Written evidence submitted by The British Dental Association (WBR0055)
1. The British Dental Association (BDA) is the professional association and trade union for dentists in the UK. Members engage in all aspects of dentistry: general practice, community dental services, the armed forces, hospitals, academia, research, and our membership also includes dental students.
2. We welcome the Committee’s decision to hold this inquiry. The British Dental Association has had long-standing concerns about stress, burnout and mental ill health among dentists and these have only been exacerbated by the direct and indirect pressures of the pandemic. In the face of these strains, dentists and their teams have been incredibly resilient for some time, but it is not viable to run the service on stretched goodwill and burnt-out clinicians. Inevitably, burnout within the profession will lead to absence from clinical practice. Every dentist lost to the workforce through burnout and mental ill health means, potentially, thousands of patients losing access to care. It is vital that dentists, both NHS and private, are provided with the support they need now to make it through this difficult period and beyond, and that we now pursue with urgency reforms that will design in workforce resilience and wellbeing to how dentistry is practised.
3. We welcomed the Chair’s recent commitment to reopen the inquiry from the last parliament into dentistry. Burnout is driven principally by systemic factors, which require a wide-ranging response reflecting both duty of care to practitioners and supporting patient access to services. This requires a contractual framework and a wider system that puts patients and dentists before tick-boxes and targets.
4. The BDA would be pleased to give oral evidence if it would be helpful to the inquiry.
5. Prior to the onset of the coronavirus pandemic, the British Dental Association had identified fundamental issues facing the profession that were leading to profound workforce issues.
6. Despite the number of dentists registered with the General Dental Council (GDC) being higher than ever, our annual surveys have consistently shown practices facing severe difficulties recruiting dentists, and that this is worse where the practice has a high commitment to the NHS.
7. Our most recent survey found that 68 per cent of practices with a high NHS commitment that had tried to recruit had experienced difficulties filling their vacancy. So too, have we found issues with retention. Our 2019 survey found that 60 per cent of those dentists with high NHS commitments planned to leave the NHS. We believe that this is a result of failing NHS dental system that is long overdue reform.
8. NHS England have long acknowledged these issues including in its evidence to this Committee’s inquiry into dental services last year. In August 2018, NHS England convened a dental workforce workshop. This day, involving a wide range of stakeholders, identified the fundamental need to reform the NHS dental contract and the need to introduce mitigating measures to reduce stress within the profession until that can be implemented. It is regrettable that progress on these outcomes has been limited prior to the onset of the pandemic.
9. It has been clear to the BDA that stress and burnout have been significant issues for dentists for some time and we have undertaken both qualitative and quantitative research into the extent and nature of this in recent years. This had found that occupational stress was a key driver of burnout and mental ill health and that more than half of dentists reported that their job was very or extremely stressful, with 44 per cent saying this stress exceeded their ability to cope with it. There was some evidence that those dentists who experience suicidal ideation do so more frequently than the population as a whole.
10. Eighty-six per cent of dentists surveyed reached the threshold for burnout; a state of mental, emotional and often physical exhaustion brought on by prolonged stress, accompanied by a feeling of occupational detachment and decreased accomplishment. Levels of burnout were highest among General Dental Practitioners with high NHS commitment. Such high-levels of burnout will inevitably impact on the workforce’s overall capacity to provide care for patients.
11. Previous research had found a range of patient-related factors as the main stressors for dentists, but the BDA’s research found that, while dissatisfied patients remained the second greatest stressor, fear of complaints and litigation was now the main factor and contractual targets, red tape and bureaucracy, and concern about over-regulation by the GDC were also leading causes of stress.
12. Dentists and their teams have clearly shown individual resilience in dealing with the pre-pandemic challenges they faced and continued to deliver high-quality patient care. However, the evidence shows a severe strain on the collective resilience and wellbeing of the profession and that the stresses that dentists are subject to as a result of a failed NHS contract, the associated bureaucracy and fear of litigation or regulatory action threaten the ability to maintain a sustainable workforce.
13. As yet, we do not have clear research data on the impact of the pandemic on stress and burnout among dentists. However, from the research that we have conducted during the ‘lockdown’ period, there was consistent qualitative feedback about the stress and anxiety caused by the uncertainty of the situation. One dentist, representative of many other comments, said “I am suffering so much stress, anxiety and uncertainty. No-one knows what we should or shouldn't be doing. There is no authority taking responsibility and telling us what to do”. While some of the immediate concerns during lockdown may have abated, the profession is still facing medium- and long-term uncertainty, pressure and stress across a range of areas.
14. Other indicators of wellbeing within the profession can help to give us an impression of the impact of the pandemic. The BDA offers an employee assistance-style service to its members, providing access to telephone counselling and other advice. The latest figures on usage of this service show a significant increase from May 2020 onwards, when compared with the previous six months. All of these calls were to seek access to counselling services and the most frequently cited reasons for requesting counselling were anxiety, employment, work-related stress, low mood and work-related demands. Similarly, the NHS’ Practitioner Health figures show that dentists are now the sixth most likely medical group to be reaching out to them for help, above surgeons and acute physicians.
15. Many dentists working in the Hospital Dental Services (HDS) have been redeployed as part of the pandemic response and have needed to work in a diversity of clinical and non-clinical roles. This has inevitably been a challenge for all of those similarly redeployed within the NHS. The BDA has particular concerns about those dentists moved to work in clinical environments with frequent life-or-death patient contacts, which are extremely rare within their normal practice of clinical dentistry. There are a number of initiatives that have been put in place to support the mental health of NHS staff, but given the particular needs of this workforce group there is need to ensure that they are well-supported in the short-, medium- and long-term.
16. While practices have been supported with their NHS incomes through this period, those reliant mostly or solely on private sources of income have been able to access very little of the Government support and have therefore been particularly affected by financial stress. Were the Treasury to extend the criteria for schemes such as the self-employed support scheme and the business rates relief scheme, it would make a significant difference to the viability of these practices in continuing to serve patients and to the stress and wellbeing of the practice owners and the dentists who work in these practices, while being a modest expense compared to the overall cost of these schemes.
17. The medium- and long-term uncertainty about how dentistry will function as we manage and emerge from the pandemic and whether practices will remain financially viable into the future is evidently a source of significant anxiety now. The overwhelming majority of practice owners in private and mixed NHS-private practices see the slated end to the Coronavirus Job Retention Scheme (CJRS) as posing a financial risk to their practice, if clinical activity levels have not recovered by that point.
18. There have also been reports from dentists about the physical and mental exhaustion they experience after working for extended periods in higher-level PPE. This is already having an impact on wellbeing, potentially leading to burnout in some cases, and this will likely only become more widespread if the current PPE requirements remain in place for a long period. Anecdotally, we are hearing that this is already leading dentists to look to reduce their working hours.
19. Clearly the impact of the pandemic itself has given rise to concern about the health of dentists and their families. This has been particularly heightened for those groups which have been identified as at increased risk, for example, BAME dentists.
20. As discussed, the long-term impact of coronavirus on dentistry will be felt in a profession with pre-existing issues of workforce stress and burnout that were among the factors contributing to widespread recruitment and retention challenges. This risks having a profoundly detrimental impact on patients’ access to dental services.
21. Prior to coronavirus, the BDA had concerns about the financial viability of many NHS practices, with a significant proportion struggling to meet their contractual targets and £138.4 million clawed back from practices as a result. The pandemic has shifted and extended this concern to private practices, who faced a loss of almost all income during the lockdown and now have significantly reduced incomes as a result of the reduction in clinical activity resulting from social distancing and the fallow time following an aerosol-generating procedure. As a result, most practices say they will face financial challenges within the next three months; with 86 per cent of those predominantly reliant on private incomes saying this is likely or extremely likely. Without changes to the financial support available and/or the public health restrictions on clinical activity, it appears inevitable that a number of practices will go bankrupt and close.
22. Even where practices are able to survive, the additional stress placed on a workforce with already high levels of burnout will be significant. This new pressure comes in a context where our research has found a large proportion of the profession are looking to leave dentistry altogether. For example, 23 per cent of general dental practitioners are planning to retire in the next five years, including half of those aged 50-59 years old. There is also a noted trend towards part-time clinical working in order to provide greater balance to dentists’ professional lives and reduce some of the stress and burnout associated with ‘wet-fingered’ dentistry. Our concern is that the strain placed on clinicians will push more towards the exit, if action is not taken to ensure they are properly supported.
23. Dentists have also expressed the stress they feel resulting from not being able to care for their patients in a way they would like. For example, one told us that these were “extremely stressful and frustrating times, feeling powerless - unable to manage our patients’ dental health appropriately”. It has also been reported to us that managing patient expectations has become very challenging, with practices having significantly reduced capacity and a need to prioritise those requiring urgent treatment. Dentists have also told us that there is a pressure to deal with a backlog of patients that accumulated during lockdown and also that is being caused by the current restrictions on clinical capacity necessary to manage the virus. This is not limited to high-street General Dental Service, but also extends to the referral-based Community Dental Services (CDS) and HDS, where there are significant waiting lists across specialties. The BDA is particularly concerned about the impact on waiting lists for extractions under general aesthetics for children and vulnerable adults, which pre-pandemic exceeded a year in a number of cases. Dentists, of course, feel a deep responsibility and consequent stress resulting from this inability to provide timely care to often very vulnerable patients with high needs. With these waiting list issues now widespread, HDS dentists are also concerned that they will come under pressure to increase their working hours, including out-of-hours provision, to reduce the backlog and the impact this may have on their well-being.
24. Not only will this impact be felt on the individual dentists and their families, but the consequences of practice closures and a greater outflow from the profession will have dire consequences for the provision of dental services. There are already areas where access to dental services is very limited and patients struggle to find an appointment. The BDA is concerned that these issues will become more widespread post-pandemic.
25. As with our approach to dentistry, the BDA believes that prevention is key in dealing with stress and burnout, and that systems should be designed so as to support wellbeing. The pre-pandemic target-driven NHS system does the opposite and leads to a situation, where despite an adequate supply of dentists through training and other sources, the NHS experiences protracted and profound workforce supply issues. Improving the NHS working environment would strengthen workforce resilience by bringing more dentists into the provision of NHS dental services, reducing pressures on recruitment and retention, and reducing burnout by sharing the workload and getting rid of the treadmill of the current target-focused system. The BDA believes that the current dental student numbers is sufficient for the provision of dental services, provided that problems causing dentists to turn away from the NHS, clinical work and the profession altogether are addressed.
26. The BDA is currently working with NHS England and Improvement on the temporary contractual framework for the remainder of this financial year and it is vital that this seeks to support dentists to provide appropriate patient care and avoids returning to a stressful target-driven system. The need to adapt the contractual framework to the pandemic circumstances provides an excellent opportunity for us to move at pace towards a longer-term reform that supports rather than undermines workforce resilience and it is important that this is not squandered.
27. Reforming the fundamentals of the NHS dental contract will be a significant step forward to improving workforce resilience and this needs to be supported by wider measures that make the practice of dentistry less stressful through a focus on collaboration and quality improvement. The BDA has long-supported funded peer review as one means to achieve this, creating space for mutual professional support, the discussion of professional difficulties and sharing of solutions without the immediate threat of punitive action by regulators or systems.
28. As noted, the BDA welcomes the pandemic provision of mental health support for NHS staff and has been engaged with the processes to develop this. It is vital that we ensure that these services are inclusive of all dentists, including those working on a self-employed basis in general dental practice, to avoid clinicians who need support falling through the cracks. It is also crucial that the NHS and the Government ensure that these services are given the resources necessary to meet the need for them on an ongoing long-term basis, given that many issues will only manifest themselves some time in the future when the profession and the country might return to more a more ‘normal’ situation (post-traumatic stress). It is anticipated that 20 per cent of healthcare workers will requiring ongoing support. Specifically, there is a need to ensure that the Practitioner Health Programme is fully resourced to support dentists and other clinicians with the mental health impacts of this pandemic and beyond.
30. In relation to pandemic-related financial measures, the BDA continues to urge the Government to review the financial support packages it has in place to ensure that private dental practices have access to them. The ability to get this support would go a long way to reducing the stress of dentists in these practices and to ensuring that these practices remain viable and able to serve their patient communities into the future. In particular, we feel there is a strong case for a sector-specific extension to the Coronavirus Job Retention Scheme to support dental practices in the transition back to full clinical capacity.
Sept 2020