Written evidence submitted by the Association of Dental Groups (DTY0038)

Introduction

1. This submission from the Association of Dental Groups (ADG) responds to the Health and Social Care Committee call for written evidence for its inquiry into access to NHS dentistry.

2. The Association of Dental Groups (ADG) is the trade association for large dental providers in the UK. Our members include 20 of the largest groups of dental practices in the country, representing approximately 10,000 clinicians delivering NHS and private dentistry to more than 10 million patients every year.

3. We welcome this inquiry as addressing the inter related problems of recruitment and retention and the NHS dental contract remain the most important step in dealing with the backlog of care and future demand for oral healthcare in England.  The Executive Chair of the ADG would be available to speak to our submission in an oral evidence session of the committee.

Dentistry is the forgotten healthcare service.

4. Before the arrival of Covid-19, dentistry services were already facing a series of significant challenges, pressures and uncertainties. The ‘Dentistry in England’ report from the National Audit Office showed a fall in the contribution of NHS funding to primary care dentistry of 10% in real terms in the last full spending period (2014-15 to 2018-19). [1] It is estimated that £880million would be required to restore funding to 2010 levels[2]. Despite the Conservative Party manifesto reference “that between 2018 – 2023 we will have raised funding for the NHS by 29%”, none of this funding has found its way to NHS Dental Services apart from an additional £50million[3] in January 2022, which was time limited until the end of March 2022.

5. The last major investment in UK dental training was made in 2004 as part of an expansion in medical and dental training places and the subsequent establishment of new dental schools at Peninsula Dental School (Plymouth) in 2006 and University of Central Lancashire (UClan) in 2007. At the same time a recruitment campaign, “Project 1,000”[4] was launched by the then Secretary of State for Health, John Reid, aimed at recruiting a total number of 1,000 extra dentists both at home and from abroad. Since then, no further significant investment in the dental workforce has been made.

6. In 2006 the Department of Health brought forward the current NHS dental contract. The contract sought to pay dentists for Units of Dental Activity or “UDAs” with the objective of tackling waiting list pressures. There was little focus on quality or more prevention based care. A 2008 Select Committee report was scathing of the contract noting that it has led to ‘patchy’ access and a drop in the reduction of complex procedures.[5]

7. The Coalition Government sought to evolve the NHS dental contract through the publication of ‘NHS Dental Contract: proposal for pilots’[6]. This document acknowledged the flaws in the 2006 model and sought to “bring weighted capitation funding for the patients they take on and motivated to provide the best clinical care through incentives to improve quality and clinical outcomes.”[7]  Evaluation of “prototypes contracts” which our members told us were popular with both clinicians and patients has been ongoing for the best part of a decade but finally ended last year[8].   Discussions on incremental dental system reform began in the summer of 2021[9] and the outcomes of what we view as a “first step on the road” published in July 2022[10].  However, continuing with a broken contract is still driving clinicians out of NHS dentistry - dental professionals are beginning to give up hope that full contract reform will take place.

Recruitment and retention of the UK dental workforce

8. There is a lack of clear data about the UK dental workforce to guide training recruitment and project future demand, however what we do know is that fewer dentists are joining the General Dental Council (GDC) register than a decade ago.  Nuffield Trust research has found that new additions to the GDC register have fallen from 2,500 in 2011 to 1,600 in 2020 with a significant decline from EEA countries and “UK registrants have also fallen back”[11].  We believe it is vital that dental workforce planning should be embedded within the NHS to arrest this long term decline and we supported the amendments tabled by the then Chair of the Health and Social Care Committee, Jeremy Hunt during the passage of the Health and Care Act. Improvements in the oral health of the population since the 1990s began to plateau before the pandemic and geographical inequalities are now widening[12] as we also anticipate more complex care needs for an aging population which can only be addressed by long term workforce investment.  The opposition of the Government to independent evaluation and forecasting was disappointing.

9. Last year, the ADG revealed the worst hit parts of England –  what we call “dental deserts”.  NHS workforce figures in the table below contains the top 5 Clinical Commissioning Groups (CCGs) in England with the lowest number of dentists with NHS activity per 100,000 of population.

10. Latest workforce figures, published in the NHS Annual Dental Statistics Report August 2022[13] confirm the continuing workforce crisis in these same areas.  The table below shows the top 5 Integrated Care Board (ICBs) with the lowest number of dentists with NHS activity per 100,000 of population.

11. Access in these areas cannot improve without building the workforce.  These new figures for 2022 confirm the concerns of many MPs from the East of England that things are not getting better. Our own workforce survey of members has also found that recruitment difficulties mean parts of England are becoming “dental deserts”,  including Lincolnshire and the East Yorkshire coastline, Norfolk and Suffolk, Cornwall, Portsmouth and the Isle of Wight.  Analysis by the Local Government Association[14] also confirms that “a growing number of “dental deserts” across the country with more deprived or rural local authority areas having fewer NHS dentists than those in more affluent areas”.

12. The ADG welcomed the lifting of the “cap” on dental school places in September 2020 and the subsequent extra places in 2021[15]. The ADG has recommended to Government a national recruitment campaign with higher targets to recruit more dentists and we are disappointed that Ministers reimposed a cap on places in 2022. A review is now needed of dental intake numbers (and the dental academics needed to train them) as part of longer term workforce planning.

13. Overseas recruitment.  As with the wider healthcare workforce dentistry recruits from overseas.  In 2021 UK qualified new registrants with the General Dental Council (GDC) formed 61% - the remaining 39% of new registrants coming from EEA countries or other overseas routes to registration[16]. Dentists with overseas qualifications now make up 28.5% of all dentists on the register.  Following Brexit, mutual recognition of EEA countries qualifications (or as near as) has been maintained until the beginning of 2023[17] when a review is due to take place.  In time, new overseas registration or mutual recognition processes  are expected to be established to maintain recruitment from all overseas countries. However, analysis by the Nuffield Trust[18] has concluded that Brexit has had a significant negative impact on the number of dentists from EEA countries (halving the numbers joining the GDC register) and even the current “holding arrangement” have caused friction in individual recruitment[19]  with our members reporting a wider lack of understanding and concern amongst potential EEA applicants about what is required now to live and work in the UK. Even if the Government was prepared to invest in a significant number of additional new UK dental student places, they will not be entering the workforce for another 6 years.  For this reason alone the UK will remain dependent on overseas clinicians, including EEA states just to maintain the current workforce.
14. The recruitment of overseas professionals from countries outside the EEA halted in March 2020 as the examination they are required to take to register (the Overseas Registration Examination, commonly known as “ORE”) was suspended during the pandemic period. The ORE is administered by the GDC and widely acknowledged to be no longer fit for purpose.  The GDC themselves describe the ORE as a “flawed system made worse by the pandemic.”[20]. We welcome that the Department of Health & Social Care (DHSC) brought forward legislation to facilitate this reform.[21]  GDC figures estimate that there are currently just over 2,000 candidates[22] that have applied or are currently registered, often for several years, to complete the ORE process. Reforming the ORE to enable the GDC to conduct the examinations for these candidates and for successful applicants to register and enter the workforce would be a considerable step forward in addressing the recruitment crisis and one of the most cost effective for the public purse.

15. Once an overseas applicant has successfully passed the ORE and is registered with the GDC, they can enter straight into private practice. However, to practice as an NHS dentist they have to complete Performers List Validation by Experience (PLVE) training to join the NHS Performers List. Many of our members feel the conditions of PLVE are onerous and prescriptive.  The PLVE assessment process is currently managed by Health Education England/NHS England at a regional level. Each region runs PLVE differently, spanning application dates and processes.  One process for all regions would be much simpler resulting in a better candidate experience and improved recruitment. Variation in PLVE is now a significant obstacle to recruiting to NHS dentistry and the Committee should test NHS England and the Minister on what reforms can be made to PLVE to stem the loss of able clinicians to NHS dental practice.

16. It is clearly not desirable for the ORE to be the sole route to registration in the UK for overseas applications and new mutual recognition process need to be agreed with countries where the GDC as regulator believes that standards meet ours. We believe that the GDC should scope out further opportunities for mutual recognition globally with Commonwealth countries such as India. Before 2001 the GDC had a number of bilateral agreements with Commonwealth countries including Australia, Singapore, Hong Kong and South Africa whose qualifications met UK standards and potential agreements should be explored again.

17. Incremental steps have been made in addressing some of the workforce challenges through the Advancing Dental Care Review. Published in September 2021[23] the Advancing Dental Care Review Final Report commissioned by Health Education England (HEE) sets out a ”blueprint for reforming the postgraduate dental training structure and developing and optimising the skills of Dental Care Professionals (DCP) through the education and training pipeline” We share the view that “current training models are outdated and siloed” and believe a number of recommendations are of relevance;

• Co-ordination and distribution of postgraduate training posts so that they are better aligned to areas with the highest level of oral health inequalities.

• Centres of Dental Development. To help overcome the difficulties in recruiting in certain areas of the country, which is partly caused by the geographical imbalance of dental schools in England, “Centres of Dental Development” are proposed for the latter stages of undergraduate training. This will require capital investment but could address the lack of dental schools in East Anglia and Lincolnshire highlighted by local MPs[24].

• Dental Care professionals being able to use their full scope of practice in multidisciplinary teams. One of the most common examples is dental therapists who under the NHS contract have not been able to open a course of routine dental treatment (such as fillings) and work to the level appropriate to their training.

• Apprenticeship routes into dental careers. Much modern oral health improvement does not require a fully qualified dentist. The report recommends more flexibility around entry routes to widen access into the oral health profession.

Dental contract reform and the future role of Integrated Care Systems (ICS)

18. Many of the difficulties impacting NHS dentistry predate the pandemic and will hold back recovery unless they are addressed. Contract reform has been mooted for the past decade through the “prototype” contracts but not taken forward by DHSC. However, we welcome the renewed desire by Ministers as stated in the letter of 29th March 2021 to the profession for national contract reform[25]. Increasing the flexibility to target particular “local needs” will be key and aligns with the desire to see more integrated care systems. It is welcome that policymakers and NHSE are now considering dental system reform and trying to identify “quick wins” which can be made within existing contractual arrangements. However what is required is a new contract with a greater emphasis on preventative dentistry to improve oral health outcomes.

19. NHS England priorities of urgent care and new patient access can be constrained by the  current legislative framework, however more focus on flexible commissioning would seem to be a good example of incremental change that is possible without legislative change. With ADG members’ nationwide coverages, we can now see significantly different levels of interest in flexible commissioning models and a more innovative approach to the use of dental contract funding emerging in some regions.

Specific examples we are aware of which have been well received are

• ‘Urgent/High Risks Patient Access sessions’ which provide access to high need groups,  but also recognise feedback from clinicians about the need to be more fairly remunerated for the level of care needed, offering a fair sessional rate, with the option to substitute these for normal contract activities and not subject to clawback.
• An alternative is ‘incentivised support for urgent care appointments’ with a tariff of 3 UDA’s for dental care appointments rather than 1.2 per urgent appointment.
•  ‘Golden hello’ arrangements being offered in some of the hardest to fill areas (such as Lincolnshire), which we understand are based on the principles of using funding through flexible commissioning.
• Reducing the UDA targets but retaining the original contract value so that the overall budget balances and allowing an increase in UDA rate (in some cases to £30 per UDA). This is a more pragmatic approach rather than contracts being handed back only to be re-procured often at a higher UDA rate and causing disruption for patients.

20. The examples of flexible commissioning given are an opportunity to deliver both NHS England and the Minister’s stated intention to improve access to patient care, particularly for high needs and new patients, “at pace” and within the current spending envelope whilst we work towards more substantial contract reform.

Water fluoridation and targeted toothbrushing schemes

21. Water fluoridation will be the single most effective “whole population” public health measure any Government could take to improve the oral health of future generations.  It is estimated by the British Society of Paediatric Dentistry (BSPD) that water fluoridation could reduce dental disease by as much as two thirds in the most deprived areas[26].  However, building fluoridation schemes requires time in terms of planning and infrastructure. Community targeted supervised toothbrushing schemes are clinically effective and cost effective[27]  They can be targeted at those areas most in need and have been funded in some areas of England by creative use of flexible commissioning and are widespread Government initiatives in Scotland (Childsmile) and Wales (Designed to Smile).

Concluding comments

22. A review of dental schools intake should form part of the work of longer term projections and a workforce plan. The ambition must be to take forward the development of new undergraduate and postgraduate education and training in those parts of the country where it is most needed, Lincolnshire and East Anglia being two such examples. The “Centres of Dental Development” provide a model to address this. HEE/NHSE should also work with service commissioners to deliver more dental foundation training opportunities. We invite the Committee to note the action taken by the previous Labour Government’s national recruitment campaign to bring in extra clinicians from both home and abroad into NHS dental services. This approach has much to recommend it.  An overarching recruitment campaign, learning from the success of Project 1000 should be launched for provision in particular high needs parts of England.

23. Reform of the ORE to enable applicants to successfully pass it in a timely manner and bringing forward bilateral mutual recognition arrangements. This is now urgent to maintain overseas recruitment and avoid it being completely choked off when or if “holding arrangements” with EEA countries are ended.

24. Retention of the existing workforce will be intimately related to the prospects for reform of the current “UDA” dental contract. In order to cease the flow of dentists exiting NHS activity a roadmap has to be set out by Ministers and NHSE in 2023 including not only “quick wins” but the ambition for a new weighted capitation contract model to ensure the sustainability of NHS dental services in the decade ahead.

25. Whilst outside the terms of reference of this Inquiry, dental care in the UK is a mixed economy with affordable private dentistry meeting much of the population need that is not met by NHS Dental services (whose funding is only adequate for half the population[28]).  However, many of the problems identified regarding recruitment are also impacting on private dentistry.