Lessons from recent history
Improvements in oral health may not be impacted by Brexit, but the effects on the profession will be significant
It may be difficult to reliably forecast the future – but looking to events of the recent past can provide some pointers. Michael Donaldson, Consultant in Dental Public Health and Head of Dentistry at the Northern Ireland Health and Social Care Board, has spent time over the past few months trying to predict the likely effects of Brexit on dentistry – by comparing prospects for the UK’s exit from the EU with what happened after the 2008 banking collapse.
Armed with economic forecasts for the UK and Irish economies post-Brexit, studies of the impact on oral health in the US and Europe of the global recession 10 years ago, evidence of trends in healthcare spending, and analysis of shifting dental workforce patterns, Donaldson found that the consequences for the UK and Ireland are likely to be significant – though not wholly negative.
“As we detach from the consolidated legislation of the EU, the healthcare system in the UK is going to become more bureaucratic, and therefore expensive,” he said. “In terms of our children’s oral health, [decayed teeth] averages are likely to continue to decline with lower levels of decay in both the UK and Ireland.
“However, there will be ‘left behind’ areas in both jurisdictions. And we are going to see wider inter and intra-national variation in access to state-funded primary care dental services. In the Republic, this will very much depend on the funding settlement for its new oral health policy.”
Speaking in a personal capacity at the Faculty of Dentistry, RCSI, Annual Scientific Meeting in Dublin last November, Donaldson explored the impact of Brexit on the economy, oral health, healthcare spending, access to dentistry, the workforce, and the movement of drugs and medical devices.
With the exception of Patrick Minford, chair of Economists for Free Trade and professor of applied economics at Cardiff Business School, who has said that the UK’s gross domestic product (GDP) will grow by 4 per cent as a result of Brexit, the majority of projections have it 4 per cent lower by 2030; representing £100bn in that year alone, still following an upward – but flatter than no Brexit – trend line in the preceding years and continuing upward in the years that follow. It is a similar picture in Ireland, albeit its economy is smaller. Brexit is projected to reduce GDP in the Republic by 3 per cent by 2030; representing £10bn in that year alone.
In the downturn that followed the 2008 banking collapse, oral health in the UK improved with the Decayed, Missing, Filled Teeth index (DMFT) showing a marked decline. In Ireland, there was a similar trend. In Iceland, whose economy was particularly hard hit, researchers studied the oral health of a 4,000-strong cohort in 2007 and again in 2009 and found that the collapse “did not have drastic negative effects on dental health behaviours of the population in Iceland.” They added: “Our findings suggest that men may have opted for healthier dental health behaviours following the national economic collapse”(1). However, Donaldson pointed out that there was evidence of a negative effect on health inequalities and that there are areas of the UK and Ireland that are likely to be affected more than the average, along with specific population groups such as migrant families, travellers, and those in receipt of benefits.
Despite the UK and Irish economies displaying signs of recovery from 2010, healthcare spending in both countries declined in the years following, with the UK experiencing the largest reduction in spending as a percentage of GDP in its history. Despite UK Prime Minister Boris Johnston’s election pledge to spend an additional £2.8bn on the NHS, Donaldson’s view was that it was “very unlikely that healthcare spending will rise above trend”.
Access to dentistry
A US study published earlier this year,(2) showed that the 2008 recession resulted in a decrease in the demand for general oral health care and orthodontic care, the latter significantly. Medicaid spending, covering those on a low income, increased. In Northern Ireland, spending on private dentistry declined significantly in the years 2009 to 2012 as about 200,000 people – from a population of 1.8 million – registered with health service dentists. At the same time, the number of dentists working in primary care was increasing – by 18 per cent – supported by a 50 per cent increase in funding over a five-year period. In the Republic, the most recent available figures, from 2015, show spending on the Dental Treatment Services Scheme, Dental Treatment Benefit Scheme, and salaries to be around €150m.
Projected spending on Ireland’s new oral health policy, Smile agus Sláinte, is around the same. Donaldson said that, in his view, with the demand-led contracts that exist in Northern Ireland and Scotland, the system could cope with a downturn in the economy. Not so in England and Wales, with their fixed-level contracts.
In Ireland, he said, “it is always going to hinge on the level of funding in this new oral health plan”. The issue there would be whether the funding would be sufficient to support a trend away from private to public dentistry.
Currently, UK and Irish graduates with a dental qualification from either country can register in one or the other. This will hold true until
30 June 2021. Beyond then, there is no clarity. If new arrangements are not put in place, then those graduates will be treated as ‘third country’ applicants – similar to someone from Australia or India, for example – in either jurisdiction. This would present a “significant” challenge for the UK’s General Dental Council and the Dental Council of Ireland, said Donaldson.
There has been an increase in the number of dentists on the GDC register over the past decade, but that has levelled off. The number of graduates joining from the EU has dropped significantly; 500 fewer each year from 2011 to 2017. If subsequent UK immigration policy does not address this challenge, then dentistry, and the health service in general, will be under significant pressure.
Currently, about 17 per cent of dentists on the register are from the EU. If the pound continues to fall against the Euro, then many of those already practising here may leave. According to a report commissioned by the GDC and published last January, almost a third of those from the EU registered in the UK are considering leaving.
The issue is not as pressing in Ireland, where the common travel agreement will remain in place, and there is a good supply of dentists into the profession. A problem may occur with over-supply, however, if those opting out of the UK choose to register instead in the Republic.
“As we detach from the consolidated legislation of the EU, the healthcare system in the UK is going to become more bureaucratic, and therefore expensive“Michael Donaldson
Regulation of medicines
The European Medicines Agency (EMA) allows pharmaceutical companies to seek EU-wide approval for their drugs. Europe represents around 26 per cent of the global market; the UK, about 3 per cent. The consequence of the UK leaving the EU is that companies will seek approval in the US first, then Europe and, much further down the line, the UK. “The UK is going to be receiving new drugs considerably later,” observed Donaldson. The UK is negotiating to remain part of the EMA, but no agreement has been reached. In terms of the current supply of drugs into the UK, 75 per cent come through Europe. If there is a no-deal Brexit, supply could be disrupted. There could also be a knock-on effect for Ireland, as 60 per cent of its drugs come through the UK. Realisation of this has caused Ireland to look to other suppliers.
- More bureaucratic and expensive dental systems.
- Most children will continue on a low caries trajectory.
- The numbers ‘left behind’ (i.e. high caries outliers) could increase.
- Wider inter and intra–national variation in access to state–funded primary care dental services.
- Effects of a national economic crisis on dental habits and checkup behaviours – a prospective cohort study. Christopher Bruce McClure & Sigurður Rúnar Sæmundsson. Community Dentistry and Oral Epidemiology Volume 42, issue 2, April 2014, pages 106-112.
- The effect of the Great Recession on the demand for general oral health care and orthodontic care. Albert H. Guay & Andrew Blatz. The Journal of the American Dental Association, Volume 150, Issue 4, April 2019, Pages 287–293.