Do your teeth hurt yet?

Soon it will be even harder to find an NHS dentist. Liz Hunt hears suspicions of a plot
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"Hi, I've just moved to the Wells area and I'm looking to register with an NHS dentist." The women behind the desk regarded me with little interest. "Are you on income support or family credit?" one of them asked in a bored voice. "No, I'm not, I'm..." She cut me short. "Well I'm sorry, but this practice no longer takes fee-paying NHS patients."

"Why not?"

"Because the dentists have opted out. Here's a list of the charges," she said, thrusting a sheet in my direction. "And there's Bupa Dental cover and Denplan too," she added helpfully. "They are insurance schemes covering dental care."

"Who do you take then?"

"The dentists will still see children and people who are exempt from NHS charges."

"Oh that's all right, I'm pregnant," I said, hoping that this small untruth would make me a more attractive proposition.

"I'm sorry, but women who are pregnant or who have a child under 12 months are excluded from free NHS treatment at the practice."

I scanned the charges, from £29.50 for a consultation as a new patient (it costs £4 for an NHS check-up) to £290 - minimum - for acrylic dentures (NHS plastic dentures are £83.40). "But I've always had an NHS dentist. What do you do if you don't want to go private or can't afford the charges or insurance?"

"Write to your politician," chipped in another of the women. "I think the nearest NHS practice still taking people is in Somerton. That's about 15 miles away."

After I was turned away from two more surgeries, I rang the Somerset Dental Helpline. A young man called Andrew sympathised with my plight. They were handling about 100 calls a week, he said. He confirmed that of the 11 dentists in Wells, 10 were now excluding new NHS fee-paying patients and scores of patients had been "deregistered" by the practices. The 11th was an orthodontist. He directed me to Shepton Mallet, about five miles away, where two practices are mopping up the rejects from Wells - for now. "Have you got a car?" he asked. "Public transport isn't good I'm afraid." The first available appointment with a dentist in Shepton Mallet was not for a month.

What dentists are doing in Wells and in other towns throughout Somerset provides a glimpse of the future of dentistry: there will be "Rolls-Royce" treatment for those who can afford it, and a subsidised "pain and maintenance Lada" service on the NHS for those who cannot, according to one embittered local practitioner.

Almost 10,000 people in the county have so far been deregistered by their dentists, and new deregistrations are running at 140 per week. Somerset's dentists are leading the national exodus from the health service into the promised land of private practice. There they can charge what they like, see fewer patients and - probably - make more money.

According to figures published by the Liberal Democrats yesterday, more than 800,000 adult and child patients have been deregistered by their dentists over the past four years, and the problem is worst in the south- east and south-west.

A Consumers' Association survey published last month found that the number of people obtaining some or all of their treatment privately has almost doubled in the past two years. The same survey reports that higher charges are keeping people away from their dentists. According to the General Dental Practitioners' Association, the number of practices that would accept any NHS patient - fee-paying or exempt - has fallen from 90 to 50 per cent since 1990.

More than half the dentists in the constituencies of Wells, Somerton & Frome, and Taunton, say they have stopped taking new NHS patients. For many others it is only a matter of time. The Somerset Family Health Services Authority is defensive but concedes there are "difficulties". Senior Tories such as Tom King (Bridgwater) and David Heathcoat-Amory (Wells), are said to be getting twitchy about angry letters from constituents who can't get the treatments they need.

Abandoned patients are faced with stark choices: pay private fees or join an insurance scheme. Or find another dentist (if you can) and take your turn on the conveyer belt of NHS dental care with the 30 to 40 patients a day a dentist claims are needed, at health service rates, to cover the cost of staff, equipment, lab and premises - and their own salary. A private dentist - or independent practitioner, as they prefer to be called - will see half this number of patients as a maximum. They can use high-quality materials not used by the NHS, such as white fillings for back teeth, and spend up to twice as long on a treatment.

For Somerset patients who can't afford to pay, or who can't travel, a visiting emergency service started in November. But it's as well to remember to have your emergency on the one day of the week that the Family Health Service Authority dentist visits your area.

Martin Fulford, principal partner in one of the Shepton Mallet practices, is receiving up to 10 inquiries a day from deregistered patients. He is committed to the NHS but sympathetic to colleagues who have left. As chairman of the local dental committee he wants to avoid the idea of "dental wars" in Somerset. "People think it's all about money but it's not, it's about quality of care and of life for the dentists. I know many who have gone into independent practice and are earning less but enjoying their work again."

But money is a predominant factor in the disintegration of NHS dentistry, and exodus of dentists. It is one that is being cleverly wielded by the Government which is anxious to divest itself of the cost for the bulk of dental services, and reduce the £1.2bn it spends.

In 1992, a 7 per cent cut in NHS fees paid to dentists was imposed, and more cuts are predicted. This follows a Government-backed drive to recruit more patients in 1990, under the terms of the new NHS Dental Contract, which resulted in thousands more registrations with dentists - and £200m worth of extra work that hadn't been budgeted for. The Department of Health wants to "claw back" this overspent money and the outstanding sum now stands at £11,000 from every NHS dentist. The profession is, understandably, up in arms about losing payment for work already done, and this is a factor behind the opt-outs.

Another factor has been plans to reform the NHS dental service. Since 1990 there have been, in addition to the new NHS Dental Contract, two major reports - the Bloomfield and Nuffield reports in 1993 - and a Green Paper in July 1994 on the future of dentistry. All failed to give a clear direction for NHS dentistry. A White Paper is due but nobody knows when. While health ministers dither, more dentists opt out.

"It is not hard to spot a hidden agenda," says Peter Thomson, a dentist who has worked in the NHS and private practice in North Dorset. "The overt message is, `We want to keep dentistry in the NHS.' The covert message is, `We want someone else to pay for it'."

And the timing is perfect; for the first time since the inception of the NHS in 1948, the public is beginning to accept that NHS funds are not infinite and, in future, paying for some health care may no longer be a choice. If dentists, who collectively, are often seen as a bunch of gold diggers, take most of the blame for this, the Government won't worry too much.

In response to public and professional concern about disappearing NHS dentists, the Department of Health boasts that the number of practitioners in the general dental service and the number of patients registered has never been higher. But registration of patients only began in 1990, and the number of NHS dentists is no indicator of who is getting treatment. All dentists in Wells, for example, are NHS dentists because they still see exempt patients.

"It is lies and clever use of statistics," says Bob Nixon of the General Dental Practitioners' Association. "A dentist can have 99 per cent private practice but if he has one NHS patient he will have an NHS contract number."

In an interview late last year, the Health Secretary, Virginia Bottomley, revealed some of her feelings about dentists. She had gone with toothache to see her GP, who prescribed the cheaper of two antibiotics. It failed to work, so she returned and was prescribed the more expensive drug which relieved the problem. Just why she visited a doctor rather than a dentist was never explained. Perhaps, like the residents of Wells, she couldn't find one.

Dental decay: what will they do next?

Government proposals for reforming NHS dental services

These are short on detail, particularly costs, but include:

1. A reduced fee for check-ups.

2. Patients to pay 100 per cent of the NHS fee for complex treatments such as bridges (now 80 per cent). Proposals for costs of most common treatments are not known.

3. A ceiling to remain on fees for a course of NHS treatment, amount unspecified.

4. Family health service authorities will purchase NHS dental services (pilot studies due). Patients registered with NHS dentists: 21m adults and 6m children

Patients deregistered by NHS dentists: 829,719

Patients registered with Denplan: more than 550,000, paying £6-£19 a month

Patients with Bupa Dental Cover: 26,500, paying £6-£18 a month

Sources: Consumers' Association; Department of Health; Parliamentary written answer

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