Dentistry. The very word is enough to sink hearts on the fourth floor of Richmond House. The dental status quo is always said to be terrible. And every change allegedly makes it worse. That is what happened after the 1990 dental contract, and again after the 2006 contract.

So what is the truth? In 1948 there were around 10,000 dentists. Now around 21,000 provide NHS care. Back then you had Nye Bevan declaring: “The condition of the teeth of the people of Britain is a national reproach.” And over a third of the population were still toothless two decades later. Now it is just 6 per cent of the population. (My grandparents’ dentures in a glass remain a vivid childhood memory. Fortunately, born in Birmingham, I benefited from fluoridated water).

But there are still class inequalities in oral health, and geographical differences in access to NHS dentistry. Oddly enough, it may now be harder to find an NHS dentist in better off areas: one of the dentists’ lobbying organisations claims: “If you live in Bradford or Teesside you will probably find access fairly easy. If you live in Epsom or Winchester you will not be so fortunate.”

It does not answer fundamental questions that have bedevilled the temporary fixes of two decades. First, what is the ultimate goal of NHS-funded dentistry?

How did we get here? The 2006 contract was an attempt to put some flesh on the bones of a rash and ill thought through announcement by Tony Blair in 1999. He committed that, within two years, access to an NHS dentist would be available to anyone who wanted it. That suggestion quickly transmuted into the idea that you could phone NHS Direct and they would give you the address of one. But it provided the British Dental Association with the political wherewithal to keep prodding the Department of Health for a replacement to the despised 1990 contract. The 2006 contract was the result. Whereupon the BDA promptly denounced that as well.

Ultimate goal

So it is a sign of bravery that the Conservatives have just set out their new plans for NHS dentistry. They want to revert to the 1990 contract’s idea of patient registration, to scrap the current crude measuring of dentists’ output, and to fine patients who miss appointments. They want to give five year olds an oral health check-up, while stopping patients being “recalled for routine check-ups just weeks after treatment and without clinical need”. Dentists could start up and sell practices more easily, dental hygienists would have a bigger role, and newly trained dentists would have to work for the NHS for five years.

Lots of this makes sense. But it does not yet answer two of the fundamental questions that have bedevilled the temporary fixes of two decades. First, what is the ultimate goal of NHS-funded dentistry? And then how are you going to tackle the entrenched perverse effects arising from the current structure of the “mixed economy” of dental provision?

Let’s start with some hard economic facts. Primary care trusts’ net allocations for NHS dentistry are around £2.3bn this year. On top of that, NHS dental patients are paying about a quarter of their costs via dental charges. And on top of that, a further £3bn or so is being spent privately. Given the impending NHS spending crunch, we can assume no government is about to propose displacing that personal spending.

The real choice probably boils down to this. With the half of total dental spending the NHS controls, is the fundamental public policy goal: a) to provide a full service for poorer people, or b) a tightly rationed core service for everyone? In other words, the money will buy you a comprehensive but non-universal service, or a universal non-comprehensive service Which is it to be? At the moment we have neither - and chronic confusion and dissatisfaction.

Perverse incentives

The second problem to address is the mess arising from the interaction between public and private provision. The NHS has not decided whether dentists are really quasi-public providers to nurture and coax, or independent contractors to commission and manage accordingly. It treats them as the former, while dentists often behave as the latter.

Evidence for that assertion? Dentists pick and choose how much NHS work to undertake - and for young dentists it is now only a third of their income. And dentists have shown themselves highly “transactional” over incentives. Within a year of their new NHS contract, the number of complex treatments involving lab work fell 50 per cent, and root canal treatments fell 45 per cent. At the same time the number of tooth extractions rose. Who knows whether the “before” or “after” was clinically optimal - but evidently it was income not new clinical insight that drove the change.

Indeed, the Conservative dental strategy explicitly states that “perverse incentives drive dentists to provide unnecessary treatments”. To which the DH huffily responds that “failing to provide the most clinically appropriate care to gain financial advantage is of course a breach of professional standards, of patient trust and of NHS contractual requirements”.

Well yes, but what are we going to do about it? More aggressive market “stimulation” by primary care trusts would be one approach. Greater use of salaried dentists another. But what won’t work is simply trying to expand supply through the new dental schools or overseas recruits, without tackling these incentive issues, and clarifying what NHS dentistry is actually trying to achieve.