An entirely imagined exchange, from Sara Hurley
Scene: The Department of Health and Social Care. A new Secretary of State for Health, recently arrived from the Treasury, is being briefed on NHS dentistry.
His Permanent Secretary, Sir Humphrey, enters carrying a large, dog-eared departmental folder, its corners softened by use and its contents thickened by history. On the cover, in fading ink, it reads:
NHS Dental Reform — England
- 2006 Contract
- 2009 Steele Review
- 2011 Pilots
- 2016 Prototypes
- 2026 Reset
Inside are Select Committee reports, the Steele Review, pilot evaluations, prototype reports, a National Audit Office investigation and a yellow sticky note reading: “Urgent — update lines to take.”
Since the 2006 dental contract was introduced, a dozen Secretaries of State have held the Health brief. The folder, unlike most of them, has remained in post.
Minister: Humphrey, why does this folder say 2006, 2009, 2011, 2016 and 2026?
Sir Humphrey: Continuity, Minister.
Minister: Four of the dates are crossed out.
Sir Humphrey: Also continuity, Minister.
Minister: It looks as though the same problem has been passed from one Secretary of State to the next for twenty years.
Sir Humphrey: I would not say passed, Minister.
Minister: What would you say?
Sir Humphrey: Sequentially retained within the Department’s strategic reform horizon.
Minister: Kicked down the road, then.
Sir Humphrey: Only in the sense that the road has been subject to ongoing review.
Minister: How many Health Secretaries have had this file since the 2006 contract?
Sir Humphrey: That depends whether Minister wishes to count individuals, tenures, or opportunities for decisive reform.
Minister: Individuals.
Sir Humphrey: Twelve, Minister. Thirteen, if one counts Mr Barclay twice, which some officials do, depending on the spreadsheet.
Minister: And the problem is still here?
Sir Humphrey: Very much so, Minister. That is how one recognises a truly durable policy issue.
Minister: There are Select Committee reports in here.
Sir Humphrey: Several, Minister. They add weight to the file.
Minister: Alongside the early warnings after the 2006 contract, the Steele Review, the pilots, the prototypes and the 2023 Health and Social Care Committee report?
Sir Humphrey: A comprehensive record of concern, Minister.
Minister: And implementation?
Sir Humphrey: A more selective record, Minister.
Minister: The 2006 reforms were supposed to improve access.
Sir Humphrey: That was certainly the aspiration.
Minister: But they did not?
Sir Humphrey: Not universally, Minister.
Minister: It says here that Steele pointed towards clearer patient pathways and a better-designed system, less dependent on treatment volume alone. Then came pilots on registration, capitation and quality. So, this is not a new conversation.
Sir Humphrey: No, Minister. It is a mature conversation.
Minister: Seventeen years mature?
Sir Humphrey: Maturity takes time.
Minister: And in 2023, Parliament was still calling for urgent and fundamental reform.
Sir Humphrey: Parliamentary memory can be inconveniently long.
Minister: It also noted frustration that recommendations made fifteen years earlier had still not been implemented.
Sir Humphrey: Minister, consistency is important in public administration.
Minister: Not when it is consistency of failure.
Sir Humphrey: We would normally call that an enduring delivery challenge.
Minister: So nothing good happened in all that time?
Sir Humphrey: On the contrary, Minister. A great deal of good happened. That is what makes the absence of reform so difficult to explain.
Minister: Go on.
Sir Humphrey: Prevention became increasingly prominent: Dental Check by One, phased courses of treatment, early intervention and an impressive accumulation of commissioning standards. All the ingredients of modern oral health system, Minister. Admirably assembled, if not entirely embedded.
Minister: But not the contract.
Sir Humphrey: Not entirely.
Minister: So prevention was recognised, but not built in. Surely it should sit at the heart of the contract, not as an adjunct. Remunerated, measured, expected and supported.
Sir Humphrey: That would require changing incentives.
Minister: Yes.
Sir Humphrey: And changing incentives changes behaviour.
Minister: That is the point.
Sir Humphrey: It is also the risk.
Minister: So we admired the direction of travel without necessarily travelling in that direction.
Sir Humphrey: A fair summary, Minister. Though perhaps a little direct.
Minister: And the prototypes?
Sir Humphrey: The prototype programme tested changes to activity-based dental contracts, including clinical and remuneration models. A veritable garden of reform.
Minister: And then?
Sir Humphrey: The garden was returned to lawn.
Minister: Meaning?
Sir Humphrey: The contract reform programme was recalibrated into the Department’s longer-term reform trajectory, Minister. The participating practices returned to the existing activity system.
Minister: So, after more than a decade testing how to move beyond UDAs, the system returned to them?
Sir Humphrey: With the benefit of learning, Minister.
Minister: Learning what?
Sir Humphrey: That reform is safest when it remains under evaluation.
Minister: And the Dental Recovery Plan?
Sir Humphrey: A most encouraging title.
Minister: The National Audit Office said it was not on course to deliver more than 1.5 million additional courses of treatment. And even if it had, activity would still be millions of courses below pre-pandemic levels.
Sir Humphrey: Context is important, Minister.
Minister: Meaning?
Sir Humphrey: One must judge a recovery plan not only by recovery, but by the seriousness with which recovery is intended.
Minister: So it did not recover the service.
Sir Humphrey: It recovered the appearance of a plan.
Minister: But patients still cannot access care. Children are still presenting with preventable disease. We have dental deserts. The manifesto promised urgent appointments, supervised toothbrushing, recruitment to underserved areas and contract reform. What is the actual plan?
Sir Humphrey: The plan, Minister, is to deliver the commitments.
Minister: Yes, but how?
Sir Humphrey: Through implementation.
Minister: Implementation of what?
Sir Humphrey: The delivery programme.
Minister: And what does the delivery programme deliver?
Sir Humphrey: The plan, Minister.
Minister: Humphrey, this sounds circular.
Sir Humphrey: Not circular, Minister. Iterative.
Minister: And where is the patient in this iteration?
Sir Humphrey: At the centre, Minister.
Minister: In what sense?
Sir Humphrey: In the sense that all documents say so.
Minister: I came from the Treasury, Humphrey. I understand money. The BBC recently reported that around £900 million in NHS dental funding was returned through clawback over two years. That’s roughly £1 for every £7 commissioned. That does not sound like a simple story of “no money.”
Sir Humphrey: No, Minister. It is a story of resource allocation, contractual performance, delivery variance and local system utilisation.
Minister: A commissioned pound returned through clawback has not bought access, prevention or trust.
Sir Humphrey: True, Minister. Although it has bought a commissioning intention.
Minister: Patients cannot chew with a commissioning intention.
Sir Humphrey: No, Minister. Though one should not underestimate the value of intention in public administration.
Minister: Let us talk about urgent appointments. They matter.
Sir Humphrey: Absolutely, Minister. Urgent access is central to restoring public confidence.
Minister: But urgent access is not recovery. An extraction, a temporary dressing, no onward pathway, no stabilisation, no prevention, no recall, that is not a functioning service.
Sir Humphrey: It is a responsive intervention, Minister.
Minister: It is a pressure valve.
Sir Humphrey: Precisely. And pressure valves are very important in a system under pressure.
Minister: The aim is to reduce the pressure, Humphrey.
Sir Humphrey: In the medium term, naturally.
Minister: And in the short term?
Sir Humphrey: We announce the pressure valve.
Minister: Urgent access may reduce headlines. It does not reduce incidence.
Sir Humphrey: A stark formulation, Minister.
Minister: Is it wrong?
Sir Humphrey: Not wrong, exactly. Merely insufficiently reassuring.
Minister: Reassuring to whom?
Sir Humphrey: Those announcing the pressure valve, Minister.
Minister: Let us talk about the contract. The Unit of Dental Activity counts activity, but it does not capture prevention, complexity, stabilisation, continuity, patient experience or long-term health gain.
Sir Humphrey: It has the great virtue of being countable.
Minister: So does failure.
Sir Humphrey: Yes, Minister, but failure is harder to include in an annual report.
Minister: Can the number of UDAs tell me whether disease has been prevented? Whether a child avoided hospital extraction? Whether a cancer patient received timely oral health support before treatment?
Sir Humphrey: Not as a standard contract metric.
Minister: Then what does it tell me?
Sir Humphrey: Activity, Minister.
Minister: And what does activity tell me?
Sir Humphrey: That something has happened.
Minister: Not whether the right thing happened.
Sir Humphrey: That would be an outcome, Minister.
Minister: Do we measure outcomes?
Sir Humphrey: We aspire to.
Minister: But we pay and performance-manage through UDAs.
Sir Humphrey: Principally, yes.
Minister: So the system talks outcomes but counts activity.
Sir Humphrey: A concise summary, Minister.
Minister: And then we are surprised when activity drives behaviour.
Sir Humphrey: Surprise is often an important stage in policy development.
Minister: If we want prevention, stabilisation and health gain, we need data that can show them. The NHS already has much of it: general practice, hospitals, community services and pharmacy. But dentistry is disconnected from all of it.
Sir Humphrey: Dentistry has its own systems, Minister.
Minister: That is the problem, not the answer. A patient with diabetes, frailty, cancer or pregnancy does not become less relevant to dentistry because the data sits somewhere else. And their oral health does not become less relevant to the rest of the NHS because it sits in a dental record. If we are building a Single Patient Record, the mouth is part of the body.
Sir Humphrey: Anatomically correct. Administratively complex.
Minister: Then the administration needs to catch up with the anatomy.
Sir Humphrey: Again with the anatomy, Minister.
Minister: And ICBs. Do they have the tools to commission differently?
Sir Humphrey: They have responsibility, Minister.
Minister: I asked about tools.
Sir Humphrey: Responsibility is a powerful tool.
Minister: Not if they inherit fragile markets, constrained flexibilities, limited data and national expectations still shaped by activity rather than health gain.
Sir Humphrey: Local flexibility must be exercised within a clear national framework.
Minister: Which means?
Sir Humphrey: They may innovate, provided they do not do anything too different.
Minister: Some areas need new forms of provision: multidisciplinary clinics, sessional models, urgent-to-stabilisation pathways, and services connected to children’s health, care homes and wider primary care.
Sir Humphrey: Innovation is welcome, Minister, once it has been piloted, evaluated, assured, risk-assessed, aligned, re-scoped and rendered sufficiently familiar.
Minister: Humphrey, that sounds like innovation being processed until it is no longer innovative.
Sir Humphrey: We prefer to call it responsible transformation.
Minister: Announcements, roundtables, dashboards, action plans, stakeholder events, carefully crafted ambition, none of it is progress unless patients experience care, dental teams can deliver, and commissioners can commission differently.
Sir Humphrey: A demanding definition of progress, Minister.
Minister: It is the only useful one. So what do you recommend?
Sir Humphrey: A phased programme of engagement to develop a shared vision for sustainable NHS dental transformation.
Minister: NHS dentistry has spent too long strapped into the policy rollercoaster: big promises, sharp turns, no clear destination. It needs direction.
Sir Humphrey: An unfortunate metaphor, Minister.
Minister: Is it inaccurate?
Sir Humphrey: Not necessarily inaccurate. Merely unhelpfully vivid.
Minister: Patients want care, not metaphors.
Sir Humphrey: Quite. Though metaphors are considerably easier to procure.
Minister: Then let us be precise. I want to avoid four mistakes: mistaking allocated funding for delivered care; activity for access; access for continuity; and continuity for health gain.
Sir Humphrey: Philosophically elegant, Minister. Operationally troublesome.
Minister: And let us be clear about the ambition. NHS dentistry cannot be repeatedly relegated to the margins of universal healthcare. Oral health is not optional, and access to care is not a favour to be rationed when the system finds it convenient.
Sir Humphrey: A powerful phrase, Minister. Shall I ask communications to incorporate it into the stakeholder pack?
Minister: No, Humphrey. Put it in the operating model.
Sir Humphrey: Ah.
Minister: Are you going to help me fix this?
Sir Humphrey: Minister, I shall ensure the Department gives the matter the fullest and most urgent consideration.
Minister: That is what I was afraid of.
Sir Humphrey closes the folder marked NHS Dental Reform, taking care not to disturb the Select Committee reports, the Steele Review, the National Audit Office investigation or the yellow sticky note marked “Urgent — update lines to take.”
He places it carefully on top of another pile labelled Future Options.
Minister: Humphrey, why is that pile so large?
Sir Humphrey: Because, Minister, the future has always been the safest place for dental reform.
Author’s note
This piece is written in affectionate tribute to the satirical tradition of Yes Minister and Yes, Prime Minister, whose genius lay in exposing the gap between political intent, administrative process and public service delivery. Any resemblance to actual departmental conversations is, of course, entirely coincidental.
Jay A, Lynn J. Yes Minister and Yes, Prime Minister [television series]. London: BBC Television; 1980–1988.
About the author
Sara Hurley CBE served as Chief Dental Officer for England from 2015 to 2023. This piece draws on her experience of the policy landscape she inherited and the endeavours to drive forward change. She wishes the new Secretary of State well in delivering on his party’s manifesto pledges.
Sources informing factual references
- House of Commons Health Committee. Dental Services: Fifth Report of Session 2007–08. HC 289-I. London: The Stationery Office; 2008. [Findings on PCT commissioning, the UDA system and unmet access targets following the 2006 contract.]
- Steele J. NHS Dental Services in England: An Independent Review. London: Department of Health; 2009. [Recommendations for a patient pathway model and reduced reliance on treatment volume as the primary measure.]
- Department of Health / NHS England. Dental contract reform: pilots and prototype programme. 2010–2022. [Barry Cockcroft’s December 2010 letter outlined plans for piloting a new national dental contract based on registration, capitation and quality from 2011; prototype testing followed from 2016.]
- British Society of Paediatric Dentistry. Dental Check by One. Available at: bspd.co.uk
[Campaign established with the Office of the Chief Dental Officer for England, recommending that children see a dentist as their teeth come through, or by their first birthday.] - House of Commons Health and Social Care Committee. NHS Dentistry: Access Denied. HC 418. London: House of Commons; 2023. [Found that NHS dentistry faced a crisis of access requiring urgent and fundamental reform, and noted frustration that recommendations from fifteen years earlier remained unimplemented.]
- Department of Health and Social Care and NHS England. Faster, Simpler and Fairer: Our Plan to Recover and Reform NHS Dentistry. London: DHSC; 2024. [The Dental Recovery Plan, setting out commitments on additional courses of treatment, access, prevention, workforce and reform of the NHS dental contract.]
- National Audit Office. Investigation into the NHS Dental Recovery Plan. HC 308. London: National Audit Office; 2024. [Found that the recovery plan was not on course to deliver more than 1.5 million additional courses of treatment in 2024–25, and that even full delivery would leave activity 2.6 million courses below 2018–19.]
- NHS England. Data analysis: impact of the Dental Recovery Plan. 5 February 2026. Available at: england.nhs.uk [Found that the Dental Recovery Plan did not increase delivery of UDAs in 2024–25, excluding those earned through the new patient premium tariff.]
- BBC News. Dentists return hundreds of millions in NHS care cash. 5 March 2026. Available at: https://www.bbc.co.uk/news/articles/cpqwwvnp7z8o [Reported that around £900 million in NHS dental funding was returned through clawback over two years, approximately £1 for every £7 commissioned.]
