Written evidence submitted by The Care Quality Commission (DTY0083)

Introduction

1.      The Care Quality Commission (CQC) is the independent regulator of health and adult social care in England. Our purpose is to ensure health and social care services provide people with safe, effective, compassionate, high-quality care and we encourage them to improve.

2.      Under the Health and Social Care Act (2008)[1], primary care dental practices in England must register with CQC if they carry out a regulated activity. There are approximately 11,000 registered locations. The majority provide a mixture of NHS and private care, with approximately 2,000 providing private care only. CQC undertakes approximately 1,000 assessments of providers in the dental sector each year. 

3.      CQC inspectors monitor and inspect the quality of care of providers and highlight to them where they need to make any improvements in their standards of care. If they do not meet the legal requirements, CQC takes action to make sure they improve. Further information on how CQC monitors, inspects and regulates primary care dental services can be found on our website[2].  

4.      CQC does not attribute a rating to providers of primary dental care services as they are exempt from CQC’s legal duty to rate.  

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

5.      Access to oral health varies significantly across England. In CQC’s most recent

State of Care report[3], we highlighted people’s struggles accessing NHS dental care. We also produced a COVID-19 Insight into dental access during the pandemic in May 2021[4], where we highlighted that the pandemic has compounded previous issues about access to dental services.

6.      Bodies such as Healthwatch have reported[5] a significant reduction in the availability of NHS dental care nationally, particularly for children and young people. These reports also highlight that where you live affects your chances of accessing an NHS dentist and this unequal access is exacerbating health inequalities, with people on low incomes and from minority ethnic backgrounds finding it harder to afford treatment.

7.      We support calls for Government and NHS England to improve access to NHS dental services, including continuing to review the NHS dentistry contract.

New models for dental commissioning

8.      There are no national standards for the number of dental practices per head of population[6], and the current distribution of the dental workforce does not match need or demand for dental services.

9.      In our Insight report linked above, we posted several questions for the sector to address. As we asked, the Government and NHS England should consider if new models for dental commissioning are needed to more accurately reflect need nationally. This needs to include areas of the country that are typically harder to recruit and retain staff, and where health inequalities tend to be greater.

10.  Government and NHS England should also consider if there is enough NHS dental capacity commissioned, and how to ensure those who are vulnerable and without a dentist have access to NHS care. This includes commissioning to support preventative oral healthcare.

11.  Government and NHS England also need to consider whether additional commissioning of dental services is required for sectors such as social care. Our report Smiling Matters[7] found that awareness of, and access to, oral health was limited in care homes for adults. We are soon to publish a follow up report to Smiling Matters, where we will highlight what has changed since our original report. This will show that more needs to be done to make sure that oral health care is prioritised in adult social care, and CQC is making changes to its adult social care regulatory approach to support this.

Urgent dental care

12.  In our reviews of Urgent and Emergency care pathways in 2022[8], we found that patients with dental needs were going to A&E departments because they could not access a dentist. They were often presenting with worsening health than if they were to have sought oral healthcare earlier. This does not help the wider system, which is at a crisis point. Most urgent dental conditions can be dealt with in a primary care dental setting.

13.  Government and NHS England should consider improved access to urgent dental care and what measures need to be taken to prioritise and improve access to urgent dental care through NHS 111 to prevent patients presenting at Accident and Emergency and putting further pressure on an already pressured part of the NHS.

Public awareness

14.  We know that there is a lot of confusion about what patients are entitled to when it comes to NHS dentistry. We believe that people’s experiences should influence any future model of NHS dentistry, but this relies on adequate understanding and awareness of the current model.

15.  We would support Healthwatch England’s call that the public needs to be better informed about NHS dentistry.

16.  Government and NHS England should listen to the views of the public on access but, without public awareness of how NHS dentistry works, it is harder for people to understand how they can access care and meaningfully engage in debates about the future delivery of care.

17.  We are yet to see whether the new requirements for dental practices to regularly update their information on the NHS website will help patients locate practices taking on new patients and improve access.

Utilise opportunities from greater integration

18.  Government and NHS England should consider access to oral and dental health care in a system of integration. With the establishment of integrated care systems, consideration should be given to how oral health will be seen as an integral part of the system, providing access to the right service, in the right place, first time.

Upskilling and better utilising the skill mix of the dental profession

19.  We support recent initiatives by NHS England to address access challenges by increasing the skill mix in the dental sector, and better utilising a wider range of professions to deliver dental care. This includes the recent skill mix guidance[9] allowing dental hygienists and dental therapists to provide direct access to care, without the need for a referral from a dentist.

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

20.  There is an opportunity for ICSs to improve dental services in their local area, including access and tackling health inequalities, but this relies upon primary care, including dentistry, having a strong enough voice on their Integrated Care Boards (ICBs).

21.  In our COVID-19 Insight into Dental Access[10] during the pandemic, we reported that our Provider Collaboration Reviews[11] had found that dental services were not always invited to be an integral part of the system for shared planning and system-wide governance. This resulted in services being left out of joined-up technology initiatives, including electronic prescribing services. Dental services also did not have access to summary care records, creating a barrier to people moving efficiently through the health and care system. Therefore, there are some understandable concerns from the sector about how much of a voice they will have.

22.  The pre-existing issues with the NHS Dental Contract also haven’t been resolved, meaning that ICBs will be taking on all the existing challenges of this contract. Healthwatch England had called for the NHS Dental contract to be reformed before ICBs took this on.

23.  Under the Health and Care Act 2022 we have a new duty to review and assess each local integrated care system (ICS). These powers, in relation to local authorities and integrated care systems, will give us the opportunity to ask systems directly how they are planning to improve dental services in their area and target areas of oral health inequality.

24.  We know it is important to understand the quality of care in a local area or system in order to improve it and keep people safe. It’s often when people are unable to access services or move between care services that they fall through the cracks and have poorer experiences and outcomes. This evidence came through in 2018 when we were commissioned by the Secretary of State for Health and Social Care to look at local health and care systems[12]. While we found that in some areas, different parts of the system were working well together, we also found concerns that in others, there were barriers to joined up care and support. As a consequence, people’s needs were not always met, and their health and wellbeing could have been badly affected.

25.  Our assessments will provide independent assurance to parliament and the public about how well health and social care partners within an ICS area are working together to deliver on their purpose. Our new powers will enable us to report on quality across all sectors, including dentistry, and levels – from individual services to local authorities and integrated care systems. This will allow us to explore in more detail the factors which drive quality and safety, for example culture and leadership.

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

26.  We believe many of the solutions to NHS dental access and inequalities in access can be addressed through commissioning and the NHS dental contract, set out in other questions.

27.  In our most recent State of Care[13], we reported that the use of dentists was significantly lower for people living in the most deprived areas (43% compared with 65% of those living in the least deprived areas). This is supported by evidence from Healthwatch. Healthwatch also reported in May 2021 that people from ethnic minority groups said they were less likely to be registered with an NHS dentist and more likely to struggle to access one when they needed to.

28.  The British Dental Association highlighted the growing backlog for child tooth extractions[14], as the number of treatments in NHS hospitals more than halved during the pandemic. It also reported that children from the poorest areas are 3 times more likely to have extractions than those from the most affluent communities. There is clear and consistent evidence for social gradients in the prevalence of dental conditions, impact of poor oral health and service use which is outlined in this Government report[15] and supported by data from the National Dental Epidemiology Programme for England[16].

29.  Oral health is closely linked to a person’s wider health, so poor access to dentistry is only likely to exacerbate other health inequalities. This is why a preventative approach is important.

30.  From this evidence, we can infer that people from the most deprived areas are less likely to access preventative care or receive care at an early stage when their condition may not be as serious.

31.  Our new duties under the Health and Care Act 2022 will support us to deliver the ambitions in our strategy by allowing us to look more effectively at how the care provided in a local system is improving outcomes for people and reducing inequalities in their care. However, improvements also need to be made to commissioning, as set out above, to address some of the systemic causes for these health inequalities in dentistry.

Q. Does the NHS dental contract need further reform? 

32.  Concerns about the NHS dental contract from the sector have been well reported. We support NHSE’s first steps to reform the NHS contract, but would also agree with voices from the sector that more needs to be done to resolve issues like access to NHS dentistry in the longer term.

33.  In particular, any reform to the NHS contract needs to sufficiently incentivise NHS dentistry in the most deprived areas of the country where the need is greatest. This would address the gaps in dental access across the country.

34.  We also believe that contract reform should support the sector to place a greater focus on prevention, which in turn would reduce health inequalities.

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

35.  We know that there are workforce shortages in dentistry and that more and more dentists are choosing not to work under an NHS contract. It is critical that Government and NHSE find new ways to recruit and retain dental professionals in the NHS, so that people can access NHS dentistry when they need it. One incentive the Government may wish to explore is the expansion of the NHS pension scheme to incorporate all members of the dental team, including dental hygienists and dental nurses. Another is premises costs support, similar to GPs, for NHS dentists, as an incentive to retain NHS cover.

36.  In our latest State of Care, we reported our findings from our Urgent and Emergency Care reviews. All 5 areas that we reviewed highlighted staffing problems, including within dental care. We also polled providers about staffing. 92% of dental care providers who responded (88 of 96) agreed or completely agreed that they are currently struggling to recruit staff. Similarly,  59% dental providers (57) who responded said they are struggling to retain staff.

37.  We are seeing the difficulties with recruitment and retention, and the resulting workforce shortages, in our assessments of dental practices. There is a shortage of both dentists and dental nurses in the NHS. This is partly due to professionals moving into private practice.

38.  The NHS Dental Statistics for England 2021/22 Annual Report shows that the number of dentists performing NHS activity during the year was below 2017/18 levels, and the number of dentists per 100,000 population fell from 44.1 in 2014/15 to 42.9 for 2021/22. Regionally this varied, with the number of dentists per 100,000 population highest in London (49.8) and lowest in the Midlands (42.0). Only the North West saw an increase compared with 2017/18. In addition, this data does not necessarily reflect a true view of NHS dental capacity in the system. This is because many dentists on the NHS performers list may be part time or not delivering NHS services anymore.

39.  As DHSC’s consultation into changes to the General Dental Council’s international registration legislation[17] showed, the international registration route to recruit overseas qualified professionals is slow and was delayed further during the pandemic because the examination used to register them was suspended. We support recently announced changes[18] to the GDC’s international registration processes, which should address challenges with dentists from overseas registering and practising in the UK. However, we would agree with calls to ensure that this does not reduce the standards expected of internationally qualified staff, to ensure that patient safety is maintained.

40.  We support NHS England’s latest guidance to promote a more effective skill mix. We would support any initiatives to further train the profession in order to better deliver this.

41.  We also support Health Education England’s Advancing Dental Care review[19], and its recommendations to develop the dental profession.