Open wide, please! (Your wallet, that is)

Aggressive private dentist chains are destroying the few remaining national health practices, and go

When, at the end of last month, a dental surgery in Wales announced that it could accept a further 300 National Health Service patients, more than 600 hopefuls queued to get on the list. About 300 waited 11 hours before being turned away. A few hundred miles east, in Essex, a friend has been told that she can only become a national health dental patient "if someone dies". She lives in hope.

Up and down the country, dental practice after dental practice is switching to private-only provision. Official figures published last year showed that four out of ten dentists refused to take on new NHS patients.

Take Brackley. This pleasant market town of 9,000 or so inhabitants on the borders of Northamptonshire and Oxfordshire has a wide choice of shops, a well-stocked public library, a 13th-century coaching inn and, until recently, the possibility of registering with an NHS dentist.

Last year, however, Oasis Healthcare plc made the owners of Park Lodge dental surgery an offer they couldn't refuse. Now the new owners inform enquirers that while private customers are welcome, the practice is "unable to accept" any new NHS patients on to its waiting list. Last month, the town's only other practice that took on NHS patients followed suit.

The undermining of the ideal of a national dental service free at the point of use is almost as old as the service itself. Fifty years ago, Hugh Gaitskell helped pay for the Korean war by imposing charges for dentures, and successive governments added to the growing list of charges for NHS treatment. None the less, the private dental market remained small. As recently as 1990, only 5 per cent of a dentist's income came from private earnings. Yet over the past ten years, the situation has changed dramatically. The value of private dentistry grew from £289m in 1994-95 to just under £2bn in 2001-02. Now, for the first time since the creation of the NHS, 51 per cent of the income earned by dentists comes from private earnings.

As private dentistry grows, so the number of people with access to NHS dentistry plummets. The decision of John Major's government to cut fees payable to dentists for NHS work in 1992 undoubtedly contributed to the steady exodus of an estimated 1,000 dental practitioners from the NHS system. These defections have been damaging enough. But now we are seeing the emergence of private dental chains and, in particular, the extraordinary growth of Oasis Healthcare plc.

Formed only six years ago, the Norwich-based company has grown in just six years to be the leading owner and operator of dental practices in England and Wales. Its aggressive expansion strategy would do Walmart proud. The recent acquisition of two competing operators, Ora Dental Group Holdings and the Dencare Management Group, for £5m and £20m respectively, now gives Oasis a total of 124 sites (more than 500 surgeries), up from 55 a year ago, and has taken the group's turnover to more than £75m.

The rise of Oasis owes much to the entrepreneurial flair of its chairman, the former Texas Homecare managing director Ron Trenter, and its chief executive officer, Malcolm Hughes. But the company's success, and the boom in private dentistry in general, is also an indictment of the failure of successive governments to maintain and support national health dentistry. It may also demonstrate that private dentistry cannot easily coexist with NHS provision without a two-tier system developing.

In an interview with the Wall Street Transcript three years ago, Hughes made no bones about his company's anti-NHS expansion strategy, declaring that one of his company's principal objectives is "to introduce increasing elements of private treatments" in all its practices. Converting to private-only patient care is standard procedure whenever Oasis acquires a dental practice. Last year, Trenter boasted of the ever-increasing proportion of Oasis turnover accounted for by non-NHS care. He contrasted his company's strategy - of "acquiring established, successful practices and then focusing on the delivery of a full range of private treatments" - with that of other operators who had chosen greenfield operations or built businesses with a primary focus on NHS care.

Oasis has minimised the initial effect on existing dental patients of converting a practice to private-only patient care, arguing that, because most NHS patients already pay 80 per cent of their treatment costs, the change represents only an "incremental" cost to the consumer. The reality, however, is different. The increases in private fees have greatly outstripped the rise in NHS charges in recent years, and private treatment is usually about four times as expensive. The average fee for a private dental examination is four times higher than the NHS fee.

Private dental companies make much of the wider choice of dental and cosmetic treatments available. Oasis offers not just drilling and filling, but "advanced crown and bridgework, tooth-coloured veneers and inlays, bleaching, orthodontics, temporomandibular joint [jaw] problems or periodontal care". And appropriately enough for these narcissistic times, consumers are able to go out and purchase "the Baywatch smile". Those less concerned with purchasing a Baywatch smile and more interested in affordable, basic dental care will have to look elsewhere.

Malcolm Hughes recently announced that it was time for his company to concentrate on the "build" part of its "buy and build" strategy and that "only a handful" of dental practices would be bought this year. But the Oasis boss has no doubt how British dentistry will look a few years from now. Enthusing over the "tremendous growth possibilities" of the private market, Hughes envisages that: "With the emergence of a strong, well-marketed, branded position like ourselves [sic], and perhaps one or two competitors establishing strong positions in the market, too, we will collectively build up awareness dramatically."

Anyone who doubts that the future of British dentistry is a corporatised one should, according to Hughes, look at what has happened to chemists and opticians, which, in his words, "were similarly very large but highly fragmented and underdeveloped 15 years ago. Today, following the same process of consolidation and brand-building, those markets are dominated by well-branded, successful organisations."

Whether you like Hughes's ambitions for dentistry or not, they are surely incompatible with the vision of NHS access for all outlined by the Prime Minister at the Labour Party conference four years ago.

Tony Blair also pledged that, within two years, everyone would be able to see a national health dentist. But the truth is that, six years into a Labour government, we are further away from that ideal than we were under the Conservatives. The most recent figures show that just 48 per cent of the population in Britain is registered with an NHS dentist. Roughly 1.5 million fewer people have access now than in 1998, and five million fewer than in 1994. In the 24th richest nation in the world, the shameful fact is that one in five people is deterred from going to the dentist because of fears over treatment costs.

All this has already had an impact on the nation's oral health. In some parts of the country, the incidence of tooth decay is up 50 per cent over the past decade. Mouth cancer is also on the rise, with 3,800 new cases diagnosed in the UK each year.

None of these developments should surprise us. A predominantly private dental service inevitably means a two-tier service: good mouths and gleaming smiles for the rich; disease, tooth decay and emergency extraction dentistry for the rest. For the millions of Britons who merely require access to low-cost, basic dental treatment, the scenario is bleak.

Dr John Renshaw, chairman of the British Dental Association, says his organisation "wants to see a thriving private dental market existing alongside high-quality funded NHS provision which is available for all who want it". But how can this be achieved when the private market is led by a company whose growth strategy is explicitly antagonistic to NHS provision?

Stung by recent reports highlighting the extent of Britain's dental problems, the government has published its blueprint for NHS dentistry in the Health and Social Care Bill, giving primary trusts the power to commission dental services to "meet reasonable need". While the initiative is welcome, it is difficult to see what long-term benefit will come of it unless the government also gets to grips with the rise of private dental chains such as Oasis, and faces up to the threat they pose to national health dentistry.

The introduction of a wholly nationalised system, with dentists paid salaries instead of the fees they receive under the discredited piecework system, may seem an extreme remedy. But if we are to arrest the decline in Britain's oral health and provide affordable, easy access to dental care for all, regardless of means, it may be the only solution.

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