25/01/23

Healthwatch England submission to the Health and Social Care Committee’s Inquiry on NHS dentistry.

  1. About Healthwatch
    Healthwatch England is the independent statutory champion for people who use health and care services. We were launched in 2013 – along with a network of 152 local Healthwatch - to make sure that those who run local health and care services understand and act on what really matters to people.
  2. A local Healthwatch exists in every area of England. We support them to find out what people want from health and care services and to advocate for services that work for local communities. Local Healthwatch also act as our eyes and ears on the ground, telling us what people think about local health and social care services.
  3. We use the information the network shares with us and our statutory powers to ensure the voice of the public is strengthened and heard by those who design, commission, deliver and regulate health and care services.

Summary

  1. Since the launch of Healthwatch in 2013, we have constantly heard from the public about problems accessing NHS dentistry. However, in 2020, we saw an explosion in feedback - rising from 5% of all experiences about health and social care to 19%, and overwhelmingly negative.  By December 2022, it was still accounting for 14% of all overall feedback.
  2. Healthwatch England has published three major reports on NHS dentistry, covering findings of national polls we commissioned of 6,000 representative adults, as well as evidence shared by thousands of people with local Healthwatch:

          A review of 31 local Healthwatch reports and a YouGov poll of 2,048 adults in 2016[1]

          Evidence from 1,313 people shared with local Healthwatch and a YouGov poll of 1,900 adults in 2020[2]

          A briefing on 1,375 people’s experiences shared with local Healthwatch and results of a poll by Yonder Data Solutions of 2,019 adults in 2021[3].

  1. Our recent Cost of Living report also includes some national findings on the impact of dental charges[4].
  2. Our qualitative and quantitative data, along with 411 local Healthwatch reports referencing dentistry issues and based on 70,000 people’s views, track a worsening picture of patient experience, moving from a handful of ‘dental deserts’ through to swathes of England now unable to provide NHS dentistry, as this news article describes[5].
  3. The Covid pandemic worsened access as practices were told to close from 25 March to 8 June 2020 for routine appointments. As a result, Local Healthwatch saw enquiries skyrocket, sometimes comprising up to 50% of their workload.
  4. When practices re-opened, people faced long waits due to pandemic backlogs and new infection control measures requiring one-hour decontamination time between appointments. People now tell us of a ‘two-tier’ system, where their NHS dentists can offer treatment in days if they pay privately but will have to wait months or years to be seen on the NHS. Under the current cost-of-living crisis, many people can’t afford dental charges and we hear that people with some protected characteristics are affected more than others - creating not just a health crisis, but social injustice.
  5. Healthwatch England’s evidence, along with unflinching reports from local Healthwatch that describe, for example, DIY dentistry and people suffering in pain, have been instrumental in shining a national spotlight on the issue. We’ve had more than 1,500 pieces of media coverage on our ‘Fix NHS Dentistry’ campaign since April 2020. There were also more mentions of dentistry recorded on Hansard in the first two years of the pandemic than there had been in the entire preceding decade, including a Westminster Hall debate in which multiple MPs cited Healthwatch findings[6].
  6. We have written to the government[7] and met the Chief Dental Officer and NHSE officials to press for change.
  7. While NHSE did announce £50m in January 2022 for ‘up to 350,000 extra dental appointments’[8], it had to be spent by the end of March that same year. Some Local Healthwatch told us none of their local practices had applied for funds because it wasn’t possible to deliver extra appointments in the three-month window. Ministers, as far as we know haven’t disclosed the total spend, but answers to a Freedom of Information request suggest it was less than one-third of the amount[9].
  8. In July 2022 the DHSC announced the first changes to the NHS dental contract in 16 years[10], which took effect in November 2022. It is too early to tell if they will lead to promised improvements of incentivising dentists to provide complex care to those who need it and ensuring dentists provide up-to-date listings on www.nhs.uk.
  9. Fledgling integrated care boards, which must take on statutory NHS dentistry commissioning responsibility from NHSE by April 2023, are also as-yet untested in tackling problems.
  10. We believe more fundamental and swift changes are required, including restoration of the dentist-patient relationship, a drastic overhaul of the NHS dental contract, and ultimately more funding.

 

 

Key themes of public feedback

  1. Lack of locally available NHS dentistry

Stories of NHS ‘dental deserts’ have consistently been shared with Healthwatch as these patient stories, seven years apart, show:

          “I have been looking for a dentist for over three months and have still not found oneI am now in extreme pain. They are all saying that they will only take on private patients, not NHS.
As told to Healthwatch Kirklees, 2014

          “My dentist went back to Bulgaria in 2016 and ever since no dentist has been willing to take me as a new patient on the Isle of Wight. The results are three teeth almost missing, two other chipped and constant pain with several abscesses…. I don't have the means to go private which is the only option offered to me! It's scandalous.”
As told to Healthwatch England, 2021

Our national polling confirms these experiences, with eight in 10 people finding it difficult to access timely care in 2021, up from 73% in 2020 and 20% in 2016.

  1. Problems accessing urgent dental care

At the start of the pandemic, NHSE set up urgent dental centres for people with new, serious problems or who needed ongoing care, accessible by referrals from their usual dentists or NHS 111. But many people described ‘a merry-go-round' via dentists, 111 or complaints departments, and still not getting help:

Last week I ended up in hospital for three days because I had severe pain and could not find a dentist for emergencies or otherwise to fix my teeth. I ended up taking too many paracetamols and had to go to A&E on the advice of NHS 111. I ended up on a drip for 36 hours and…I still do not have a dentist.
As told to Healthwatch Suffolk, March 2021
 

In extreme cases, some people resorted to DIY dentistry, like a man in Portsmouth who used pliers (and pints of beer as anaesthetic) to remove teeth[11].

Post-pandemic we still hear from people about how urgent dental care isn’t working. The current contract only really supports people to get a short-term fix in, and then because routine treatment is even harder to access, the underlying problems are not fixed.

 

  1. Unaffordability of NHS dental charges

A national poll we commissioned just before the Covid lockdown in March 2020, found that 73% of adults believed that NHS dental treatment charges were expensive and 42% said they struggled to pay or avoided treatment because they couldn’t afford the costs. This was up from 2016, when 17% of people told us they avoided dental care because of cost.

Our 2020 poll also found that 72% believed it wasn’t easy to find information about NHS dental treatment charges. In some cases, people said their dental practice had given them wrong information about help with costs if they were on benefits.

In our 2021 poll, 39% people felt they had been charged extra for NHS treatments, despite this going against NHS guidance, like covering the costs of PPE for dentists:

“My husband uses an NHS dentist. He has been advised he will be charged an additional £7 for a check-up and £35 for a filling - to cover PPE costs!”
As told to Healthwatch Gloucestershire, 2020

  1. Pressure to go private

Our 2021 poll showed that 30% felt pressured into going private by their usual NHS dentist, even for serious problems like being unable to eat. Local Heathwatch also have many examples of this:

“[They] had been advised by her dentist that a root canal and a crown is needed but that ‘due to Coronavirus this is not available on the NHS and only available to you privately’, at a cost of over £1,000.”
Healthwatch Central Bedfordshire, 2020

This persists as an issue, due to lack of local NHS provision:

'My NHS dentist quit so now I am forced to pay exorbitant fees to private dentists.'
Respondent to Cost of Living survey, 2022.

Inequalities

We have found that some parts of society are affected more than others, including:

          Women

Practice closures at the start of the pandemic and ongoing problem dental deserts, mean that pregnant women or new mothers have been unable to benefit of from their maternity exemption certificate, entitling them to free NHS dental care. If their pay has been reduced while on maternity leave, they also haven’t been able to afford to pay privately. Our calls for the exemption duration to be extended until NHS provision becomes available, hasn’t been taken up by government.
Our 2021 poll also showed that more women (10%) than men (7%) have avoided dental treatments because of cost, especially those on lower incomes.

          Children and young people

Although under 18s (or under 19s in full-time education) are entitled to free NHS dental care, some parents say dentists have told them they won’t see their offspring unless the parents sign up as private patients:

“I have been trying to obtain an NHS dentist for my 10-year-old daughter, myself and my husband…. One dentist said they could add us to a list that had a 3-year wait for an appointment. Another told me that the only way that my daughter could be seen would be if myself and my husband took a private place at a cost of £75 for an initial consultation! This is disgraceful and holding people to ransom for their children to be able to access basic dental treatment.”
As told to Healthwatch North Yorkshire, 2021

 

We have also heard of some children who have never seen a dentist due to the poor access to NHS dentistry, thereby missing out on vital prevention advice. Government figures show removal of decayed teeth under general anaesthetic remains the most common reason for hospital admissions in 6-10-year-olds – with children from the most deprived communities nearly four times more likely to be admitted than those in the most affluent areas[12].
Closures of some orthodontic services, have also left some children stranded midway through braces treatment.

People from a minority ethnic background

Minority ethnic people from lower socio-economic grades, were twice as likely to avoid dental treatment because of costs, compared to similar White people, our 2021 poll found. Fewer ethnic minority people (26%) than White people (41%) also said they were planning to go to a dentist for regular check-ups, post-pandemic.

Statistics from the national 2021 Oral Health Survey[13] also highlight that more people in deprived neighbourhoods (where ethnic minority people are more likely to live than White people[14]) have pain (41%) or broken (36%) or decayed teeth (40%) compared with those living in the least deprived neighbourhoods.

  1. We have also highlighted access problems for:
     

          care home residents (which led to an NHS Long Term Plan commitment that they would receive greater support for oral health[15] but we have not seen an evaluation of progress)

          people with learning disabilities (who need extra time and specialist staff), and

          asylum seekers (who are entitled to free NHS dental care but often can’t find practices willing to see them or get interpreters provided at appointments).

  1. Out of date information

People’s concerns have been compounded by out-of-date information on the NHS website or from NHS 111 about where people can find an NHS dentist. Many local Healthwatch have plugged the gaps by doing time consuming ring arounds of all practices in their area to get correct information.

 

  1. People being ‘de-registered’
    As far back as 2014 we have heard from people who said they’d been removed from dentists list for missing, or not making, appointments for routine care. This was happening even in extenuating circumstances, such as receiving treatment for other health problems like cancer.
    This highlights the lack of public awareness that NHS dentists don’t operate in the same way as NHS GPs and see you for life. However, in practice, dental surgeries keep databases of people they see regularly and use terminology with patients like ‘registration’, which conflicts with information on the NHS website about the differences between dentists and GPs. The other issue is lack of national consistency over time intervals between ‘regular’ check-ups. Many practices have historically recommended six-monthly check-ups, but NICE guidance says intervals of two years – or individualised timeframes – are acceptable for certain patients.
     
  2. Response to committee questions
    Our recommendations address the following questions posed by the inquiry:
    What steps should the government and NHSE take to improve access to NHS dental services?
    What role should ICSs play in improving dental services in their local area?
    How should inequalities in accessing NHS dental services be addressed?
     

We recommend:

24. Dental practices should operate more like GPs

Although people may have a usual practice they go to, they don’t have the same right to treatment as with their GP, which is confusing and leads to a whole host of problems when NHS appointments are scare. The new contract should ensure dentists run the same way as GPs, so people have more certainty about where to get care when they need it. Rebuilding the link between dentist and patient, does have significant implications relating to capacity, which would need to be resolved before this can be universal.

 

  1. Changing the contract to avoid rewarding dentists to see only healthy people

The current contract makes it more likely for dentists to see people who only need a check-up or simple treatment, rather than people who require more complex treatment, such as root canal. We need changes which provide timely treatment to people with complex needs, otherwise we leave them in pain and they end up elsewhere, like A&E.

 

  1. Action on inequalities

 

In considering oral health in terms of equity, we require a clear view of both the need. and the services required to meet that need. This should take into account that many people who want to use NHS dentist are currently using private services because they see no other option. Local oral health needs assessments should identify the overall need (including responding to shorter-term issues) as well as how these will be met. This should give local people a realistic view of what they can expect from NHS dentistry.

Having decisions made locally by ICBs, and the involvement of local authorities in ICSs, may mean that commissioners can respond more clearly to local circumstances and health inequalities. Partnerships with local Public Health teams and links with schools also offer opportunities to prevent tooth decay and instil oral health hygiene habits in children.
We urge ICBs to engage with local Healthwatch, who can provide a wealth of qualitative evidence and can reach those experiencing the greatest health inequalities.
ICSs will also need good quantitative data on oral health inequalities and this requires national efforts to overcome the ‘paucity’ of evidence as described in a national review[16].
It is also to be seen whether NHSE dentistry commissioning expertise will be lost in the transfer of responsibility to ICBs.
Overall, ICSs will still rely on national policy for issues such as training numbers and contract negotiation.

The other fundamental change needed is to NHS dental charges, which our research shows disproportionately deter certain groups.

 

  1. Real-time information for patients
    Measures are needed to remove the onus on patients to ring around multiple practices to find dental care. Listings on www.nhs.uk are often not updated and even when they are, circumstances change so quickly that they may become out of date very quickly. While available capacity is likely to be taken up very quickly, it should be possible to devise a mechanism so that there is real time information about available appointments under the current system. This is yet another issue that would be improved by reinstating the relationship between dentist and patient.

 

  1. Ultimately, more money


Today, dentistry remains the only part of the NHS that receives a lower budget in cash terms than in 2010. The amount we spend is only enough to treat half the population anyway. A fully overhauled contract cannot come quick enough and must secure meaningful funding based on the level of the country's dental needs.

 

 


[1] Access to NHS Dental Services: What people told local Healthwatch, Healthwatch, 2016

[2] What people are telling us: A summary July-September 2020, Healthwatch, 2020

[3] What people have told us about NHS dentistry: A review of our evidence - January to March 2021, Healthwatch, 2021

[4] Health and the Cost of Living, Healthwatch, 2023

[5] DIY dentistry on the rise…’, The Guardian, 8 August, 2022

[6] Oral Health and Dentistry Westminster Hall Debate, Hansard, 25 May 2021

[7] Open letter to then Chancellor, Healthwatch England and British Dental Association, October 2021

[8] NHSE announcement, NHSE, January 2022

[9] NHSBSA FOI disclosure, NHSBSA, August 2022

[10] NHSE announcement, NHSE, July 2022

[11] News article, Portsmouth News, 14 October 2020

[12] Hospital tooth extractions of 0 to 19-year olds, Public Health England, August 2021

[13] The impact of COVID-19 on access to dental care: a report from the 2021 Adult Oral Health Survey, Office for Health Improvement and Disparities, December 2022

[14] Ethnicity Facts and Figures, www.gov.uk, September 2020

[15] Paragraph 1.15, page 16, NHS Long Term Plan, 2019

[16] Inequalities in oral health in England, Public Health England, 2021