Written evidence submitted by Healthwatch Norfolk (DTY0055)

Introduction

The difficulty of accessing NHS dental care makes up almost 50 per cent of all feedback we have received at Healthwatch Norfolk in the last 12 months.

• There are no NHS dentists accepting new adult patients
• There is just 1 NHS dentist accepting new child patients
• Patients tell us it is virtually impossible to get NHS non-emergency care if they are not already registered as a patient
• Practices tell us they are either at capacity or struggling to get either contracts or staff to expand NHS provision
• We are aware of many practices that have stopped working under their NHS practice and now only practice of a private fee-paying basis in recent years
• The rural nature of Norfolk with poor public transport infrastructure makes accessing the very few dentistry services available difficult.

This submission sets out the evidence for these statements and our recommendations for improving the current situation. It is based on the feedback we have received, our knowledge of the health and social care sector, and the pressures we are hearing from dentists/practice staff too.

Evidence

Around 50 per cent of all the reviews and feedback we receive at Healthwatch Norfolk are about people’s dentistry experiences.

The figures for the 12-month period January 12, 2022, to January 12, 2023:

Telephone calls and email enquiries

We received 234 enquiries from people unable to access NHS dental care out of a total number of 545 enquiries on all health and social care issues. That equates to 43 per cent of all our enquiries during that 12 months.

There were an additional eight enquiries over that period specifically about quality of dental care.

Website and face-to-face feedback

We received a total of 77 reviews based on 33 different dentists.

80 per cent related to difficulty getting access to appointments/care

Reviewers can give a ranking for their service from 1(poor) to 5 (Excellent) with dentistry across Norfolk receiving an average of only 2 out of 5.

Demographics

The concerns around dentistry access are affecting everyone across Norfolk. We have heard from every demographic in terms of age and sex during this period.

•                      We have heard from people from every age including young families, a university student, working age people and elderly people.

•                      We have heard from people with children aged 1 to 16. Most of this evidence is related to trying to register young children or teenagers as NHS patients for the first time.

•                      We have heard from people who are pregnant

•                      Disabled people or with other long term or multiple health conditions including Wheelchair users, multiple sclerosis, Asperger’s/Autism, Cancer, Crohn’s Disease, compromised immune systems, Down’s Syndrome, dementia, deaf, and the vision impaired.

•                      Someone who required urgent heart surgery but needed to see a dentist before they could have a heart operation. Healthwatch Norfolk intervened in this case and managed to secure this patient an NHS appointment through our contacts.

•                      People on benefits or Universal Credit, one of which told us they used a homemade Etsy kit to create dentures

•                      We heard from the People from Abroad team at Norfolk County Council, a Ukrainian family, and a site manager at a Travellers’ site.

•                      People who need domiciliary dentistry and required treatment in their own home, as well as from nursing and care homes.

•                      People who have mental health issues or their mental health has been significantly impacted by their teeth issues, people saying they cannot leave the house anymore because of it or that they are feeling suicidal.

Current Situation January 2023

This month we have undertaken random sampling of 50 dental practices spread across  Norfolk (eight from Norwich and seven from each of the county’s other council areas) to ask if they are accepting adult and child patients on an NHS basis. These telephone calls were carried out on January 13 and 16, 2023. The full list can be read at Appendix 1

The key findings were:

• 100 per cent of practices called are not taking on NHS adult patients.
• Only one practice (Brundall Dental Practice) would take on NHS child patients and just one other (Diss Dental Health Centre) will do a one-off check-up on children but is not able to register them.
• 14 per cent do not even have capacity to take on private patients
• Four practices told us they were actively trying to recruit more dentists
• John G Plummer and Associates in Great Yarmouth said they had been actively seeking further NHS contract approval to extend their lists and help meet demand but have had no success to date
• Hopton Dental Surgery wanted to continue offering NHS care, but NHS England had reduced their NHS hours in a contract renegotiation. A full statement can be read within the table on Appendix 1
• There were waiting lists for NHS care at some practices. At Dentistry For You in Marham, that waiting list is sitting at 3500

Previous Research Findings

We previously carried out research and published a report in July 2021. Many of the findings are the still the same or the position has declined further. These included:

• A limited Norfolk NHS dental provision (there is now only emergency NHS care)
• Dentists cannot take on new NHS patients (still the same)
• Vulnerable patients are missing out on treatment (no change)
• Very few practices have a waiting list or emergency treatment available to non-registered NHS patients (no change)
• There is a lack of communication between patients and some dental practices (no change)

Additional Norfolk-wide Concerns

There are specific concerns around dentistry in Norfolk which have already been raised by Norfolk’s Health and Overview Scrutiny Committee (HOSC). The Committee’s Chair has written to Dr Louise Smith, the Director of Norfolk Public Health, asking to explore the return of a school dental service for the county. Their other concerns included:

• The need for strategies to engage with children and young people on oral health
• People calling 111 and being referred to NHS dentists who were either unable or unwilling to help
• Although any NHS patient is entitled to receive treatment at any NHS practice, this is not possible and most dentists have ‘closed lists.’
• Some NHS dentists are not holding some appointments open for urgent appointments referred to them by the 111 service
• Concerns that the business mix of practices offering both NHS and private care was not working well

The full list of recommendations and concerns from the meeting can be found at bit.ly/HoscAutumn2022

In addition, there have been issues around the loss of service in particular parts of Norfolk which have created concerns where the sudden closure of practices or loss of staff has had a major impact on local communities.

Two examples are:

Manor House dental surgery in Long Stratton went into liquidation leaving hundreds of NHS patients with no alternative for care https://www.edp24.co.uk/news/health/20615282.dental-woes-worsen-towns-troubled-surgery-closes-permanently/

Beech House dental surgery in Dereham has no more NHS dentists and cannot find anyone new to join the practice forcing them to rely on locum cover only. https://www.derehamtimes.co.uk/news/23237908.dereham-beech-house-dentist-blames-woes-brexit-covid/

Recommendations

Based on the evidence outlined in this submission, we suggest the following to help improve the dental situation in Norfolk:

In common with many areas of health and social care, there is a plea for more money, but this sets out other recommendations to improve access to dentistry for Norfolk people:

Further dental contract reform

The changes to contracts announced in November 2022 did introduce fairer payments for dentists undertaking more complex work but this does not seem to have made much difference in Norfolk when it comes to easing waiting lists based on our feedback. There was a promise from Neil O’Brien, Parliamentary Under-Secretary of State for Primary Care and Public Health, that this would improve access, but this does not seem to be the case in Norfolk. Work needs to be done now to re-set the current system to ensure it is fair and equitable.

Workforce Investment

Any kind of re-set will not be effective without an increase of more people into the profession and the growth of multi-skilled practices like GP practices where some of the treatment can be taken on by hygienists/ dental therapists. NHS England published the need for a skill-mix in practices this month (https://www.england.nhs.uk/long-read/building-dental-teams-supporting-the-use-of-skill-mix-in-nhs-general-dental-practice-long-guidance/) and welcomes the idea but there does not appear to be any practical help/support/guidance for practices to make this a reality from NHS England. Without this, we are concerned this will be merely a tick box exercise to say practices are aware of the situation. We would ask Norfolk and Waveney ICS to encourage dental practices to adopt this method and support those who wish to do so.

Communication

From the feedback we have received, patients feel they have no information from practices about the availability. Although the Department of Health made it a requirement for dentists to update their NHS patient status on the Find A Dentist website from November 2022, the Norfolk part of the website has still not been updated by a number of them. In addition, many have either out-of-date or incorrect information on their websites. We would urge the Department of Health/ICS to urge dental practices to update this to ensure patient information is up-to-date and to help reduce the number of enquiries to busy reception teams at each practice.

Prevention

We would also recommend the rolling out of schemes like the Happy Smiles project which is run by the John Plummer and Associates practice in Great Yarmouth, Norfolk, to ensure prevention is part of the answer going forward. The scheme goes into schools to give young people some early oral health advice. You can read more about it at https://www.plummers.co.uk/happy-smiles-club/ We feel this is a successful idea which could be rolled out elsewhere in Norfolk and beyond equipping both children and their parents to ensure the next generation are equipped with information to help preserve high levels of oral health

Positive Actions and Encouragement

Nationally, there is a need for more people to enter the dental profession. This is particularly acute in Norfolk with the lack of any non-emergency NHS dental care for unregistered patients.

On January 17, 2023, we found the following recruitment ads when searching Norfolk on various job sites:

Indeed recruitment website – 55 dental job advertisements

British Dental Jobs – 48 dental job advertisements

Dental Elite – 2 job advertisements

Dentist Jobs – 7 job advertisements

*Please note some of these may be posts advertised on multiple sites*

Dental School

The lack of a dental school in the East of England is an issue. Despite the University of East Anglia offering exploratory discussions for one in Norwich, this was ruled out in October 2022 by then-Dental Minister Will Quince (https://www.edp24.co.uk/news/23042195.setback-uea-dentistry-school-bid/.

Every other region of England has one according to the list of dental schools at Appendix 2.

Financial incentives should be made available to encourage dental practitioners to work and settle in Norfolk (as is in place in neighbouring Lincolnshire).

Conclusion

To summarise our views and findings based on patient feedback in Norfolk:

• There needs to be another urgent and full review of the NHS dental contract across the country recognising that the current arrangements do not meet the needs of many people who cannot access NHS dental care
• The Norfolk and Waveney ICS should launch a campaign to help attract more dentists to Norfolk or in collaboration with others for the Eastern region
• There should be a requirement for all NHS dental practices to update their websites with correct information on whether they are taking on new patients as well as the NHS website
• Further discussion and consideration to the concept of a dental school in the East of England
• A feasibility study into schemes like Happy Smiles to ensure the prevention of future dental issues for younger people is front and centre of future dental policy

In addition, Healthwatch Norfolk will be writing a formal letter to the Norfolk and Waveney ICS to ask what actions are being taken in relation to dental service provision prior to their commissioning responsibility that begins in April 2023. We will offer our support with this including sharing data and insights.

Appendix 1

A table of NHS appointment availability at 50 practices in Norfolk on Jan 13-16, 2023

Appendix 2

List of dental schools in the UK

Dental schools

There are sixteen dental schools in the UK of which two are graduate entry. There are also two postgraduate entry dental institutes.

Belfast - Queen’s University Belfast School of Dentistry
Birmingham-School of Dentistry    
Bristol - Bristol Dental School
Cardiff - Wales College of Medicine
Dundee- University of Dundee
Glasgow-Dean of the Dental School
Leeds-School of Dentistry
Liverpool-School of Dentistry
London – King’s College Faculty of Dentistry

London – Barts and the London School of Medicine and Dentistry
London -Queen Mary University of London
Manchester - Faculty of Biology, Medicine, and Health
Newcastle -School of Dental Sciences
Plymouth -University of Plymouth
Sheffield -School of Clinical Dentistry University of Sheffield
 

Graduate entry schools

Shortened graduate entry degree courses are offered by Liverpool Dental School and Kings Dental Institute in addition to the two schools below:

Aberdeen -Institute of Dentistry University of Aberdeen
Preston (University of Central Lancashire) School of Dentistry
 

Postgraduate only dental institutes

UCL Eastman Dental Institute
Edinburgh Dental Institute University of Edinburgh
 

Jan 2023