Say Arghhhhhh!

by | 16 Feb 2024

Scotland is about to see a major change in dental policy and the result is a retreat from the principle of prevention and yet more tweaks to a failing internal market. Scotland doesn't seem to learn the lessons of the recent past.

First published by Common Weal

I’ve reached that age where going for a medical check-up and being told that nothing has got worse is like a little victory. ‘Congratulations Mr McAlpine, your eyesight is still rubbish but it’s no more rubbish than last year!’ Cue a tiny air-punch.

So when I came away from the dentist this week with a ‘your teeth are stable and your dental hygiene is good’, it was one such little victory. But this time that’s not what I was left thinking about, because this also coincides with an impending major change in dental policy in Scotland – and not for the better.

The intricacies of NHS dental policy are hideous and I won’t go through them all with you here (at least in part because, despite having it explained to me a few times, my own grasp of it all is a little fuzzy). So I want to pick out two things which are emblematic of what is wrong and draw that out into wider lessons about why we keep making the same mistakes in Scotland.

So, here is change one and implication one; you are now not entitled to two NHS check-ups a year but only one. And this will almost certainly end up costing more than it saves – but only in a year or two. Why do I state that with such confidence? Because we have a very recent experiment on the impacts of withdrawing regular dental treatment and its lessons are stark.

As you know, during the pandemic almost all health services were severely curtailed but dentistry was all but stopped in its tracks. You’ll know people who had toothache during lockdown and ended up having to go to A&E where all they could do was pull out what was potentially a perfectly health tooth. I certainly know a couple.

But most of us didn’t have to go for emergency dental treatment and waited patiently for dentistry services to be reopened again. The experience of dentists of what that meant is quite stark – a two-year backlog of deteriorating national dental hygiene in a nation not known for having the world’s pearliest pearly whites.

Take away two years of regular check-ups and you end up with absolutely record numbers of extractions. For many it was too late for simple treatments and teeth that could have been saved had to be extracted. That is forever and ever.

So what does anyone think is going to happen to the wider Scottish population as one-year waits for checkups become the only option unless you pay for one yourself? My dentist was quite clear about his views – we’re going to get deteriorating dental health and increased major interventions. That costs money, almost certainly more money than a regular check-up.

Even more than that, the ‘entitlement’ approach isn’t the medical approach. Dental diseases are dynamic and change at variable rates throughout our lives and are heavily affected by behaviour, so while I only need one a year, there are people who could really do with three or four at particular times. Two is an arbitrary average; why not let a dentist decide?

If you change the price of one procedure it revalues that procedure in relation to another, changing the incentives

But what else is changing? Well, payments for false teeth are being increased. Why? Because of the NHS internal market which isn’t a market but ‘monopsony’ where one purchaser sets the price of goods irrespective of their cost (a monopoly is when there is a single seller and a monopsony is when there is a single purchaser).

The purchaser for dental services is, overwhelmingly, the Scottish Government. And given Thatcher’s introduction of an ‘internal market’ into the NHS, everything has to be given a price which is inevitably decided by government. If it gets a price wrong it sends out a ‘false market signal’ and causes changes in behaviour which may be utterly counterproductive.

In this case the pricing error was in dentures. The amount that was paid to a dentist’s practice for moulding dentures for a patient was set too low. This meant that if a dentist was to produce dentures for a patient, the practice would actually have to subsidise it. It would cost the dentists their own money to give you falsers.

Unsurprisingly they therefore would avoid doing so. Which means that if you were in need of dentures there is a good chance you didn’t get them because the pricing mechanisms incentivised the dentist to do something else instead.

This has been a bone of contention for some time, so now the price paid for denture work is to be increased. Which means the problem is solved then? No, no it is not solved, because dentures is only one service in a host of dental services which are priced by the internal market.

Which means that if you change the price of one procedure it revalues that procedure in relation to another, changing the incentives. I’ve been at the wrong end of this. A number of years ago I had a dental problem which my dentist wouldn’t carry out because the NHS payment wasn’t high enough. I could do it privately, but it was £500 and I didn’t have the cash at the time.

So I crossed my fingers, hoped that a patch job would do and something would come along, and it did. What came along was a little hard bit of gristle in a burger at a music festival which ended all hopes for that tooth. It had to be extracted (meaning the not insubstantial patch job turned out to be totally wasted resource) and given that a replacement was also not possible on the NHS and I didn’t have £6,000, I have a hole where my molar should be.*

OK, what are we learning from these two examples? Sadly the correct answer to that question is ‘absolutely nothing’. What we ought to be learning is that prevention saves money (I almost feel I should put that in capitals for you…) and that internal markets distort healthcare in negative ways. But to tackle what the Scottish Government recognised was a problem it tackled it by putting in place another problem.

This will presumably all go wrong again and all be revised again in a few years. I don’t want to suggest that the better path to walk here is easier, but it really is a lot better. It offers not only an analogy for how to save much of the NHS but how to save public services more generally.

That ought-to-be lesson one about prevention is crucial. The whole lot of them, every civil servant I’ve ever met, goes on about the Christie Commission report which turned out to be a landmark in making an incontrovertible case for preventative spending. But none of them does it, because they’re constantly fire-fighting the costs of the last failure to prevent.

Your experience of dentistry services is about to get worse (though you might not notice particularly because your experience of all public services is about to get worse)

We’re too busy throwing our money at remedial activity to stop and redirect some to preventative activity. That is often driven by narrow political imperatives. Take for example the decision to cut funding for community health workers, a decisions as shortsighted and social class-driven as they come.

There are various models of supporting community health and they’re all insanely efficient for what you get out of them. I can give you examples of this for a week but a good way to stop an old lady with poor mobility falling and breaking her hip requiring surgery can be to make sure her toenails are regularly trimmed to prevent tripping. I don’t think I’m giving much away in revealing that you can trim a helluva lot of toenails for the price of a single hip replacement.

But the Scottish Government cut community health funding in part so it could announce £100 million to reduce cancer waiting lists. A lot of that money will be wasted because the bottleneck is not having enough trained oncologists and no amount of money will offer you a quick fix for that.

Still, it gives the Scottish Government something to say at First Minister’s Questions and provides an impressive-sounding rebuttal to the idea that these waiting lists got out of control under this government. So it is good PR – but I’d strongly argue it’s a waste of resource. If that same money had been invested in community health it would have been truly transformative.

The second ought-to-be lesson is that fake markets don’t work. I’m not totally against theories of self-balancing markets because in certain circumstances there is truth in it. Consumers with choice can boost or cut the fortunes of any individual brand or product which will send market signals straight to the producer which means they must adapt or die (though unfortunately ours is an era of mass market-rigging by powerful corporations which means markets work poorly in reality).

But there is no feedback mechanism for prices in the health service, so if they’re wrong they just stay wrong until it gets bad enough that government has to do something. The clever thing would be to dispose of the ideologically-slanted internal market altogether, but the purpose of the internal market is to crack open the NHS for private provision and prepare it for eventual privatisation.

As I’ve point out before, senior policy-makers are deeply entrenched in that ideology. Many of them really do want to privatise the NHS in one form or another. So your teeth are sacrificed to their ideology and nothing ever changes in a finance-and-management led health service – other than things getting worse.

Your experience of dentistry services is about to get worse (though you might not notice particularly because your experience of all public services is about to get worse). You will pay more tax than necessary for your healthcare because we do the wrong things. I can explain this persuasive and comprehensively and still nothing will change, because the vested interests in policy-making circles won’t let it change.

I’ve reached an age where trying to explain to people why public policy is going wrong is so frustrating. I can tell you, and so can many thousands of frontline public sector workers, but no-one listens to them and the people with power have different priorities. So things get worse and no-one does anything about it.

Getting some kind of change in that stupid failure loop? Now that would be a big victory and would merit not only a full air-punch but a full-throated ‘YES!’.


*Note: I had the wrong numbers in this originally, missing out a zero. I think it was my subconscious blocking out the shock when I received the bill…

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