHS opened for business in 1948 two of its biggest product lines quickly became the supply of spectacles and dentures. According to the British Dental Association, in the first nine months of the NHS, dentists provided over 33 million artificial teeth, 4.5 million extractions, and 4.5 million fillings. Dental surgeries were overwhelmed by the demand for treatment.1 Since then dentistry has moved on from drilling, filling, and extraction—but so too has the public’s dental demands. Are we approaching a point where it will become increasingly hard to justify tax funding for dentistry? Is the perfect smile a medical necessity worthy of public subsidy?

There is no doubt that the nation’s gnashers have improved tremendously over time. In 1968 a staggering 37% of the adult population of England and Wales had no teeth.2 A decade later, in England, this proportion had fallen to 28%, and by 2009 it was just 6%.3 Over the 30 years to 2009, the proportion of people with 21 or more teeth increased substantially; among people aged over 55, for example, it more than doubled from 30% to 63%.3

The improvement in the number and quality of people’s natural teeth reflects general improvements in living standards and diet, but also reductions in smoking, greater use of fluoride toothpaste, and the efforts of the dental profession. The number of dentists has increased—by 20% in the past decade—and they are doing more work, although this has flattened out over the past few years (fig 1).4


Fig 1 Numbers of dentists with NHS activity and courses of dental treatment relative to 2006-07 (value 100) in England for financial years 2006-07 to 2015-16 4

But although the epidemiological trends in dental health have been going in the right direction, we still have not only a substantial burden of dental disease but also considerable variation—across regions and socioeconomic conditions. The national 2013 children’s dental survey, for example, found that around one in seven children had severe or extensive tooth decay, or both.5 The factors associated with an increased risk of severe dental problems included living in Wales or Northern Ireland, eligibility for free school meals, only attending the dentist when they had tooth trouble, and the consumption of sugary drinks.5 Variation in line with levels of deprivation more generally is also evident in adults’ use of dental treatment. For example, figure 2 shows a positive observed relation (correlation coefficient +0.73) between deprivation and the rate of teeth extractions across local authority areas in England in 2015-16 and a negative relation of a similar magnitude between deprivation and fitting of crowns.6


Fig 2 Number of extractions and crowns per 100 courses of dental treatment in England by local authority based measure of socioeconomic deprivation for financial year 2015-16 (author’s calculations)6

One reason for the different direction of relations may be that in 2015-16 the patient charge for an extraction was £51.30 (€58; $64) compared with £222.50 for a crown. As the findings from the children’s survey indicate, variation in use of different types of dental treatment is influenced not only by lifestyle behaviours related to dental health but by the financial barriers to accessing dental care and how much patients are charged for a treatment.

For a health system based on the separation of treatment and ability to pay, the negative impact of dental charges—even substantially ameliorated by exclusions—is shocking. In 2009, for example, around a quarter of adults surveyed across England, Wales, and Northern Ireland said that their dental treatment had been influenced by cost. For those with very poor dental health this figure reached 50%.7 Nearly a fifth of people had delayed treatment because of cost, and a partially overlapping group of around one in seven said treatment had been both affected and delayed because of cost 7 (fig 3).


Fig 3 Influence of cost on choice and timing of dental treatment in England, Wales, Northern Ireland, 20097

Dentists may not have the same denture workload as they grappled with in the early days of the NHS (fig 4), but despite improvements in people’s general dental health, many people still require the services that dentists provide. And continued inequalities in dental health (partly exacerbated by patient charges) suggest the NHS should perhaps be doing more—not less—to fulfil its fundamental mission on equal access for equal need.


Fig 4 What do dentists do all day? Total number of clinical treatments for adults and children, England, 2015-16


  • Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.