Written evidence submitted by Healthwatch Brighton and Hove, Healthwatch East Sussex and Healthwatch West Sussex (DTY0048)

A response by Healthwatch Brighton and Hove, Healthwatch East Sussex and Healthwatch West Sussex to the Health and Social Care Committee inquiry into dentistry launched following a survey that showed 90% of practices across the UK were not accepting new adult NHS patients.

- January 2023

1.              Local background and context

1.1              Healthwatch are the independent champion for people who use health and social care services. We are here to make sure that those running services, put people at the heart of care.

Across Sussex, access to NHS Dental Care remains a priority for local Healthwatch, as we continue to receive enquiries from the public, with most people asking us “how can they find a dentist who is offering NHS treatment?”

1.2              Healthwatch Brighton and Hove

Requests for help to find an ‘NHS dentist’ are the second main reason people contact our helpline. We saw a 271% increase in dental queries between 2020 to 2021. The number of queries received between 2021 to 2022 was 215, a substantial increase on pre-pandemic levels.

1.3              Healthwatch East Sussex

Between November 2020 to 2022, we received 24 Feedback Centre reviews and 214 enquiries to our Information & Signposting service related to dentistry themes. It has consistently been in the top three enquiries we receive.

1.4              Healthwatch West Sussex

Enquiries regarding dental care remains the second main reason why people contact us, with 184 people making enquiries about dentistry in 2022.

3.              Healthwatch research with patients

3.1              In January 2023, the three local Healthwatch in Sussex (working as ‘Healthwatch in Sussex’) launched a joint dental survey to gather the latest insight into people’s experiences of using or seeking to access NHS dental services in our county. We wanted to hear from anyone who had contact with any NHS dental services since the 1st December 2022. Our goal was to learn whether reforms to dentistry, which came into effect from November 2022, are leading to any beneficial local changes.

3.2              The survey is still live but interim results from 169 respondents (correct as at 16th January 2023) are:

3.3              In addition:

• 1 in 4 people said they had accessed NHS dental appointments or treatment without any issues
• 46% of respondents had not been able to receive NHS dental treatment because they could not find a dentist able to offer NHS treatment
• Nearly 1 in 4 people paid for treatment privately, because they could not find a dentist able to offer NHS treatment.

3.4              Desktop review

In January, we also carried out a desktop review of all the dental practices in Sussex using a NHS dental provider list supplied by our Integrated Care System (ICS). Using the NHS.uk website “search for a dentist near you” we found:

3.5              However, we also found that in several cases, providers advised that they were only taking new NHS patients who have been referred to them from another dentist.

3.6              Our earlier dentistry research can be found on our websites:

Healthwatch Brighton and Hove

Healthwatch East Sussex

Healthwatch West Sussex

4.              Questions asked by the commission: our response

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

4.2              We consider there needs to be clarification on who NHS dentistry is seeking to serve. Is this everyone, or those least able to pay for it themselves? Once this is clearer, steps can then be taken accordingly.

4.3              There should be an emphasis on evaluating the demand for NHS dentistry provision, within the context of current NHS/private provision. An analysis of whether there is enough overall dentistry capacity to meet demand in total might reveal an imbalance between NHS/private provision indicating that not enough resources are being dedicated to the NHS to meet demand for those services. If this theory was proven to be correct, then steps could be taken to address this.

4.4              There should also be a pro-active mapping exercise of capacity and subsequent incentivisation to establish and retain NHS dentistry in areas with low provision.

4.5              The NHS website should be improved. Our recent desk top analysis of the NHS website “search for a dentist near you” highlighted how challenging it was to use this function. It is not just the accuracy of the information it holds; it is the usability of the platform which is also a major limitation.

4.6              The website is meant to provide information on which dental practices are currently accepting new patients, whether they offer urgent appointments, and how other people have rated the service, but this data is missing.

4.7              In May 2022, Caroline Lucas MP asked a question in Parliament on our behalf which identified that only 47% of dental practices have updated their information on the NHS website.

4.8              In January 2023, two months after revised guidance was issued, Healthwatch in Sussex carried out a desktop review of all the dental practices in Sussex to find out how many practices on NHS.uk website had clearly updated their status on accepting or not accepting NHS patients.

4.9              We found:

• In West Sussex, only 36 practices (23%) from a list of 158 had clearly done this
• In East Sussex, only 31 practices (27%) from a list of 114 had clearly done this
• In Brighton and Hove, only 6 practices (11%) from a list of 56 had clearly done this.

4.10              This demonstrates that despite dental reforms which now require all practices to update their details and availability on the NHS website, this is not happening. The guidance governing this requirement must be made stricter with appropriate penalties for not complying.

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

5.1              As already described in Question 1, we also consider that ICSs should invest time in mapping local supply and demand of dentistry services and the balance between NHS and private provision.

5.2               ICSs should take steps to improve patient information. In 2022, Healthwatch in Sussex responded to this void and produced a patient guide which explained patients’ rights. ICSs can build on this earlier work, and a recently created webpage, ensuring that clear patient-friendly guidance is made available and that all dental services are required to display this and pro-actively share it with patients. This should tackle common misconceptions such as what registering with a dentist means. Healthwatch can support ICSs to develop patient communications.

5.3              ICSs must clearly inform patients about what dental reforms mean for them. For example, the latest reforms include:

• a move away from six monthly check-ups to 12 or even 24 months in line with NICE guidance for those with good oral hygiene, allowing dentists to focus on interactions which have the highest clinical value
• enabling dental professionals other than dentists - such as hygienists - to deliver a wider mix of treatments. 

5.4              Some patients may not be happy with these changes – or even know about them - unless they are properly explained. Patient materials must be co-produced to explain any changes and Healthwatch can support ICSs to do this.

5.5              To aid the public’s understanding, ICSs should also communicate:

-          the work they have been doing to build their understanding of local dental provision since they took on delegated commissioning from 1st July 2022

-          publish their priority/delivery plans for local dental provision as soon as possible, with clear time lines

-          explain within those plans, how they intend to tackle health inequalities.

5.6              ICSs must focus on meaningful incentivisation that matches capacity. Under the latest contractual reforms, high-performing dental practices will have the opportunity to increase their activity by a further 10% and to see as many patients as possible. Additionally, where a contractor has delivered less than 96% of their contracted activity for three consecutive years, and no voluntary plan or reduction can be agreed, commissioners will be able to unilaterally reduce the size of a contract to the highest level of delivery in the preceding 3 years. These reforms allow ICSs, in theory, to better meet identified needs within contracts that don’t appear possible currently. ICSs need to be transparent about how they will carry out these functions.

5.7              ICSs must commit to working with local dental committees. Healthwatch in Sussex attend local dental meetings, represented by local dentists and practitioners and our local ICS has also engaged with these groups. This has helped to create an appreciation of the demands that dentists are experiencing. ICSs must work with these groups to inform commissioning, but also to show support for dentists at a time when practitioners are withdrawing from NHS delivery or leaving the system altogether – the system must show that it is listening to them.

5.8              ICSs must ensure that they commission through better data and intelligence. Without accurate data, commissioning will not fully meet local need and ICSs have a key role to ensure that sufficiently robust data is obtained to support this process. For example, data examining how far patients are travelling for appointments; numbers of ‘Did Not Attends’; how many children are unable to see a dentist for NHS treatment, as well as determining the reasons which stop dentists from bidding for re-procurements, will support ICSs to better understand local need.

5.9              ICSs must also openly share data. People’s accounts suggest a lack of access to NHS dental care is having an impact on many other parts of the NHS, including increased calls to 111, people attending A&Es and in desperation contacting their GP Practices for help. We have asked our ICS about the data they hold that may or may not shine a quantitative light on the scale of additional demand on services that are already operating beyond capacity this winter.

5.10              And lastly, ICSs must commit to working with Healthwatch. As the independent champion for health and care, ICSs must work with local Healthwatch and use their independent patient feedback to support the commissioning process and the principle of rewarding high performers and reallocating resources away from underperforming practices.

6. How should inequalities in accessing NHS dental services be addressed? 

6.1              Many services delivered under the NHS banner are viewed as accessible to all, including dentistry. Unfortunately, the gap between NHS dental capacity and demand appears to be increasing.

6.2              A significant concern that has arisen during 2022, has been the ‘cost of living’ crisis which may also impact on people’s ability to pay either NHS or private charges for dental treatment. Sadly, Healthwatch too often hear from patients who have been declined NHS treatment but offered private care, which is unaffordable to them.

6.3              Healthwatch is concerned that dental costs and the cost-of-living crisis may disincentivise people to seek treatment, potentially leading to worse outcomes in the longer-term, particularly amongst those on low incomes.

6.4              Healthwatch routinely hears:

• from parents who are unable to find a dental appointment for their children
• from groups representing refugees being unable to find NHS dental treatment
• about examples of people receiving, or due to receive, cancer treatment struggling to find NHS dental care.

6.5              The groups mentioned above are supposedly a priority, but the reality paints a different story.

6.6              Actions which could be taken to address these inequalities include:

• All priority groups must be treated as such
• Meaningful contractual reform is needed as described in the next question
• We have found some good practice by NHS dental providers in promoting oral health checks in young children by outreach into community locations. However, these are not targeted at those in the most deprived areas. We see there are opportunities to address health inequalities, for example: commissioning similar activities in areas of deprivation.

7. Does the NHS dental contract need further reform? 

7.1               In short, yes. And reform is needed quickly. For over a decade, there have been talks about NHS contract reform for dentistry. The latest changes introduced in 2022 are not regarded by the British Dental Association (BDA) as contractual reform, just marginal changes.

7.2               The impact of delays in contractual reform are self-evident. Healthwatch has learned from speaking to local dentists that some dental practices are handing back their NHS contracts. These practices have ‘gone private’ and the lost NHS activity has not been replaced. For many practices, the current NHS contract sets payment limits that can be awarded to dentists for the work they carry out. Some of these limits were set in 2006, and whilst recent changes have increased payments for certain treatments these are not deemed sufficient. Practices should not be placed in a position of ending up subsidising the NHS for the costs of treatment that they carry out.

7.3              It is recognised that these changes are the start of a process to address the challenges faced in delivering effective and accessible NHS dental provision, but they do not end it.

7.4              There are plans to move quickly to a next phase of engagement with patient and sector representatives, starting in the summer of 2022, to build on these changes and tackle longer-standing concerns. But how long will this next round take to produce something? How is this being done, and by whom? What is Healthwatch’s role in this? There is limited detail available around this process.

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

8.1              The key issue of workforce must be addressed. We are aware of recent data which indicates that over 2,000 dentists will have left the profession in the last year[1]. They are estimated to serve over four million patients. The NHS dental workforce headcount in England has apparently reached its lowest level since 2013/14[2] . We also read that many younger dentists are not willing to work under the current conditions imposed by the NHS contract and are more inclined to want to work part-time, whilst many older dentists are now of retirement age, or choosing to retire early. All of this has led to a recruitment problem.

8.2               The impact of this is shown in a recent survey which revealed that 60% of the public feel that it has become harder to visit an NHS dentist for any type of appointment compared to ten years ago[3]

8.3              The availability of dentists has worsened because of the impact of the COVID-19 pandemic, and the strains placed on the recruitment of NHS staff in the wake of Britain’s departure from the EU.

8.4              Currently, training to become a fully qualified dental practitioner takes five years to complete. It is unclear whether enough British students are opting to study dentistry in the UK to fill this shortage alone. The only answer seems to be an increase in recruitment of dentists from outside the UK followed by investment in our future domestic workforce through more funded placements.

8.5              The Government is consulting on legislation to reform the Overseas Registration Examination (ORE) but decisions following this need to be taken and acted upon quickly to increase overseas recruitment both from within the EU, but also from the rest of the world.

8.6              But recruitment is just one side of the coin. Efforts need to be made to ensure the retention of key workers. At the heart of this lies meaningful contractual reform and wholesale review of the banding structure and payments awarded for different treatments. Incentives that make a difference can only be co-designed with the dental profession.

Jan 2023