Written evidence submitted by Healthwatch Liverpool (DTY0027)

About us and our interest in dentistry

Healthwatch Liverpool is the independent champion for people who use health and social care services in Liverpool. We’re here to make sure that those running services put people at the heart of care. One of our main purposes is to understand the needs, experiences and concerns of patients and service users and to speak out on their behalf. As part of a national network made up of local Healthwatch organisations in every local authority area of England (and Healthwatch England, the national body) our work contributes to a nationwide perspective on health and social care services.

At Healthwatch Liverpool we also provide a dedicated information and signposting service which puts people in touch with services and activities that can help their health and wellbeing. Even with the rest of the NHS under huge pressure, dentistry is the main problem that people want to ask us about.  Dental problems used to be about 20% of our enquiries but are now over 60%. The number of people contacting us looking for dental care is more than five times higher than before the pandemic and is continuing to rise.

Chart 1

Pre-pandemic we received an average of 39 dental enquiries per month. Since June 2021, this number has risen to an average of 194 per month, more than a 500% increase.

Chart 2
 

Pre-pandemic, around one in five of our overall calls related to dentistry. This would typically be for dental registrations for people recently moved to the city or wishing to register with a dentist for the first time. Occasionally, we would direct those seeking urgent dental care to the emergency dental service. Since June 2021, more than half of our enquires relate to dentistry with most of these experiencing long standing dental issues and unable to register with an NHS dentist.

The state of NHS dentistry in Liverpool 

Before covid

Before covid it was at times difficult to find an NHS dentist near where people lived. We regularly rang around local practices and could always suggest an NHS practice if people were willing and able to travel. Fear of dentists, financial concerns and complex lives meant some people fell behind on dental care, but it was always possible to find care when someone encountered dental problems.

Impact of the pandemic

A huge amount of unmet dental need built up during the pandemic in Liverpool as elsewhere. Although activity levels are now closer to pre-covid levels there is a long-lasting impact. Many people are without a dentist and unable to get one. This includes people who didn’t have a dentist before covid, those who have moved to Liverpool (including students and asylum seekers) and young children who weren’t old enough to need a dentist pre-pandemic. It also includes people who have been removed from the books by overstretched practices for not having attended in recent years. In many cases it is only when someone has toothache and tries to make an appointment that they realise they have been removed from the books, not having had notice or a reminder and many of whom did not attend because of covid restrictions.

We now have a massive gulf in care between those who have an NHS dentist, or are able to pay privately, and those who don’t have a dentist and are only able to receive one-off emergency treatment if their pain meets the emergency criteria.

The situation is not improving and people calling us are becoming more desperate. Some practices have opened waiting lists for patients who are looking for dentists. With thousands of people on these lists, some practices are estimating their wait in years not months.

For most of 2022 there were no dentists in Liverpool (or elsewhere in Merseyside and Cheshire) taking on new adult NHS patients and very few accepting new child patients. Currently (January 2023) there is one dentist taking on new adult patients from a small postcode area of the city.

To be seen by a dentist, the only option for people who are not signed up with an NHS dentist is to sign up with a practice as a private patient. This is not an affordable option for most people locally, even before the cost-of-living crisis given Liverpool’s deprivation statistics.

Some Liverpool dental statistics

• Less than a third of Liverpool adults (33.1%) saw an NHS dentist in the past 2 years. This is lower than elsewhere in the country and the rest of Merseyside and Cheshire.

• Less than half of Liverpool children (44.3%) saw an NHS dentist last year. This is lower than every other area in Merseyside and Cheshire other than Halton.

• The Emergency Dental Service sees a huge number of local people in urgent need and great pain for one-off care such as antibiotics or a temporary filling. It is vitally important that this continues. However, people are then stuck without a dentist to fix their actual or underlying dental problem. A planned change to Emergency Dentists doing substantive treatment on the cause of the emergency will be very welcome but may reduce the number of people who can be seen for emergencies.

• Because of low incomes many local people would be eligible for free NHS dental care if it was available. Even those who do need to pay for NHS dental care face costs many times higher if they go private. https://www.which.co.uk/reviews/dentists/article/private-and-nhs-dental-charges-al0jA6J1Swyl

• There are major problems with the NHS dental contract, which doesn’t work well for patients or dentists. Recruiting and retaining dentists for NHS work is difficult within the current contract and the system of paying dentists by units of dental activity (UDAs) does not seem to be meeting the needs of patients. Either we need a huge increase in UDAs or a new system for reimbursing NHS dental work and ensuring more equitable access.

What the public are telling us

• We are also seeing the problems people contact us about becoming more serious. Almost all of our dental callers already have a dental problem and have been dealing with pain for some time. Many have already been seen by the Emergency Dental Service which provides one-off care for people with urgent needs and have then been told to find a dentist for their ongoing care.

“I have tried everywhere and desperately need work done on my teeth, I have made a couple of visits to the emergency dentist who has temporarily repaired them but the pain is coming back now. ... I'm struggling to function at the moment.”

The problems affect some people particularly severely:

• People who can’t afford to pay privately;

• People who didn’t have a dentist previously (e.g. people who have moved to Liverpool, asylum seekers or refugees, people who have been homeless, people who avoided dental care previously out of poverty, other life pressures or dental fear);

• Families who have needed to move because of domestic violence and can’t safely access their previous dentist;

• People who might have been prioritised for dental care before, such as: pregnant women, young children, people with major health conditions, are struggling to get routine care and treatment.

Dental pain can be a debilitating issue with impacts on people's day to day life.

“My partner and I both have painful broken teeth but no dentists in Liverpool are taking on NHS patients and we can't afford private so we have to live with pain”

“I have tried over 20 practices in the Liverpool area who none are taking on NHS at this time.. the last time I had toothache I resorted to pulling it out myself”

For some people not being able to get dental care puts their physical or mental health at risk too:

“I would like to save what few teeth I have left from worsening/deteriorating ..., I'm at my wits end, it's affecting my diet which is in turn affecting my blood sugars as I am type one diabetic .... I get £260 universal credit a month”

“now my mental health is being affected as my confidence has been really low”

Incomes in Liverpool are lower than the national average, and now with the cost-of-living crisis many people have no chance of affording private dentistry which is all they can find:

“I am in pretty desperate need of some dental treatment and on a low wage so can’t afford to pay hundreds of pounds for treatments. It is an ongoing source of anxiety for me as I know I need my teeth looking at but don’t know how I can actually afford to pay”

“I need an NHS dentist for myself and my children. I have tried many practices who have said that I may be treated if I pay privately but I cannot afford this as I am on Universal Credit. My tooth has recently broken and I have been quoted £250 for a filling and £30 for a consultation.  Obviously, I cannot afford this.  When I asked the practice ‘what do people do who cannot afford to pay?’ I was told ‘go without’.  This is unacceptable.”

‘I am a support worker trying to support 24 people to access an NHS dentist in the Merseyside area. The NHS Dental system is broken..... Not everyone has the internet to access this information, local dentists offer no support if you are not on their books, and nobody is taking on NHS patients. There are so many vulnerable people unable to access NHS dental services - even in an emergency. People are trying to cope with the cost-of-living crisis and finding money for dental care .... is unrealistic and unacceptable. Some of the people I support have been in the care / prison system. Some cannot read or write. I worry for those who have no support and suffer in silence."

Some people, out of desperation try to pay for private care by borrowing money. Private finance for dentistry is now widely advertised but risks putting people into debt. People should have the option of NHS care. We are often in the uncomfortable position of telling people that it might be years before they will get an NHS dentist, but that private care is immediately available to those who can pay.

Action so far

• We are in regular contact with the NHSE regional team who have been liaising with dentists to get help for the most urgent of our dental enquirers, those whose dental issues are impacting on their physical or mental health to a dangerous extent.
• We have raised our concerns with other local health partners including the regional ICS at system and place level given the imminent move of commissioning responsibility.
• The short-term limited extra money for dentistry in February-March 2022 was welcome but didn’t  make a dent in the amount of people locally needing treatment.

• There have been some small changes to the contract that NHS dentists work under, but much more needs to be done.

What needs to happen?

We need a national conversation between patients, dental leaders, the NHS and politicians about how the NHS is going to meet the country’s dental health needs. This will need a united effort.

Healthwatch England is calling for the following:
 

• A more rapid and radical reform of the way dentistry is commissioned and provided 
• Using the reform of commissioning to tackle the twin crises of access and affordability 
• Greater clarity in the information about NHS dentistry
• Look at using dental practices to support people’s general health 

In addition, Healthwatch Liverpool would like to see locally:

• Honest communication between the NHS and the public about the scale of the dental challenge, how long it is likely to be before patients can get dentists and the action that is being taken.
• An action plan to stabilise and then restore NHS provision locally including fair access to the existing provision during the recovery period to minimise harm and inequality.
• Ensuring people have a fair and equal chance to get an NHS dental appointment rather than just those lucky enough to have had a dentist when the pandemic hit.
• Consideration of whether the length of time between check-ups might need to be temporarily extended to help get more people the chance of an NHS check-up during this recovery period.
• Targeted action to improve access to dental care in Liverpool to at least the Cheshire and Merseyside average to reduce the unequal access within the region (there isn’t enough NHS dental provision anywhere in Cheshire and Merseyside but at present Liverpool is particularly poorly covered).
• Action to encourage recruitment and retention of NHS dentists locally.

What steps should the Government and NHS England take to improve access to NHS dental services?

• National action is needed to fix the dental contract and make sure there is enough NHS dentistry to meet patient needs.
• We would like to see an action plan to stabilise and then restore NHS provision including fair access to the existing provision during the recovery period to minimise harm and inequality.
• Ensuring people have a fair and equal chance to get an NHS dental appointment rather than just those lucky enough to have had a dentist when the pandemic hit.
• Improved implementation of Personalised Recall Intervals might help get more people the chance of an NHS check-up and treatment during this recovery period.
• Ensure that children who missed out on dental care during and after the pandemic have the chance to become familiar with dentists. This is important to embed a preventative approach and is especially important for those who have phobias or are neurodiverse.

Longer term vision

• We would like to a see a vision set for NHS dentistry which would recognise dentistry as an integral part of a national health service and accessible to all who need it. Without a clear vision for the future, we can’t regain patient trust or inspire the potential dental workforce of the future
• We would then expect an implementation plan to help get us towards that vision. We’d like patients to have a right to register with a dentist, perhaps with catchment areas as GP practices have. Associated with this could be clarity and safeguards for when a patient is removed from a list as there is for GP practices.

What role should ICSs play in improving dental services in their local area?

With the transfer of dental commissioning to ICSs in April it is vital that ICS decision makers understand the complexities and shortfalls of dental provision. Local Healthwatch around the country have a wealth of information on the impact of these shortfalls on patients and will be happy to be part of the discussion on local solutions. Locally we are asking the Cheshire and Mersey ICS for:

• Targeted action to improve access to dental care in Liverpool to at least the Cheshire and Merseyside average to reduce the unequal access within the region (at present Liverpool is particularly poorly covered).
• Action to encourage recruitment and retention of NHS dentists locally

How should inequalities in accessing NHS dental services be addressed?

• Given the existing inequalities on NHS dentistry all action (including development of a vision, a strategy and a workforce plan) should be considered with an equity perspective. If we do not do this the inequalities in access will continue to grow and we’ll be able to tell someone’s financial status from their teeth.
• We need to remember that people living with long term dental pain have very poor quality of life and therefore may be unable to carry out their life activities well (self-care, family responsibilities and work). Longer term, damaged teeth also make having an appropriate diet difficult for some people. Locally there have been clients who have reported being unable to eat food, other than soup and soft solids for many months.

Does the NHS dental contract need further reform? 

• We recognise that a vision of NHSE dentistry accessible to all and with a right to register is not possible within the current contract. From what the public and dentists tell us it seems that the current contract fails to meet the needs of both staff and patients. We are not convinced that minor contract amendments will be enough to redress the situation.

• A new model should be built with equity at its heart – ensuring that:

• vulnerable patients can be given extra time if needed (which helps prevent problems escalate),
• each area, including the most deprived, has access and
• a focus on promoting access and take-up from those with the greatest barriers and inequalities, as is starting to happen with other preventative health care such as screening and immunisation.

What incentives should be offered by the NHS to recruit and retain dental professionals, and what is the role of training in this context?

• We need a workforce plan based on a modelling of need and the training and recruitment targets to meet these needs. We are likely to need a significant increase in the number of dental training places (for dentists, nurses and associated professionals) but we also need to motivate and incentivise those who receive this training to carry out NHS work. Perhaps a training bursary could be provided to those who commit to working in the NHS for a set period of time after qualification.
• If we are going to deliver NHS dentistry in communities on a catchment model and tackle the current inequalities, then the workforce plan also needs to have a focus on incentivising work in deprived communities and with excluded groups. Leaving the supply of dental care to the market is not currently delivering consistent and equitable provision, and this is unlikely to change without targeted action.

Chart 4

For dental activity carried out across the city on adults, Chart 5. shows Liverpool quarterly figures for adult patients seen in the previous 24 months alongside national averages. Access in Liverpool have been consistently below the national average, peaking at 5% difference in winter 2021.

Chart 5

This shows Liverpool quarterly figures for child patients seen in the previous 12 months since 2019 alongside national averages. Since autumn 2019, access in Liverpool for children has consistently been below the national average.

Chart 6

Liverpool has a greater than national average percentage of people within the population claiming Universal Credit and also a higher proportion of Liverpool’s Universal Credit recipients are not in work (Chart 8) F).

Chart 7

Chart 8

Liverpool has a lower number of dentist per 100,000 population than most of the rest of Cheshire and Merseyside and the number is falling.

Chart 9

Jan 2023