Written evidence submitted by Healthwatch York (DTY0060)
Healthwatch York was set up in April 2013. Our role is to put people at the heart of health and care in our city. As part of this, we listen to people’s experiences of local health and care services, and aim to connect them with available help. We are responding to the call for evidence as the lack of NHS dentistry locally remains one of the issues of most concern to our local population, and accounts for a significant proportion of the contacts we receive about local services.
Reform the contract. Rip it up and start again. Design the contract through coproduction with dentists who want to work within the NHS but feel the current contract is not fit for purpose, local public health professionals, dental patients including those currently unable to access services, and bodies like local Healthwatch to feed in what they are hearing. Provide funding for training schemes that allow those who have qualified elsewhere to validate in the UK as long as they stay within the NHS for a number of years. Provide incentives to practices in dentistry dead zones to take on the supervision of these people.
ICSs need to have the freedom to identify the specific barriers to providing NHS dentistry in each place, and the flexibility to commission services accordingly. This needs to reflect specific local challenges. They must be tasked with developing plans to address dental deserts.
There needs to be rapid commissioning of services to support groups who are particularly vulnerable, with clear referral mechanisms for those organisations supporting them. There also needs to be a simple way to get onto the waiting list for local NHS dentistry.
Yes, absolutely. The current dental contract is not fit for purpose. It does not focus on oral health, but on payment for units of activity. Recent tweaks to the contract have failed to improve the dental crisis we are facing in York. There needs to be a contract that makes being an NHS dentist an attractive career again. This must be about rooting surgeries in their local communities, working with a population to improve oral health outcomes.
It would be great to see opportunities for young people who would not traditionally be able to afford to train as dentists being offered significant bursary schemes linked with being tied into being an NHS dentist for a number of years after becoming fully qualified. They should also receive golden handshakes if they are from areas of deprivation and areas really struggling with dental provision if they return to those areas to practice.
Background
Previous reports and key findings.
We produced our first dentistry report in 2018. This showed a very mixed picture, with many accessing NHS dentistry, but some people finding it hard to find a dentist.
The full report can be seen here:
Our second dentistry report ‘NHS Dentistry – A Service in Decay?’ highlighted the challenges finding an NHS dentist in the city.
Volunteers and staff contacted all 39 practices in the city. At the time of the research in May and June 2021 they found that no practice in York was currently accepting new NHS adult patients. This included pregnant women,
The full report can be read here: https://www.healthwatchyork.co.uk/wp-content/uploads/2022/05/NHS-Dentistry-A-Service-in-Decay-July-2021-2.pdf
Our third report ‘Dentistry in York – Gaps in Provision.’ showed a continuing decline in access to NHS dentistry in the city.
For the report, we conducted an online survey across the city in the autumn of 2021. The results show a dramatic decline in access to dental care across the city. Since 2018 our survey showed a 30% decline in the number of people with a dentist, and 71% of people unable to access dental care saying that the main reason was ‘they couldn’t find an NHS dentist’. There has been a huge increase in the number of people unable to access dental care for 2 to 3 years. Over half of respondents reported having one or more problems associated with dental pain or poor oral health including not being able to sleep properly, feeling self-conscious about their appearance, being unable to eat healthy food, being unable to work, unable to undertake physical exercise, or unable to care for someone.
The full report can be read here: https://www.healthwatchyork.co.uk/wp-content/uploads/2022/04/Dentistry-in-York-Gaps-in-Provision-January-2022-1.pdf
Current position
Summary of key trends:
1) Between 25-50% of the feedback we receive each month relates to NHS dentistry
2) People in York are struggling to find NHS dentistry
3) There are long waiting lists for the NHS dentistry services we do have
4) Local dentists have not taken up flexible commissioning – we have zero delivering these appointments here which means there is no route for referring people in need into dental services
5) York received none of the £50M promised for extra capacity in January 2022 to be spent by March 2022
6) There is no NHS Urgent Dental Centre in York, so people are being sent to Harrogate or Leeds – increasingly people are telling us they cannot afford to travel for dental care
7) Urgent care services have very narrow criteria, leaving people unable to access help
8) Many dentists seem to have reduced the number of patients they will see on the NHS or have gone private
9) There is confusion regarding what NHS dentists are commissioned to provide in the city, and who they are providing this to
10) Patients report being offered free child places if they accept private treatment themselves. They are unwilling to report these dentists to NHS England as they feel they have no other options. Accepting private care also leads to problems for those who need ongoing prescriptions, especially those who have prepayment certificates
11) The lack of dentistry leaves us unable to support the health needs of those experiencing health inequalities, including refugees and asylum seekers, and people with serious or long-term health conditions including mental ill health
12) Some people are now experiencing significant health issues as a direct result of the failure to provide them with timely dental treatment
In more detail - current experiences
Between 25-50% of the feedback we receive each month relates to NHS dentistry
Since October 2021, we have been contacted by 110 people with regards to NHS dentistry. The main reasons for contacting us are:
People in York are struggling to find NHS dentistry
This is the feedback we receive most often. People we speak to have often tried calling around local dental practices without success. Some have tried using the NHS website to locate local practices, and have discovered the information is not kept up to date. Others have contacted the NHS Customer Contact Centre, and have been signposted to us by them. Up to date information on the state of dentistry is not being provided, leaving us having to fill that void. We have become resigned to being the bearer of bad news. It appears no one is properly enforcing the contract requirement to keep dental practice NHS listings up to date.
There are long waiting lists for the NHS dentistry services we have
Jan 2022: Seeking to register family with NHS dentist, have phoned around 30 dentists without any luck in York, best they have found is dentist in Selby with waiting list of approx. 3.5 years.
Jan 2022: “I live in York. The best you can get here when attempting to register with a dentist is a spot in a 2-3yr waiting list. When things go wrong you're waiting and with such long wait times the possibility is ever increasing, you phone 111, only to be told you'll have to travel out of York for your care, Harrogate being the closest. Because nowhere in York provides emergency care through 111/ to non-registered patients. Meaning that you either have to travel or pay privately. NHS dental care is neither free at the point of contact nor available from cradle to grave, two of the most preached NHS ideals. This isn't the fault of any one dental practice, they are merely trying to run a business. This is a systemic problem that needs dealing with. People move around over the course of their life time, they should be able to move all aspects of their dental care with them. This is a problem that needs sorting. I want a dentist in a vaguely convenient place so I can receive affordable dental care. The longer I've waited the less affordable it had become to go private so now I have no option but to hope it's not too much longer to wait.”
May 2022: “The situation in York is appalling. No surgeries taking new NHS patients. Some have a 5-year waiting list. Yet almost all keen to take new private patients.”
Jul 2022: "Our existing practice closed its NHS services last month and we have been ringing practices across Yorkshire since to try and find an alternative. We're willing to travel to access this service if we need to - we'd already only managed to get on the books of an NHS dentist situated over 20 miles away from where we live. Even searching across Leeds and other wider areas we are finding absolutely nothing. When we have managed to speak to a practice that is technically registering new NHS patients (rare and few and far between) they all advised a waiting list of 4 years or more. We simply can't afford to consider private treatment at this point in time given the general increase in the costs of living and I would like to know some more about what we can do next. This is particularly concerning as my eldest son is part way through orthodontic treatment, they are happy to continue treating him for that at the moment but the lack of NHS dentistry to partner his treatment may become an issue. The whole system seems to be broken."
Aug 2022: Man confirmed he did try Aldwark however they advised there is a 5-year waiting list. He also tried the NHS customer contact centre who just referred him back to the 'find a dentist' website, which he has already been using to no avail. He states "It just feels impossible. Thanks for your email regardless."
Jan 2023: Information from social prescriber re Community Dental service: “I have managed to get a lady with a traumatic brain injury accepted who has difficulty remembering appointments, communicating her needs etc. However she has been given a 12 month wait to be seen - she has teeth falling out and a recent abscess. Her brain injury means she has problems remembering appointments. As a result, she has been struck off by 2 York dentists due to missing appointments.”
Local dentists have not taken up flexible commissioning – we have zero delivering these appointments here which means there is no route for referring people in need into dental services
NHS England have confirmed that we have no dentists providing treatment through the flexible commissioning approach. The impact of this is that we have no mechanism locally for referring people in need into NHS dentistry.
We are seeing an increase in people contacting us who need a referral into a dentist for physical health reasons. Within York CVS, our parent body, we also host the local NHS Link Workers and other social prescribers. These teams are similarly seeing more people needing dental care that is related to a physical or mental health condition. This is over and above the routine calls we get, often redirected by NHS 111, looking for an NHS dentist.
Local GPs do not have a clear referral pathway into NHS dentistry either, and in at least one case have misled patients about potential ways round this by telling them they can have work done privately and then reclaim the cost from the NHS. This is simply not true and could lead to a patient taking on a debt they cannot afford to repay. As we don't know of any local dentist taking new NHS patients we can't send patients to them to get referred to a dentist taking referrals.
An example of the challenges created by not having referral routes is as follows:
Parent contacted us. Their child is in the middle of orthodontic treatment. Parent has been told they need to see a dentist for routine dental work in between orthodontic appointments - again no referral was made by the orthodontist and they approached us looking for an answer. Unable to signpost as no dentists currently taking children on.
York received none of the £50M promised for extra capacity in January 2022 to be spent by March 2022
We published a press release covering this in August 2022 highlighting the reality for York residents. This was picked up by a number of local press outlets. You can read one example here:
10 August 2022: York got NOTHING out of £50 million extra to tackle dental crisis | York Press
There is no NHS Urgent Dental Centre in York, so people are being sent to Harrogate or Leeds – increasingly people are telling us they cannot afford to travel for dental care
May 2022: Woman told us she travels to Leeds Dental School for treatment in their hospital because she can no longer afford to pay for private care now she is retired.
Aug 2022: Woman in need of urgent dental help. She has experienced domestic violence, and cannot afford to pay travel and NHS urgent dental charges. Friend seeking any alternative options for her.
Oct 2022: Help requested re NHS dental care. A filling fell out a few days ago and they were in pain. They phoned 111 for emergency care, and were told that they would get a call back but it didn't happen. Kept trying but no answer. Finally set an alarm to wake up at 5am to make a call and got through and they have been told that they will have an emergency appointment in Harrogate, but haven't yet been given time.
Urgent care services have very narrow criteria, leaving people unable to access help
We hear from people who feel they have an urgent dental problem, who find they are not eligible for emergency dental care. This includes people who experience significant pain when eating, and people who have dental damage due to accidents or ill-health.
Jan 2022: Man requested information about emergency dental care. Not registered with a local dentist, but knocked front tooth during a seizure and tooth now turning black. Had already phoned 111 who advised him to contact Healthwatch York.
Jan 2022: Call requesting help to register. Couple were previously registered with an NHS dentist but they were taken off the list without warning. They are both having issues with their teeth, and are taking pain killers to deal with the pain. They have phoned for emergency care but are always told they need to register with a dentist. They have been unable to do so.
March 2022: “I have been trying to get my child a dentist they are in receipt of universal credit, over 18 and in constant pain with three of their teeth. They have seen an emergency dentist who advised that the teeth can be saved and they need a dentist ASAP. As we have been advised that the teeth can be saved they do not want them taken out which is all an emergency dentist is offering. I have used the government site to find a dentist and although they update this site regularly, I was told today that even though they say they are taking on new patients that is because they have to, which is very misleading. I have contacted dentists as far as Northallerton, Beverley and am now thinking we will have to pay for a payment plan which none of us are in a position to pay for, especially as my child is unemployed.”
Many dentists seem to have reduced the number of patients they will see on the NHS or have gone private.
Feb 2022: “I've just been informed my dentist is going private only. I don't know what to do now. I receive income related benefits and disability benefits due a long-term health condition so I don't have excess money to pay for treatments etc. I could just about stretch to an annual check-up privately but if I ever needed any treatment those costs would be beyond me. Nowhere in York seems to be accepting new NHS patients either. What am I supposed to do?”
Feb 2022: “I am sure I am one of many people contacting you regarding York Dental Practice decision to no longer see patients on the NHS. As someone who is retired, has a number of health conditions and is a carer for my 90-year-old mum, I am not in a position to take on extra paid work to cover the additional cost. Even if I could afford the monthly payment plan they offer it does not cover the actual cost of any treatment needed. So I could still end up needing treatment I cannot afford. I am already economizing in order to afford increasing heating and food costs. A further £15 per month, at a minimum, will make such decisions even more difficult. It is likely that this will be an expense I cannot afford. Given the dearth of NHS dentists in York I am sure none of us will be able to find another one.”
Feb 2022: “My dentist went private roughly 2 years ago. 3 weeks ago they even stopped doing my children on the NHS. How can NHS dental care be taken away from children? So now we have to pay £8 each per month and then any treatment on top of that. Never did I ever think I would see children being charged for dental care.”
Mar 2022: “We like a lot of others have been unceremoniously dumped by our dentists by email we are both in our 70s and due to only having basic state pensions we were entitled to free treatment so they were probably were extra glad to get rid of us. However, the worst thing they have done is to dump the children on their books how disgusting is that? Their only advice to us is to find another NHS dentist knowing full well there are no places in York for anyone. It’s an absolute disgrace. Our dentists are York Dental Practice Clifton Moor.”
Mar 2022: “Hello I wonder if you can help. I am sure you know that our dentist is going private, York Dental. My main concern is that they don't know if kids can continue with free NHS treatment. What can we do about this please?”
May 2022: Enquiry about finding an NHS dentist for herself, adult daughter and grandchildren. They had all been patients at Blossom Dental, have been unable to get appointments for last two years and now told that they will not be able to be seen as NHS patients. Caller expressed concern about grandchildren in particular, but she had also had mouth cancer in the past and was concerned that this would not be picked up routinely if she couldn't see a dentist.
Jan 2023: Enquiry about finding an NHS dentist. Had been a patient at Clock House Dental, and when he contacted them during the pandemic, was told they weren’t making routine appointments due to pandemic restrictions but would contact him when they were. They never made contact and when he was next in touch with them about making an appointment to deal with a broken crown, he was told he had been removed from their list as he hadn’t attended a routine appointment.
Jan 2023: Woman reported having contacted Blossom Dental Practice to ask about routine appointments now the pandemic restrictions have been lifted. She was told that as she had not been seen in the last 12 months, she was no longer an NHS patient. They could see her if she chose to go private.
There is confusion regarding what NHS dentists are commissioned to provide in the city, and who they are providing this to
As an illustration of these issues, here is the feedback we have received relating to the service provided by 1 dental practice in York, Perfect Smile.
In July we received the following feedback.
Jul 2022: "A friend had a number of teeth extracted a few months ago by Perfect Smile NHS dentist. He was told to get in touch in 6 months to have dentures fitted, but has since received a letter from Perfect Smile saying that they are no longer doing NHS work and cannot provide the treatment.”
We shared this issue with our dental commissioning lead at NHS England. She reported back as follows:
“I did indeed ask that the team liaise with Perfect Smile when the issue of them ‘not seeing NHS patients’ was flagged with me a while back – the practice has confirmed that they are continuing with their NHS contract.”
However, we had already received numerous reports of patients not being seen on the NHS at Perfect Smile:
Jan 2022 “I've been an NHS patient of Perfect Smile York for many years and always had a great service from the Dentists and Hygienists. From the start of the pandemic, I could not get an appointment and I understood the reasons. I regularly checked that I was still a patient and was told I was. After waiting more than 2 years since my last visit, I booked an appointment on 22nd December 2021, which was cancelled via text message at short notice. I subsequently attempted to contact Perfect Smile by phone, but could not get through. Each time I got their recorded message going round in a loop for several minutes and was then cut off. I emailed Perfect Smile and they replied stating they no longer see adult NHS patients and they invited me to buy a private dental care plan instead. I responded stating I had regularly checked in with them since the start of the pandemic, had been told I was still a patient and would be seen. Perfect Smile are advertising on their own and NHS websites that they are seeing adult NHS patients, and I could have joined an alternative practice in the 2.5 years between appointments. Perfect Smile did not reply again. I have now been left without a dentist. I am a keyworker and have been at work throughout the pandemic. Perfect Smile have worse than awful customer service and are advertising services which they will not/do not deliver.”
Mar 2022: Partner already undergoing a course of treatment. Now the couple have been told they will no longer be seen as NHS patients. Been told partner's treatment will only be completed if they go private pay-as-you-go or sign up to a monthly treatment plan plus costs. They are really worried - partner is very anxious about accessing dentistry. Had a previous dentist who was lovely, really understanding, but they left. Next dentist seen was much less supportive. And now this. Have already tried lots of dentists in York but none taking people on.
May 2022: "I feel like I've been unfairly treated by Perfect Smile Clinic in York who has now gone private. I was an NHS patient there and have had x-rays showing bone loss and was due to be referred to a specialist before covid. They have now informed me I'm not an NHS patient any longer and if I wish to be seen I'd have to go private with them. I've explained the situation and seem to be getting nowhere. Surely there must be some help I can get to be seen via NHS again or continue to be referred."
Aug 2022: Woman has been told she will no longer be provided with NHS dental care. She must move on to a monthly payment plan. If she does not, her children will no longer be seen as NHS patients. She is worried about how she can afford dental costs on top of rising living costs.
Whilst all this feedback relates to Perfect Smile, they are not the only dental practice we are receiving these sorts of comments about.
Patients report being offered free child places if they accept private treatment themselves. They are unwilling to report these dentists to NHS England as they feel they have no other options. Accepting private care also leads to problems for those who need ongoing prescriptions, especially those who have prepayment certificates
Jan 2022: “Emailed to request check-up appointments for myself and 2 children, one of whom has dental problems and last year required surgery, only to be told we can't be seen as we are NHS and they are only seeing private patients!! They did offer for me to pay private and this would include my children for free, however, if I do not choose this option, my children will not be seen! It saddens me to think that we can be dropped like hot potatoes, particularly when one of my children suffers with dental issues.”
Jul 2022: "My children and I have recently lost our NHS dentist, therefore I am hoping to find another in the local area. We had been on a 3-year waiting list, finally had one and now have to return to a waiting list. We live in Holgate and I have contacted all the local NHS dentists without any luck, the majority say you need a referral from a dentist! I am a midwife and currently have booked women who have NHS dental care in York, so I know it is available. Since oral health is a public health issue, I would have thought it was paramount that dentists when turning private would be obliged to at least refer children to another NHS dental care provider! Ours will see children for free if you sign up for a monthly dental plan which I cannot afford currently. Seems crazy that adults have this care when children do not. I contacted public health England regarding the lack of NHS dental care in York but they were no help whatsoever."
Aug 2022: Woman has been told she will no longer be provided with NHS dental care. She must move on to a monthly payment plan. If she does not, her children will no longer be seen as NHS patients. She is worried about how she can afford dental costs on top of rising living costs.
Jan 2023: “I have been given a private prescription for toothpaste that is only available by prescription (high fluoride). I had to pay for this, almost £10 for a small tube, equivalent to paying almost £20 for a regular sized tube of toothpaste. My private dentist says they are not allowed to issue NHS prescriptions. They have been pulled up on doing this in the past, so they no longer do it. If I were registered with an NHS dentist, or able to get an NHS prescription, I would not have to pay for this prescription because I pay for prescriptions in advance. Since there are now no NHS dentists in York, this means that anyone needing an NHS dental prescription is unable to get one, and will have to pay for a private prescription, which will not be covered by their NHS pre-payment (if they have one). My GP is unable to help and directed me to NHS 111. NHS 111 said they are unable to help too. What can be done to ensure people are able to get NHS prescriptions for ongoing dental needs, given there are now no NHS dentists in the area?”
The lack of dentistry leaves us unable to support the health needs of those experiencing health inequalities, including refugees and asylum seekers, and people with serious or long-term health conditions including mental ill health. People who are more expensive to treat will not be seen.
Cancer Care
Sep 2022: Man in touch with social prescriber. He has barely any teeth left, but is struggling to eat. He has cancer and his doctor has told him he needs to get his teeth sorted out so he can eat to maintain his physical health and fight the cancer. His case is not seen as urgent by NHS 111 triage standards as he is not in constant pain. He is struggling financially and can't travel beyond York. He is very down about his situation and sounding increasingly despairing.
Mar 2022: Woman has throat cancer and due to this she is having a lot of issues with her teeth. She cannot get registered onto an NHS dentist in York. She has tried registering and they have been told these practices are now private.
Mental health and confidence
“We both suffer from depression and anxiety for the last 6 years. We have had a lot of problems. We are on benefits but we are not with a dentist and we both need help with dental as we have lost a lot of teeth and we both feel very embarrassed by this. That's some of the problem why we don't socialise with people we don't even have any friends as we are so embarrassed because of teeth missing from the front. Also it's hard to eat and we don't go out for meals please could you help us thank you."
Refugees and asylum seekers:
Jan 2023: “I have a Ukrainian lady who is in a lot of pain from a tooth. It is spreading to her face. She thinks she may need root canal treatment. She is planning to return to Ukraine to her town which is a war one to get dental treatment as she can't find an NHS dentist and can't afford private care.”
Jan 2023: “I work with a colleague from Ukraine. A Mum with two children. They would like to register with a dentist in York. They have been told there is no NHS availability but can register at a private practice for a Dental plan at a cost of £86 per month for one adult and two children in full time education.”
Patients who are more expensive to treat:
Jan 2022: Enquiry on behalf of brother who is deaf, registered with NHS dentist for 15 year who used to provide BSL interpreter, but now won't as he says he was having to pay for it out of his own pocket and could no longer afford to do so. For the last year, sister has accompanied, but is going back to work so no longer able to do so, and concerned that brother will no longer be able to access dental care.
Jan 2023: Information from social prescriber regarding Community Dental Service. My referrals for patients who haven't accessed a dentist in years due to dental phobia don't seem to be being accepted, or at least I'm not getting any feedback on the referral. These patients are not leaving the house due to the severity of their teeth's condition and feel unable to access regular dental care due to additional needs.
Some people are now experiencing significant health issues as a direct result of the failure to provide them with timely dental treatment
May 2022: “I started ringing around [dentists to try to get an appointment] and I got answers like, two-year, three-year, four-year, five-year waiting times. And it’s just like… no, I’ve got a tooth that needs pulling out now! I then started to try to live with it. Since then, there have been repeating infections for which the doctor has had to give me antibiotics. It just got worse and worse, no matter what antibiotics they were pushing into me, it wasn’t helping. Then this final infection happened, which ended up with me in hospital [and having surgery to remove the abscess that had formed]. I fainted the first time I saw the hole in my neck [after the surgery]. I fainted and fitted, simply because my partner showed me a photograph of the hole in my neck. On top of the trauma, I have been through I just couldn’t take it anymore. I was out like a light and I was fitting and kicking stuff all over the place apparently. This is one of the worst experiences I’ve had with my health. I’ve had two heart attacks, and they were easier to deal with than this was.”
In summary, we continue to receive calls every week from people seeking NHS dental care. We keep raising our concerns that we have nothing we can refer these people to. We can tell them the dental practices most likely to take them on, whilst warning the best that means is being added to a 3-5 year waiting list, or suggest they register as a volunteer with Leeds Dental School (whose volunteer list has just reopened.) But we have no flexible commissioning, no urgent care service, and little hope to offer. We attend regular meetings with NHS England and the Local Dental Networks across Humber and North Yorkshire. We regularly raise the problems we experience. We flag up that local NHS dentists are dropping patients and are told they still have contracts, which does nothing to help people desperate to find alternative care. None of the meetings or initiatives seem to be progressing any real solutions for York. We have to believe change is possible because too many people are being failed at the moment. We carry the burden of this, having been set up to fail the people who contact us looking for answers. We urge the Committee to help us find some.
Jan 2023