Written evidence submitted by Denplan (DTY0071)

About Denplan:

Denplan, which is part of Simplyhealth, is the leading dental payment specialist with around 1.3 million patients and 6,600 member dentists (mixed and private practices). We advocate for a preventative model of healthcare via an affordable and accessible payment plan for patients across the country – helping to safeguard and strengthen the UK’s oral health.

1.       Current State of Dentistry in the UK

Access to dental care has been one of the most prominent healthcare issues over the past couple of years – reflected in our conversations with Members of Parliament, who say it is one of the main issues they hear about from their constituents and the public.

Research by the British Dental Association from earlier this year, tells us nine in ten NHS dental practices are not taking on new adult patients[1]. Preventative measures of care, such as routine check-ups, have also been significantly reduced – resulting in part, from measures put in place to protect patients and dental teams from Covid-19.

Whilst the pandemic exacerbated issues around access to dentistry in the UK, this has been a longstanding problem. Current challenges and pressures caused by the NHS dental contract and the UDA (Units of Dental Activity) system have deeply affected dental teams, resulting in many practices scaling back on their NHS activity or leaving the NHS altogether. Data by the Department for Health and Social Care and analysed by the BBC[2] shows that over 1,000 dentists left the NHS last year – worsening an already acute problem in our communities.

Scale of the issue and post pandemic context and recovery

The dental profession across the UK continues to face an uphill battle to have the importance of oral health – and its impact on overall health – given its due recognition in policy and public debate. This is a shared challenge felt by NHS, and private practice dentists, and those who inhabit both the sectors in their mixed practices.

All dentists – NHS, mixed, and private – are dedicated to improving the nation’s oral health, but the challenges and opportunities facing these practices are not the same. The Covid-19 pandemic threw these differences into stark contrast: government response to, and financial support for practices, was vastly different amongst private and NHS practices, despite all dentists facing acute financial pressures from the cost of adapting to preventative measures. This included complying with Aerosol Generating Procedure guidance, PPE and other infection control measures – leaving practices unable to run at usual capacity due to social distancing measures.

With over 19 million dental appointments lost over the course of 2020[3] and 70% of our member dentists reporting concerns about the future financial stability of their practice (Denplan’s Member Survey, October 2020)[4] the pandemic also exacerbated issues with mental health and wellbeing. At Denplan, we have continuously engaged with our member dentists to ensure their concerns and ambitions for the sector are understood and addressed. As part of this, we conducted a member survey in October 2020 (6,600 respondents) and a survey of the general public in the UK in October 2021 (2,008 respondents), to identify the biggest challenges and opportunities facing dentists and their patients, and to improve our understanding of the impact of Covid-19 on the sector.

The surveys indicated that dentists believe there is a misunderstanding of the industry in general, which has manifested into a relatively poor relationship between policymakers and the dental profession over the years. Member dentists who responded to the October 2020 survey, indicated dental services are often treated as an afterthought, with the government’s communication with the sector considered to be lacking. 67.52% of respondents to the 2020 survey, said they “strongly disagreed” with the statement “the government understands the dental sector”[5].

Data from our October 2021 survey shows 36% of respondents said the pandemic had affected their oral health – with 50% of those who had seen a decline in their oral health, saying that they had had appointments delayed, or were unable to book any dental appointments with their dentists (49%)[6]. According to our data, the pandemic also changed people’s attitudes towards dental treatment, with 29% saying that following issues during Covid-19, they now value their oral health more and are more likely to visit a dentist. Nonetheless, existing backlogs and an exodus of staff is preventing patients from accessing the dental care they need – leading many patients to resort to DIY dentistry.

Incidents of DIY dentistry are increasing across Britain, with a recent survey commissioned by the Liberal Democrats indicating that one in four of over-65s would carry out their own dental work (including tooth extractions)[7]. The survey findings also show that overall, 41% of people in Britain said they would be willing to undertake DIY dentistry if they needed dental treatment but could not receive it due to a lack of NHS appointments. These figures were highest amongst younger people (48%) compared to 28% of seniors.

Role of private dentistry and the importance of a mixed economy

Against the context described above, it is incredibly important that government and policymakers recognise the immense contribution made by all practitioners and their teams throughout the pandemic and in its aftermath, to continue to deliver urgent treatment and routine care.

It is crucial that the government recognises the importance of a mixed economy in the sector, as the pandemic demonstrated that private and mixed dentists were vital in supporting the NHS address the backlog and provide patients with the treatment they needed. As NHS practices often focus on providing urgent treatment, NHS dentists have lost the ability and time capacity to focus on delivering high-quality and preventative dental care – something that is not rewarded by the NHS dental contract and UDA system. As a result, it is mixed and private dental practices that place a deeper focus on preventative care – which should be widely supported by policymakers.

In light of this and the government’s overwhelming focus on NHS services and workforce, we urge Ministers to recognise the role played by private dentists in tackling the backlog of cases during the Covid-19 pandemic, and to be more sympathetic with the issues that they are facing; this should include working more collaboratively with the private sector to ensure common goals around treatment and prevention are met.

There is also a need to transform the way in which government sees dentistry – particularly following former Health Minister Jo Churchill’s statement that General Practitioners were more important in the diagnosis of mouth cancer than dentists providing regular check-ups[8]. Whilst the sector waits on more funding and further contract reform, government cannot expect dental services to improve on their own, and the sector must be seen by the DHSC as equal to other aspects of health.

It is therefore vital that the entire sector – including NHS, Mixed and Private practices – comes together to bring forward practical solutions that deliver lasting results, with this inquiry representing a pivotal moment to do so.

2.       Steps Government Should Take to Improve Access to Dental Services and Recruitment and Retention in the Sector

NHS Dental Contract Reform

Whilst we welcome recent changes to the NHS dental contract and UDA system as an imperative first step, we believe more needs to be done to improve access to dentistry for patients across the country, and to improve recruitment and retention issues. This should include motivating dentists and dental teams to work in rural and coastal areas (often known as dental deserts) and enabling them to focus on a preventative approach to care.

Following recent recommendations by the British Dental Association (BDA)[9], we believe the NHS dental contract needs further reform, as the adjustments made to the contract in 2022 will do little to halt the exodus of dentists from the service or address the existing access crisis. Changes introduced in November are marginal – including offering a higher reward for treating three or more teeth and a new patient rate for complex treatment like root canal treatment on molar teeth – and they do not solve the problem.

Under the former NHS dental contract and UDA system, dentists would receive the same payments for all treatments delivered within band 2 – which includes fillings and tooth extractions – regardless of the time taken to deliver the work. This often meant that NHS dentists could not take on new patients who had not seen a dentist for an extended period and required more extensive treatment as a result.

Contract changes, already in place, stipulate that dentists will now receive five units of dental activity (UDAs) for treating three or more teeth, an increase on the former level of three UDAs, which applied to care delivered to any number of teeth. This is welcome; however, as the BDA set out in November[10], dentists will still be disincentivised to treat patients that require as many as 20 fillings, as less complex work will still be rewarded at the same rate as longer and more complicated treatments. The same applies to the new rewards for root canal treatment, which is also a challenging and time-consuming treatment.

According to the BDA, the dental contract would benefit from further reform and more granular UDAs so that complex and lengthy treatments are rewarded fairly, and NHS dentists are not discouraged from performing them to patients in need.

At Denplan, we are particularly concerned as we receive more warnings from member dentists in mixed practices, who have had to decrease their NHS commitments because it has become unaffordable for them to provide complex treatments to NHS patients. Far more needs to be done to incentivise these practitioners to maintain their NHS services.

Training and Dental Schools

Alongside further NHS dental contract reform, we believe that the government needs to take urgent action to safeguard dental teaching and increase the supply of future dentists by focusing on the funding of and training provided by dental schools.

According to the Dental Schools Council, “we do not train enough dentists for the NHS to meet UK requirements”[11], and dental schools have the capacity to train more students with the right investment. The lack of funding continues to be a prominent issue for the profession and to meet UK dental requirements. The government should urgently provide additional funding for more students to do their Bachelor of Dental Surgery at existing institutions.

The capacity of dental teams could also increase by enabling Dental Therapists to work to their maximum permissions[12]. Whilst this is in line with government plans, there are currently not enough dental therapists to meet demand, especially as the sector becomes more accepting of their increased scope of practice. Detrimentally, capacity to offer the Dental Therapy course has not increased at universities, as the funding falls short of what the course costs to deliver – with some universities halting the course altogether. We encourage the government to increase the training of dental therapists by allocating additional resources to these courses.

Government should also provide students and graduates with incentives to work in rural and coastal areas (also referred to by the profession as dental deserts), where access to dentistry has become almost impossible – in line with the government’s commitment to levelling up the country.

Finally, there is an urgent need for government to increase the number of training places within the UK – and train more graduates where they are most needed – to offset the uneven geographical distribution of existing dental schools.

Recruitment from overseas

Given the time needed to train dentists and associate professionals in the UK, the government should look at maintaining access to European dentists (in the Brexit aftermath) and opening other routes for overseas professionals to work in the UK.

Legislative changes are needed to remove barriers to overseas recruitment and ease the General Dental Council’s (GDC) registration processes – so that dentists and dental teams from EU member countries and others can enter the UK as practising dentists. The Dentists, Dental Care Professionals, Nurses, Nursing Associates and Midwives (International Registrations) Order 2022, which is currently making its way through Parliament is greatly welcome and we would be delighted to work with government to ensure this alleviates recruitment pressures as soon as it comes into law.

Since the end of 2020, when the UK left the EU, European law relating to the recognition of EEA (European Economic Area) qualified healthcare professionals no longer applies in the UK. It is now up to the regulators to determine the process to be followed for the registration of international professionals.

To ease the barriers to recruitment from overseas, the government is bringing forward legislation[13] to implement changes which will provide the GDC with greater flexibility to amend its processes for registering international dentists and dental staff. As part of this, the requirement that an assessment for overseas dentists, such as the Overseas Registration Exam (ORE), must be provided by dental authorities, or a group of dental authorities, has been removed. Registration routes for international dentists may include recognition of overseas diplomas, but the GDC will charge fees to international institutions for the purpose of meeting expenses incurred or to be incurred in relation to the registration process.

Whilst the recent legislative changes are welcome, we believe the government could go further and enable special registration tracks to members of Commonwealth countries with a surplus of trained dentists.

Support for the Next Generation

Finally, we believe there is an urgent need to expand support given to the next generation of dentists. Given the significant recruitment and retention challenges facing the sector and the need to increase support to our member dentists in the earlier stages of their careers, Denplan convened a ‘Next Gen Group’ of young professionals working in mixed and private practices across the UK.

This year, our Next Gen members wrote a policy paper[14] to share their views on how the sector should change in order to attract and retain new talent into the profession. Some of their key recommendations to drive this forward could be interesting for Members of the Committee to consider. These include:

• A national approach led by Government and the NHS to strengthen career pathways for young dentists, such as adapting Dental Core Training (DCT) so that it shows all available routes (including working in hospitals).
• Offer support to institutions already working on improving career pathways for dentists, including the College of General Dentistry.
• NHS bodies and dental organisations should offer greater peer and mentoring support to junior dentists, especially at a local level.
• Placing young dentists at the heart of change by enabling mixed and private representation on Integrated Care Boards (ICBs) to ensure that their patients’ needs are heard, and improvements can be made in the local area.

3. Summary of Recommendations

Jan 2023