A tax on dentistry - Tina or Dora?

Posted by Dr Roger Matthews on 29/05/2019
Pensions auto enrolement

It’s hardly surprising that there has been widespread criticism of the recent hikes in NHS patient charges for dentistry in England: rightly called “a tax on dentistry” by the BDA. In the past four years those fees have increased by nearly 22% (cumulative) when inflation has been just 9% over the same period.

Let’s have a look at taxes: funds raised by Government to meet national expenditure. There are different types. So-called progressive taxes (like income tax) mean the rich pay more (unless they move offshore or use other dodges) and are seen as “fairer”. Flat taxes (like VAT or TV licences) are broadly regressive, because relatively speaking they hit the poorest in society harder.

State benefits and exemptions mean that shades of “unfairness” can be mitigated of course. But what about Pigovian taxes? The economist Arthur Pigou argued that taxes should reflect the wider costs to society that certain activities caused. Smoking has morbidity and mortality implications and is an added burden on the NHS; ditto alcohol consumption. Motoring causes pollution and increases pulmonary disease. Little wonder that the Chancellor sees all of these as ripe for taxation.

But dentistry? Surely, if ever there was an anti-Pigovian tax - making people pay more to improve their oral (and indeed general) health - the recent policy would seem to truly be idiotic - and unfair to boot.

The reason, of course, is rationing. A word that is officially taboo when talking about the NHS. It’s ironic, isn’t it? If, in 1947, when the NHS was being negotiated, the GP’s had opted to be paid per treatment or per consultation, and the dentists had gone for per-patient capitation (instead of the other way around), you might now be paying to see the doctor, but not your dentist.

Dental charges were brought in to counter “over-consumption”, and sadly no-one in Government or NHS administration today recognises (or is allowed to say in public) that the needs and policies of the 1940s are now totally outmoded. We hang on to the post-war ideals of ‘making people healthier’ (and so reducing the cost of the NHS) when today we face the costly burdens of chronic disease in an ageing population and of technological and pharmaceutical innovation.

In the words of Heinz Redwood (Why Ration Healthcare? Civitas:2000), when it comes to rationing healthcare, two arguments prevail: TINA (There Is No Alternative) or DORA (Discover Other Realistic Answers).

Currently, TINA prevails - she is the principal reason why we have NICE, the CCGs and other institutions after all: they serve to control demand and provision in the NHS. Despite their activity, TINA leads us down a path where health and social care spending consumes more and more of the national wealth.

But what about DORA? Many dentists have already reasoned that TINA is hopelessly outdated and in the long-term unsustainable. TINA punishes the poorest, encourages treatment over prevention, and potentially reduces the quality of health care.

 Think about it: in dentistry, TINA means higher patient fees, reduced (in real terms) payments to clinicians and, of course, workforce control. When demand rises, patients pay more, dentists get paid less and dental professionals’ training is suppressed (or they are economised, prone to being sued, regulated and generally given bad press).

DORA might say: consider asking your patients: do you want a dental MoT, or a 10,000 Smile Service? The MoT tells you what is critically failing right now and needs fixing (preferably cheaply and quickly, although you’ll pay more), whereas a service plan prevents problems, gives you peace of mind, and critically, time to choose how your health can best be preserved. MoTs are ‘here and now’, service plans look to your long-term best interests.

For those patients who can, DORA is worth her weight in patient fees (served up in predictable bite-sized pieces, such as monthly care or maintenance plans along the lines of the model originally conceived by the DORA-inspired founders of Denplan - “other plans are available”).

Policy-makers really need to look at how they can make DORA applicable to the whole population, and restore the Pigovian balance. The late (great) Jimmy Steele is now famed for his 2009 blueprint, including (some of) the principles of the NHS Dental Pilots and Prototypes, but his proposals also called for fundamental policy change. DORA would put the tax money into essential support (for those in pain, the poor and the vulnerable), provide assistance to those in need (maybe a contribution to the service plans), and ditch the regressive taxes.

If the policy-makers don’t change, TINA will drive dentistry - and wider health care - into a spiral of higher taxes, lower quality, poor availability and public antipathy. Dentists are moving to DORA already.

This article was first published by Dental Review