Written evidence submitted by The Faculty of Dental Surgery (DTY0063)

About the Faculty

The Faculty of Dental Surgery (“the Faculty”) is a professional body committed to enabling dental surgeons and allied health professionals to achieve and maintain excellence in practice and patient care. The Faculty was established in 1947 and is an integral component of the Royal College of Surgeons of England. We represent specialist dentists who provide patient care in primary, secondary and community care settings, as well as holding key public health roles. The Faculty runs an extensive range of UK and international examinations for dentists and allied dental healthcare professionals for every stage of their career.

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

We are growing increasingly concerned about the impact of access issues on patients and dentists. There are reports of patients resorting to DIY dental treatments and dentists leaving the profession. Poor oral health has huge impacts, with patients waiting in pain, delays to hospital discharges and work or school days being lost.

As the leading professional body for dentistry, our mission is to ensure that patients receive excellent care. If staff are underpaid, over-worked, demoralised or working in under-staffed teams, they cannot deliver excellent care. Whilst we are not a trade union, and dentists’ pay and conditions are not within our remit, we urge the government to consider carefully how it can improve working conditions for our members, fellows and other NHS staff.

The profession is working hard to provide safe and appropriate care to all. Oral health is an often forgotten part of healthcare. Not only does it need more policy focus and funding from the government, we also need the government to develop a comprehensive oral health strategy that includes a focus on prevention. This should include a full analysis of areas that have the most need, both in terms of dental decay, and the lack of a full dental workforce. We welcome the fact dental professionals will be included in the NHS workforce plan and hope this can be aligned with a strategy to target support more effectively. An oral health strategy should also include consistent investment for prevention programmes like fluoride varnishing, supervised tooth brushing schemes and oral health education. We will expand on these issues in our submission to the Committee’s prevention inquiry.

We would also emphasise the need for joined-up leadership for health to bring together the professional, dental public health and workforce leadership for oral health. With PHE becoming OHID, HEE and NHSE merger, and other changes within the NHS, this could be a good opportunity to show real leadership to tackle the issues facing the dental profession.

Does the NHS dental contract need further reform?

Pay and conditions of employment of dental staff are not within our remit as a Royal College. That said, we realise the frustration and disillusionment many feel about the dental contract. It can restrict dental activity and can prevent dentists from taking on new patients. Dental teams have had an incredibly tough couple of years and we are aware of high levels of stress and burnout. In order to maintain standards of care, we must do what we can to support those working tirelessly within the profession. 

The Faculty welcomes the ongoing programme of contract reform, and hope that this can make an important contribution to shifting the focus of the dental profession towards prevention and improving access for those in need of treatment. Reforming the existing activity-based dental contract would help to improve patients’ access to primary care dental services. It would also help NHS dentists to feel valued for the vital work they do. Many dentists report that the current contract restricts the number of NHS patients they can see, and the treatments they can offer.

We sincerely hope that a resolution can be found so that patients of all ages can get regular appointments, and that dentists feel valued within the NHS framework. Although we cannot comment on the contract, we have repeatedly warned that there are huge problems with morale, retention and recruitment in the NHS, which need addressing urgently. This poses a risk to the standards of care patients receive and if we do not look after our NHS workforce, there is a risk they will leave the NHS, or decide to only work privately.

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

Tackling the backlog and improving equitable access to dental care requires a sustainable dental workforce that can meet patient need now and in the future. Our survey in 2021 highlighted that for many of those in dentistry, the experience of working through the pandemic has been the most difficult of their professional lives.[i] Additionally, 28% of respondents in England indicated that they are planning to reduce the number of sessions they work over the next five years, and 25% said they would reduce the amount of NHS work they undertook. Furthermore, 16% suggested that they would retire during this period, and 11% said they planned to leave the profession before retirement age. It is therefore vital that we support those who are considering leaving the profession in the coming years, as well as dental professionals at an early stage in their careers whose development will have been significantly impacted by the pandemic.

Collaboration across the whole dental team

It is essential that the dental workforce has the resources and skills necessary to meet patient need, both now and in the future as patient demographics and demands change. As well as improving terms and conditions of service, we believe the government should facilitates the shift to a multi-disciplinary team approach that encourages the full use of skill mix across all dental services, as recently recognised by the NHS.[ii] Undergraduate dental education should include more collaborative training so that dentists and other dental care professionals clearly understand the skill mix, and there should be a bigger focus on the links to general health and working with health professionals from other disciplines.

Secondary care dentists also need to understand more about primary care to ensure they understand the pressures within primary care and can set realistic treatment plans. Encouraging placements between both primary care and secondary care dentists could help break down artificial barriers and improve understanding that will ultimately result in more effective patient care. Similarly, the government should increase access to specialist dental services within primary care dentistry so that local population needs are catered for. This will depend on areas having a suitable specialist workforce, however would mean if a patient needs a more significant treatment like a root canal, patients can access these services locally.

Retention

As already mentioned, pay and conditions of employment of dental staff are not within our remit as a Royal College. There is however more the government need to do to tackle the system issues and retain senior clinicians within the dental profession as they can play an invaluable role in mentoring and passing on knowledge to junior colleagues. The pension tax issue should be resolved as a priority to prevent more senior clinicians from leaving the NHS.

Not only has COVID-19 been an incredibly difficult time for the dental team and everyone in the healthcare profession, the workforce have been struggling for a long time. The occupational and mental health of clinicians throughout their careers needs to be made a clear priority, and it is also essential that professionals who are struggling can access the support they need to improve their practice, particularly from a patient safety perspective.

Workforce

Ultimately, in order to maximise the efficacy of the dental workforce it is vital to develop a coherent vision for the future of dentistry and its role in an integrated healthcare system that is matched by resources necessary to meet patient need. All stakeholders need to work together to achieve this, and we look forward to continuing opportunities to engage with the government, parliament and NHS England on these issues.

The Faculty welcomes Health Education England’s work on the Advancing Dental Care review and the ongoing work on implementing the Centres for Dental Development and the redistribution of dental training.[iii] We also welcome the government’s commitment to a Long Term NHS Workforce Plan and are pleased that this will include dental professionals. We hope this will result in mapping the workforce against local population need and health inequalities, which will help the dental profession to provide adequate patient care. Effective oral health needs assessments are a powerful and critical tool to improve the dental system, with impacts to contracting care and planning the workforce requirements. These should be regularly reviewed and needs assessments must command the confidence of the profession.

Timely access to specialist care is vital for patients with more complex needs, for example the growing ageing population who keep their teeth for longer and have numerous comorbidities, presenting unique treatment issues. It is essential that all dental specialities have the numbers and resources necessary to meet patient need, and that there is a clear recognition of the importance of specialist care in all workforce reform initiatives. From the perspective of specialist care, one issue that can have a major impact on access to certain types of treatment in different parts of the country are imbalances in numbers across the various specialist lists. Certain dental specialties are facing shortages, a situation which will only be exacerbated as their members approach retirement age, and addressing this should be an important priority for workforce planning as it can be a barrier to patients’ ability to access treatment for particularly complex problems.

We would also urge the regulator to consider a robust and fair mechanism for dentists to get onto the specialist list for those who haven’t completed a recognised specialist-training pathway. This would result in more specialists and the process would be fair. The current process is not fit for purpose and as a consequence could have patient safety issues.

Exams

The government have recently simplified the registration of dentists who have not trained in this country.[iv] The FDS run The License in Dental Surgery (LDS) for international candidates, however they must take the exam in the UK. In terms of enabling overseas-qualified dentists to join the UK register and practise in the UK, FDS offers the LDS examination as a route to registration. The examination has recently been restructured to maximise the efficiency with which candidates can be assessed. The plan is to increase the examination’s capacity further, therefore maximise the number of overseas-qualified dentists who can join the UK register through this specific route, having demonstrated their attainment of the GDC’s outcomes for dentists in Preparing for Practice.

A change to the regulation to quality assure these exams overseas could rapidly increase the workforce in the UK. We would also urge the government to streamline the visa applications in line with medicine to facilitate those applying to come for training and service. This would allow posts to be filled from abroad in a timely manner, especially in hard to fill posts where services are struggling. The government should work with the sector to review current training models and curriculum based on population need.

Recommendations

• Ensure that dental training supports the shift to a multi-disciplinary team approach that encourages a good skill mix across the whole dental team.
• Undergraduate dental education should include more collaborative training so that dentists and other dental care professionals clearly understand the skill mix. There should also be a clearer focus on the links to general health and working with health professionals from other disciplines
• Encourage placements between both primary care and secondary care dentists to help break down barriers and improve understanding between services
• Increase access to specialist dental services within primary care dentistry so that local population needs are better catered for
• The pension tax issue should be resolved as a priority to prevent more senior clinicians from leaving the NHS
• The occupational and mental health of clinicians throughout their careers needs to be made a clear priority, and it is essential that professionals who are struggling can access the support they need
• Map the current and future dental workforce against local population need to ensure the dental profession can provide effective patient care
• Work with the sector to review current training models and curriculum based on population need
• Change the regulation to quality assure the LDS overseas exam to increase the numbers of dental professionals joining the register and practising in the UK
• Streamline visa applications in line with medicine to facilitate those applying to come for training and service. This would allow posts to be filled from abroad in a timely manner, especially in hard to fill posts where services are struggling.
• Urge the regulator to consider a robust and fair mechanism for dentists to get onto the specialist list for those who haven’t completed a recognised specialist training pathway

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

As dentists, dental specialists and their teams have a significant presence across primary, secondary and community care as well as in public health, they represent important stakeholders within Integrated Care Systems.

ICS’s embed specialist clinical leadership and it is therefore vital that all ICS’s have appropriate mechanisms and funding to engage with dental professionals to ensure their views are appropriately reflected in decision-making and delivery of joined up services. Whilst we recognise that it is difficult to mandate specific engagement structures centrally, ensuring that there are widely understood expectations and standards around how this should be approached will be key to ensuring Integrated Care Systems take appropriate account, not only of dentistry, but of all professional voices. It is also important to ensure that other medical and surgical Managed Clinical Networks are aware of the importance of oral health and that the ICS work closely with the dental MCN’s in their area.

There are also significant associations between oral health and a number of systemic conditions such as diabetes and cardiovascular disease. This provides an opportunity to involve the profession in delivering healthy lifestyle advice to patients, as well as potentially supporting the diagnosis of certain conditions.

The Faculty believes that the “Healthy Living Dentistry” programme provides a valuable model for how the oral health profession can promote the wider prevention agenda, and that consideration should be given to rolling it out more widely.[v] Local dental practices are engaged in wider public health campaigns around issues such as smoking and alcohol cessation. They appoint practice champions to oversee this work and identify opportunities to support the local community’s health needs, and receive accreditations based on the types of campaigns they are involved in.

The Suffolk Integrated Care Board also have a great model for dentistry that has clear pathways and maximises the efficiency of specialists.[vi] They are working with Suffolk University to form a centre for dental development and improve dental provision. Suffolk has very poor dental provision, however the Chair of the ICS has been vocal about how it has “become the biggest issue for our communities” and is committed to improving the situation.[vii] This has been incredibly important and we would hope that other ICS’s show this commitment and responsibility to improving local provision.

Recommendations

• All ICS’s should have appropriate mechanisms to engage with dental professionals and ensure their views are appropriately reflected in decision-making.
• Ensure that other medical and surgical Managed Clinical Networks are aware of the importance of oral health and that the ICS work closely with the dental MCN’s in their area.
• Involve the profession in delivering healthy lifestyle advice to patients, as well as potentially supporting the diagnosis of certain conditions.
• Learn from models like the Healthy Living Dentistry programme and the dental work from the Suffolk ICB to highlight best practice across ICS’s.

How should inequalities in accessing NHS dental services be addressed?

As well as redistribution of training schools and dental professionals, the government should urgently look at preventative policies to improve oral health in areas of high need. The Faculty will discuss this in more detail in our submission to the Committee’s prevention inquiry, however across England as a whole, nearly a quarter (23.4%) of five year olds have tooth decay, and the problem is particularly acute in areas of high deprivation.[viii] 5 year olds living in the most deprived areas experience nearly 3 times the decay (37%) compared with those living in the least deprived areas (13%).

Poor oral health can have a significant impact on young children’s development more broadly. Dental pain caused by decay can make it more difficult for children to eat, sleep and concentrate at school, and may require them to take time out of lessons for treatment. Measures to improve oral health can therefore have wider benefits for children’s attainment and wellbeing.

Supervised tooth brushing schemes have already proven successful in reducing levels of child tooth decay in Scotland and Wales as part of the “Childsmile” and “Designed to Smile” programmes respectively. There is strong evidence that supervised toothbrushing schemes are effective in reducing levels of child tooth decay and the effectiveness is stronger in more deprived areas.[ix] The government mentioned they would consult on a supervised toothbrushing scheme in England in the 2019 prevention green paper, however this consultation has not materialised. We would urge the committee to push the government to consult on, and subsequently fund, a supervised toothbrushing scheme.

The Faculty is also keen to highlight the importance of improving older people’s oral health as poor oral health has been linked to conditions such as malnutrition and aspiration pneumonia. In 2017, we estimated that 1.8 million older people could have an urgent dental condition, and this must have got worse.[x] A report from the Care Quality Commission before COVID found that 6% of residential care homes had residents who were unable to access NHS dental care, and a further 27% said they could only access NHS dental care “sometimes”, as opposed to “always”.[xi] We believe that every residential care home should be in liaison with an NHS dental practice to provide support for both care home staff and residents.

There also needs to be better dental input for patients in hospitals as poor oral care is leading to health issues and delaying discharge. The Faculty is currently waiting for data on the numbers of dental patients appearing in emergency departments or calling 111 and we will pass these onto the Committee when we get them.

Recommendations

• Develop a comprehensive oral health strategy similar to Wales and Scotland, and urge the government to consult on supervised toothbrushing schemes
• Every residential care home should be in liaison with an NHS dental practice to provide support for both care home staff and residents. Both formal and informal carers should also have training to improve oral health of adults in their care.

Improvements to data

The FDS would like to see a thorough review of the current tools that are used to measure quality and outcomes in dentistry. It is clear that the methods of collecting data for dental care should be improved. For example, improving coding and the definitions within coding would help to identify patient need and the most appropriate location for care. Taking advantage of technology by introducing apps to encourage patients to complete satisfaction surveys in waiting rooms could improve the logistics for collecting data.

Contact

For more detail on the information contained in this written submission, please contact Jennifer Summers, Policy and Public Affairs Adviser at jsummers@rcseng.ac.uk