Government Health Committee - NHS Dentistry Inquiry 
Written Submission of Evidence - Christopher Hilling, SpaDental group 




  1.    I am submitting evidence as the Managing Director of SpaDental Group. Of the groups’ nine practices, five are private, four are mixed. They are situated in the west of England, from Shropshire to Cornwall.  


  1.    Since May 2020, our four practices with NHS contracts have not accepted new adult patients. Indeed, SpaDental South-West (two practices in Plymouth PL3 and Saltash PL12) have notified circa 8,000 patients that we cannot provide NHS treatment due to lack of dentists prepared to provide adult NHS treatment. 


  1.    For clarity, comments here will focus on our cluster of two practices in Plymouth and Saltash. They are a microcosm of the concerns we see around the country - a diverse community of those who can afford private care, some who feel entitled to NHS treatment, and others who really cannot afford treatment or nutritious food.  


  1.    We have clinicians, but either they are not prepared to provide NHS treatment at the rates of pay being offered by the NHS, or they are limited in their scope by the inability of the GDC to provide them with an opportunity to sit the Overseas Registration Exams (ORE). 


  1.    In 2017-18 our Plymouth practice’s five part-time dentists and two dental therapists (DCPs) provided c17,000 UDAs.  In 2022-23 seven part-time dentists and three therapists will only complete c7,500 UDAs although we have contracted NHS funding for nearly twice this number of UDAs, we will repay the excess funds next year. 


  1.    The effects of Brexit and the pandemic, combined with the bureaucratic red tape of the NHS and GDC, has changed our business, deflated morale and the job satisfaction of our staff.  


  1.    In short, the key issues preventing SpaDental offering pre-2020 levels of NHS care to teenagers and adults are the shortage of dentists willing to provide NHS funded dentistry and the lack of an ambitious articulated government strategy to address the problem.  


  1.    The current focus must be on determining the NHS dental service the government can afford to provide, deciding who can access it, and then incentivising dental teams to provide this treatment by implementing creative solutions before all the mixed NHS-private practices all become private-only. 


  1. What steps should the Government and NHS England take to improve access to NHS dental services?  
  1.    Funding of realistic pay scales for the whole team  

NHS does not provide an income commensurate with the skills of the trained, professional dental team members. The current UDA system (even with recent increases) since it was implemented has not suited conscientious dentists. 


  1.    Work to implement mixed skilled teams and increase training of the whole team. 

Following the changes to NHS directives in 2022, a major aim should be to utilise fully dental therapists to examine and triage patients who present without pain, with a referral system in place for concerns, second opinions, and treatment outside of their scope of practice, to be escalated to appropriate dentists. Logically this should be common practice - the norm, not the exception. Each team member will then work at the higher end of her/his Scope of Practice.  

To make this work there needs to be a culture change within the dental sector encouraging referrals both up and down the skills ladder to the appropriate member of the team.  For instance, a suitably qualified nurse can provide oral health education, or a therapist most of the treatment for younger children, with more complex treatment completed by dentists. All the clinicians being remunerated appropriately for their skills and experience.  

This would increase the number and range of clinicians providing direct access to the general public, thereby rapidly improving access to NHS dental-services. 


  1. Consider the discrepancy between recognition as a fully practicing dentist on the GDC register and the additional length of time for required to treat NHS patients. 

The dentist’s performer number effectively costs a further c£20k in lost practice revenue and, if required, Performers List Validation by Experience training expenses. It is not logical, especially in a mixed practice, that a dentist can treat private patients by not NHS patients in the same practice.. 


  1.                 How should inequalities in accessing NHS dental services be addressed?  
  1. The NHS does not have the funding to provide NHS dentistry for all (free or otherwise).  

The market for private dentistry has grown, and the current crisis is widening the gap between those who can afford private care and those who cannot. Private treatment is not limited to cosmetic treatments or better-quality crowns, it is the whole patient journey from general preventive dentistry to complex cosmetic reconstructions which is becoming the norm in many parts of the country.  

Patients who have regularly attended there NHS dentist for years can no longer access NHS care: A patient review: “It is a shame there are no longer NHS dentists… An older woman came in and cancelled her appointment as she could not afford the treatment – that is poor.”   


  1.    Review who the NHS can afford to treat with existing (or new) funding. 

Is it time to consider means-testing? This already happens to some extent with patient charges and remissions for children and patients on various government credits. Is it time for a more nuanced, tiered structure with higher patient contributions? Some groups could remain fully funded as they are now: for example, children and exempt patients. It would be an unpopular and politically alienating move but without this debate NHS dentistry will continue to fail the public and in particular fail the under privileged. 


  1.     Allow charging for failed appointments.  

Failure to attend an appointment wastes a lot of clinical time but still incurs staffing and overhead costs which the NHS do not pay. It is also missed treatment opportunities for those in need. We have systems in place to charge private patients for failed appointments, this is easily extendable to charge NHS funded patients directly for missed appointments. It is important patients respect the time allocated to them and as this charge would be payable by the patient it would not increase the NHS funding requirement. 


  1.    Allow a mix of NHS funded treatment with private treatment on the same tooth. 

In practice, for example, the NHS would pay for a basic crown or denture, but the patient could elect to pay an additional cost for a crown or denture of superior material. This allows the dentist to make a sensible living for the service provided while the NHS is still funding basic dental treatment for all. 


  1.                 Does the NHS dental contract need further reform?  
  1.    Yes, to focus on preventive dentistry delivered by mixed skilled teams.  

Changes in funding framework, training and ethos are necessary for the system of mixed skilled teams to work fluidly. 


  1.    The UDA system does not work.  

The UDA bands cannot reflect the complexity or nuances of each patient’s treatment. Over the years, the UDA system has encouraged a culture amongst some dentists of benign negligence, to the detriment of patient care, especially of those with high treatment needs. Remuneration needs to directly reflect the reality of the treatment provided and the skills of the clinician providing the treatment. 


  1. What incentives should be offered by the NHS to recruit and retain dental professionals, and what is the role of training in this context? 
  1. It makes no sense for the local Integrated Care Systems (ICS) to compete against each other for the same dental professionals. 

The NHS needs to ensure that any incentive is directed towards increasing the pool of dental professionals in England and not fighting each other for the same clinicians. 


  1. Government, rather than the NHS, needs to work with the GDC to make it easier for international dental professionals to move and work in England. 

This requires the GDC to register candidates in a timely manner and provide those that need to pass additional GDC administered exams more opportunities to take these exams. 


  1.     ICS can better integrate recruits into their local communities.  

By organising events, both academic and recreational, they can make their locations more appealing to professionals from outside their region. For instance, Cornwall could arrange various CPD events linked to an afternoon of trying surfing or walking on the moors, a larger city may organise theatre or museum visits.  


  1.    A key outcome for training should be improved integration.  

It is time for a change of culture away from the insular current working practices of dentists to a team culture that embraces the mixed skills of professionals. Integration and appreciation will enhance communication, helping groups work together for the benefit of the patients. 



Christopher Hilling, SpaDental group – 25th Janaury 2023