Abolish the cap on dentistry student numbers, and let market forces in

Keynes once said that if economists could manage to get themselves thought of as humble, competent people on a level with dentists, that would be splendid.” He was attacking the pretensions of the economics profession, but dentists reading these words might feel they were being dissed at the same time.

‘Humble and competent’ indeed! Bloomsbury condescension at its finest. Since Keynes was writing, dentistry has been revolutionised and a visit to the dentist is a state-of-the-art experience and no longer a painful last resort. If economic analysis and policy had progressed as much as dentistry, our problems would be far fewer.

When my mother was 14 in the 1930s she had all her teeth extracted, and wore dentures for more than 80 years. This was not uncommon at the time. Nowadays such horror stories have gone forever. Most of us look after our teeth, have regular check-ups and keep a more-or-less complete mouthful into old age. Younger generations will be Strangers to Steradent. When we need a filling or an extraction this is usually painless, if sometimes uncomfortable.

However, we are currently experiencing something of a dental crisis, to add yet another to our ever-lengthening list of woes. For there appears to be a growing shortage of NHS dentists, with thousands leaving for the private sector or early retirement. 90% of dental practices are not accepting new patients and many parts of the country – Lancashire, Norfolk, Devon and Leeds, for example – are said to be NHS ‘deserts’, where it is impossible for new patients to register. People are having increasingly to turn to the private sector for treatment. When they do so, they get a better service than they do with GPs, with proper appointments – not telephone or Zoom, of course – for which you do not have to wait for many weeks, and which usually allow time to get to know your dentist and for him or her to get to know you. I know my dentist far better than my GP.

Dental services account for only a small proportion of the NHS budget, around 5%. Yet for many healthy people in midlife, they may be the main point of contact with formal healthcare. Unusually, even NHS-registered patients pay fairly substantial amounts for treatment. Indeed, probably around 40% of all the costs of dental care are already met out of taxed income.

The problems with NHS dental provision are not hard to discern, and they are standard central planning problems. The number of dentists trained is inadequate. It is set by the government. This September English universities (other parts of the UK have their own arrangements) will be allowed to recruit just 766 dental students. There are about 10 applicants for every place. By contrast, incidentally, there will probably be around 10,000 places for economics students; nobody knows, as the figure is not constrained by the planners.

Training a dentist takes at least five years, and they cannot operate independently for perhaps seven years. Many of the 766 lucky students will drop out or change profession before that period is up. Last year 2000 dentists left the NHS. Do the maths, as they say.

We need to expand our dental training places substantially, by abandoning the cap on student numbers.

Many dental practices are going private because the NHS contract is inflexible and the sums available for dental work – there are different payment bands for checkups, extractions, root canal treatment and so forth – can never exactly map the costs in particular practices. The details are haggled over at length by representatives of the profession, but arguably have not kept pace with inflation. Moreover, they are national scales, so you can’t address a shortage of dentists in Devon by raising NHS fees in that area alone.

If we were designing dental provision from scratch, would we have NHS involvement in modern conditions?

The classic arguments for the NHS concern market failure in the private sector. One important element when the NHS was set up is the communicability of disease – things like diphtheria and polio were rife in the 1940s. But dental problems are not communicable. Another argument is patient ignorance, both inability to diagnose problems such as heart disease and cancer and inability to judge the likely effects of surgery, drug treatments or other therapies. This leaves them open to neglecting serious health issues on the one hand and exploitation by greedy doctors on the other. By contrast, patients usually know pretty well what the problems with their teeth are and can judge what they want the dentist to do.

A major concern in healthcare funding  – highlighted by examples I know personally from the USA – is catastrophic health problems. If someone is struck with motor neurone disease or other incurable and totally disabling conditions requiring round-the-clock-care, few individuals or their families can meet the cost (or insure) without state assistance. But this is hardly an issue with dental care.

Furthermore, a growing proportion of dental procedures are elective cosmetic measures such as teeth straightening, whitening, veneers – where the arguments for state subsidy are very far from clear.

There is indeed a strong argument for saying that dental care should be, for the most part, privately provided and privately funded – either by out-of-pocket payment or, more likely, insurance. A basic private dental care plan for two adults and two children could be had for £600-700 a year. If matched by a cut in taxes (or a dental care tax allowance), this would be manageable for most families. It is on a par with gym membership or what people spend on hairdressing.

If the older arguments for NHS dental care are weak, there is still an issue about care for minors, and a wider ‘equity’ case for access to dental care. This may provide a rationale for requiring families to obtain dental insurance – as is the case for wider elements of health care insurance in countries such as the Netherlands – and for subsidising this for those on low incomes or on universal credit.

A switch to such a system would recognise the inadequacy of the current set-up for dental care, and turn supplicant patients into active consumers for dentists to woo rather than turn away with a shrug. If successful, it could well serve as a template for wider changes in the provision of many NHS services.

The current problems of NHS dental care will not be resolved simply by larger injections of taxpayer money and marginally upping the planning numbers of university places. It needs economists to help resolve the problems of  dentists rather than dissing them.


Editorial and Research Fellow

Len Shackleton is an Editorial and Research Fellow at the IEA and Professor of Economics at the University of Buckingham. He was previously Dean of the Royal Docks Business School at the University of East London and prior to that was Dean of the Westminster Business School. He has also taught at Queen Mary, University of London and worked as an economist in the Civil Service. His research interests are primarily in the economics of labour markets. He has worked with many think tanks, most closely with the Institute of Economic Affairs, where he is an Economics Fellow. He edits the journal Economic Affairs, which is co-published by the IEA and the University of Buckingham.

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