NHS dentistry: a system failing by design

 BMJ 2026; 393 doi: https://doi.org/10.1136/bmj-2026-100078 (Published 29 June 2026) Cite this as: BMJ 2026;393:e100078

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In their article about NHS dentistry, McColl and colleagues describe a system in managed decline.1 The 2006 contract was flawed by design: a “unit of dental activity” model rewarding throughput over prevention and volume over complexity. The disconnection between clinical judgment and financial reward was always likely to drive attrition among the most conscientious practitioners. That practices are returning £900m of NHS funding—not owing to lack of demand but to financial unsustainability—is not a market failure. It is a policy failure, two decades in the making.

The underuse of the wider dental team is equally inexcusable. Therapists, hygienists, and nurses with extended duties represent a substantial workforce that the current model systematically fails to use. The barriers are not regulatory but contractual: a payment structure that does not reimburse team based care. Any serious reform must redesign the skill mix architecture, not merely adjust dentists’ rates.

The announcement of 50 additional dental school places from 2027 is welcome in direction but negligible in scale. With five year training pipelines and no guarantee of NHS commitment on graduation, this cannot tackle current access pressures. Compulsory tie-in periods deserve consideration but only as part of a genuine compact: improved contractual terms, mentorship, and a credible career pathway. Mandating service on an unreformed contract will not improve retention—it will simply defer the exodus.

What is missing is an equity lens and coherent public health framing. Dental disease falls hardest on those least able to access care. From a global public health perspective, this is an equity emergency. Oral diseases share the same social determinants as diabetes, cardiovascular disease, and respiratory conditions. The WHO Global Oral Health Strategy (2023-30) and the Lancet commission have made this case clearly.23 England should be leading implementation not trailing behind.

Incremental adjustment will not reverse 20 years of drift. The government must commission an independent review of the NHS dental contract with a clear mandate for fundamental redesign—one centring prevention, equity, whole team care, and integration with the non-communicable disease agenda. Anything less is rearranging deck chairs.