Winchester isn't the sort of place that usually comes up in conversations about poverty. The Hampshire cathedral city has long been a byword for genteel affluence and desirability, routinely topping lists of the UK's "best places to live" – testament to the harmony of its reassuringly half-bucolic mismatch of buzzing high street, sleepy arterial roads and solid, unflashy suburban sprawl.
But a scratch at the surface reveals a different picture. Ten minutes walk from the station is Trinity House, a local homelessness centre that works with around 600 of the county's most vulnerable people – though there are others from around the UK who also seek sanctuary here.
I'm here because this is where Dentaid's mobile unit is set to be stationed for the next few hours, on what's quickly becoming a bracingly cold winter's afternoon. Since 1996, the Salisbury-based dental charity have worked to provide oral health education and treatment, at first in the developing world, though since 2015 their efforts have increasingly focused on addressing domestic needs, by taking their mobile van wherever the problem is greatest or the urgings of local authorities are loudest.
It's a mission that's grown in intensity over the last decade, as changes to how NHS dentists are paid have thrown some of the most needy into what is effectively permanent exclusion from treatment. It used to be that dentists were paid by the job. If a patient needed complex work, you’d be paid for every unit done. But 2006 saw a controversial new contract introduced, where a set amount of Units of Dental Activity (UDAs) were allocated. Every basic procedure now earns one UDA, with fillings and extractions earning three and a course of more complex treatment gleaning 12.
So far, so streamlined. However, the UDA covers an entire course of treatment, no matter how complex. It's irrelevant if the dentist performs one filling or 20; payment will still be the same: three UDAs. To risk seeing "poor quality mouths" could mean a full day of work for the equivalent of an hour's labour on a simple extraction. Simply put, the needy became financially untenable. It's partly what's led to a spike in DIY dentistry – the almost Dickensian process in which people are taking oral health into their own hands, sometimes with disastrous consequences.
On arrival, I get chatting to Jill Harding, Dentaid's communication director. The biggest chunk of their work revolves around targeting areas of the country where the struggle to access NHS dental care is at its most acute: Wolverhampton, Blackpool, Leeds, York and swathes of the North-East. They see plenty of people who have slipped through the increasingly porous safety net of the state; the homeless and the vulnerable, some struggling with complex webs of addiction and other deep-seated issues. In short, precisely the kind of people desperate enough to attempt DIY procedures.
"In Dewsbury [West Yorkshire], for example, there can be huge times for an NHS waiting list. So the local authority will fund us to take the van and set up community outreach clinics," she says. "We park outside community centres, schools, the town hall, and people can turn up without an appointment. That's it – no registration or anything like that. We just [see patients] and get them out of immediate pain. It's basic dentistry, not the fancy stuff. [We do] fillings, extractions, scale and polish."
Often, those arriving for treatment might be living a lifestyle that makes navigating services and keeping appointments that bit more difficult. The second patient of the day is Daniel, who has arrived for an extraction. He looks in his mid-thirties, perhaps slightly older. He's willing to chat about his experiences, depending "on how it goes in the van", as Jill puts it.
As Daniel takes himself up the stairs, I'm introduced to Andy Evans, Dentaid's personable CEO, who also works as manager of a separate dental practice. Though it's barely past 11AM, it's already been a long day, he laughs. It's tough, he says, to know how many of their patients would be able or willing to access dental care through more traditional avenues.
"Walking into a dental practice can be quite a big thing if you're struggling with other problems," he says. "It's similar with going to a GP. [For example,] Daniel has come to see us around three times. He's come for another tooth out today and he might well be a bit high on something – but that doesn't matter."
Prevention is important when it comes to dental health. The patient before Daniel "had a potentially cancerous situation going on, but we've seen him and can refer him off. Now, if that had gone undiagnosed – then the outcome could have been a lot worse. If it is [cancerous], then it's been caught early. If it's not, then fantastic."
For Dentaid, there are very few "typical days". The NHS's equivalent vans do it differently, as there’s a host of restrictions around who can access them. "For example, if you're not on benefits, you have to pay the charges. So [if an NHS van were to show up here], that would be their first question," Andy tells me. Ironically, it's Dentaid that provides the free point of access care that was once the preserve of the state, though it’s not a question of apportioning blame to practitioners. Andy is clear that his sympathies lie with dentists who are often simply priced out of offering treatment. As a practice manager, he knows just how hard the financial squeeze can be.
What they can offer is a slightly more holistic approach, with a member of staff documenting medical histories, as well as the dentist and dental nurse on board. "Trinity House [and Dentaid] aren't run by the local authority," says Andy. "They could never fund something like this, but a charity can. But Trinity help rough sleepers, which the council contributes towards – which is great. That's why we're stepping in."
When it comes to DIY dentistry, no one is quite sure of the problem's scale, due to the purely anecdotal evidence involved. It takes seconds to bring up a gallery of kits for sale online, with the cheapest coming in at under £5. There's an abundance of grimly comic brand names, from Toofypegs Emergency Repairs ("4 Crowns x 4 Fillings") to DenTek's Filling Material Repair Kit, which comes set with an applicator and a small vial of eugeonal, a commonly used therapeutic in ordinary dentistry – but one that can still cause irritation and adverse side effects in a minority of patients.
Figures on precise usage of these kits is tough to obtain, though work by journalist Stephen Armstrong suggests that DenTek sell around 250,000 a year. Other research, compiled by the British Dental Health Foundation in 2012, found that one in five Brits would remove a tooth themselves, or ask for help from a friend to do so, if they couldn't afford treatment.
John Fegan is a builder from west London. His own DIY experiences span a number of years and instances, several of which have passed straight into family folklore. There have been occasional chipped teeth that have required immediate intervention, usually dealt with by a small drill, fixed with a grinding attachment to "file the sharp edges down", he tells me during our correspondence.
Fillings that have fallen out have been replaced, glued back into position with an epoxy resin. But his most infamous episode occurred when the gold cap on a rear molar came loose one night, which a half-asleep John promptly swallowed.
"I suppose most people would put that down to experience and go for a new one, but I didn’t see it that way, and decided that as nature took its course I’d retrieve the swallowed treasure," he explains. "This involved the use of a kitchen sieve and quite a period of waiting. Without going into the finer details, the gold cap was eventually retrieved, sterilised and stuck back in place using more epoxy glue, and is still there today."
Though it's easy to laugh about now, John is moved to a caveat, telling me that he's "quite sane, it just seemed a lot easier than the cost and wait to see a dentist". He's by no means the only one who feels the same; several others I speak with offer the same analysis – that the very idea of going to the dentist is equivalent to a luxury, not a right to be expected under the umbrella of universal healthcare. Of course, there are more lurid horror stories. Of teeth half-ripped off and grisly infections from botched self-inflicted procedures.
It's not that the existence of the DIY kits is sinister, in and of itself. They're a parasitic symptom, rather than the root cause of a deepening health inequality across the UK. One that doesn’t necessarily run across the fault lines of the north/south divide, or pour most of its misery into a single at-risk group. Though, when it comes to dentistry, you’re marginally better off in Scotland or Northern Ireland, where examinations are at least free, even if the cost of treatment itself remains the same.
It's simple: the poorer you are, the less likely you are to access treatment. And as austerity entrenches, there are growing numbers who fall into that camp. As the NHS contracts have changed and prices risen, fewer people feel the costs outweigh the benefits; £20 for a check-up can be a little, or a lot – and dental health can quickly fall in priority when it's a choice between a filling or keeping the heating on for another month. So why not do it yourself, the logic dictates? One young woman I speak with in London has used DIY kits for the best part of five years, whenever the need arises. "I don't have a spare £50, full stop. Let alone for my teeth," she tells me with a hollow laugh.
As the afternoon light starts to dim, I get chatting to Simon, a wiry middle-aged man from just outside of Liverpool. He lives rough, though doesn't like the term rough sleeper. Simon takes his tent around the country, stopping along wherever feels comfortable or right. North in the summer months, winter in the south, with Trinity House providing some welcome temporary respite as the nighttime temperature begins to fall.
It's decent for now, he tells me, as "when you sleep outside, you have to sleep in your clothes as you never know what sort of madness is going to happen. It's nice to let your skin breath a bit." Simon's here because he broke his dentures eating an apple, over two years ago. He couldn't get them fixed before, he tells me, because they're posh ones he paid "quite a bit of money for". His peripatetic lifestyle meant that NHS treatment was out of the question, both in expense and in the administrative rigmarole involved. £600 was the quoted figure, just to replace the bottom set.
It's his first time at Dentaid, though it's a name he’s come across before. "It broke right where the implant receiver is, which meant you couldn't just glue it or take care of it yourself. I was in Tamworth, though I got them done in Aberdeen originally," he says. Though Simon’s first impulse would have been to DIY, it wasn’t feasible, in this instance. It was luck and circumstance that brought him here today, while he’s completely upfront in outlining how "self-medication" is his usual way of dealing with the pain.
For the fortunate, dentistry means cosmetic flourishes and the occasional necessary evil. For many, it has come to mean a nightmare of exclusion and sometimes self-inflicted pain. Though charities like Dentaid do an admirable and impressive job in fighting against the tide, their increasing indispensability is a damning reflection on a crumbling system. As with food banks, they speak of a basic kindness, while laying bare some of the most damning failures and avoidable cruelties of our state.