Written evidence submitted by the University of East Anglia (DTY0101)
This submission to the Health and Social Care Select Committee is provided by the University of East Anglia (UEA). Established in 1963, UEA is a dual intensive, campus university based on the Norwich Research Park in Norfolk. UEA is ranked in the UK Top 25 (The Times/Sunday Times 2021 and Complete University Guide 2021), and the World Top 200 Universities (The Times Higher Education World University Rankings 2021). We are home to 17,000 students across a diverse range of undergraduate and postgraduate degree courses. UEA’s Norwich Medical School was established in 2002. The University is an integral partner of Norwich Research Park, one of Europe's biggest concentrations of researchers in the fields of environment, health and plant science.
The evidence and recommendations in this submission are based on the ongoing feasibility study conducted by the Norwich Medical School’s Health Economics Consultancy. This study is in the process of evaluating the national and regional circumstances for access to dental services and the costs associated with developing a regional dental centre for education and research and an undergraduate dental school.
What steps should the Government and NHS England take to improve access to NHS dental services?
There is considerable variation in the number of NHS dentists per head of population within England. NHS Digital reports NHS dentists who perform activity by local area, so there is some double counting of dentists between areas. Despite its limitations, the data highlights that large geographical areas of the country have very low levels of NHS dentists per head of population. The extremes of this variation are from 3.4 dentists per 10,000 people in West Norfolk and North Lincolnshire to 12.6 dentists per 10,000 people in Bradford City.
The GP Patient Survey undertaken between January and March 2019 reported that, nationally, 92% of patients who tried to get an NHS dental appointment in the preceding two years were successful in getting an NHS dental appointment, with 6% unsuccessful and 2% unable to remember. Locally, the results demonstrate considerable variation between areas, which ranges from 17.5% in West Norfolk to 1.7% in Nottingham North and East.
The following key points from the data reviewed to date, highlight the paucity of dentists and levels of service delivered within our East of England region.
Moves to improve the NHS contract for dentistry are undoubtedly a step in the right direction. Also welcome are plans for regional dental development centres, concentrating on specialist post-graduate training or roles allied to dentistry, such as dental hygiene and dental therapy. However, the number of dentists available to undertake NHS roles, particularly within our region, are a real limitation to the growth and improvement of local services. The total number of NHS dentists available will also therefore have a negative impact on the benefits of providing greater numbers of those in professions allied to dentistry with a lack of dentists available to head up and supervise work in the practices that would employ them.
A focus on upskilling dentists through specialist training, with the aim of improving retention and skills development, is taken up in the region although this has been markedly reduced. The local NHS Secondary Care Trust runs a dental foundation programme for 13 foundation dentists and development training sessions in endodontics, paediatrics, oral surgery and periodontics. However, this activity accounts for only 112 hours of teaching a year. Whilst upskilling is an approach to retaining and developing the workforce, it also presents regional retention problems as higher skilled professionals move away from the region to practice, leaving more gaps in dental practices.
Given the regional difficulty in recruiting and retaining dentists, we reviewed approaches taken in other parts of the UK. Evidence suggests that providing an increased number of undergraduate dentistry places in a training facility in the East of England would be immediately effective in increasing NHS dentistry capacity. This could be pre-empted by a nationwide review of current undergraduate training locations and a ‘levelling up’ approach to where training should be located. This would even out and support regional recruitment and retention.
UEA, the Norfolk and Norwich University Hospitals (NNUH) and the Quadram Institute (for digestive health and microbiology research) have joined forces to investigate the feasibility of collocating a new Dental Development Centre (including dental teaching and research) on the Norwich Research Park. A new Centre such as this would enjoy close links with communities and practices across the region and make an immediate and positive impact on NHS dental provision by attracting and retaining qualified dentists within the region in joint teaching roles with NHS practice and by programming.
Much like UEA’s current undergraduate medicine programme, student placements would begin from Year 1 ensuring students are placed in practices supporting the throughput of NHS dental patients. This approach would support the local region with an uplift in the workforce immediately, help to retain and attract dental personnel with joint academic appointments, support diversity and inclusion focussed on growing a regional workforce and help to retain students within the region post qualification.
Research shows that medical personnel trained in East Anglia mostly remain in East Anglia after graduation. Dentistry students would be expected to follow suit and this would impact positively on the number of dental personnel available within the region. Increases in both NHS and private practice capacity would be immediate with improved retention (feeling valued) and attraction of new dentists with a range of enticing academic posts and teaching practices. Students would also boost capacity by working under (limited) supervision from early in the training programme.
The distribution of dental schools across England is uneven, with six schools in the North, two in London, two in the South-West, one in the Midlands and none in the East. Health Education England’s (HEE) recent report on Advancing Dental Care (September 2021). There is a lack of dentistry training in the East of England, and additional difficulty in retaining trainees in remote areas. There is a general impression that East Anglia is a relatively prosperous region, but, in reality, there are areas of major economic deprivation and health inequalities. These are highlighted in the English Indices of Multiple Deprivation and the East of England Development Agency summary reports. For example: a regional survey of children found that 35 - 40% of 5-year-olds in Norwich, Great Yarmouth and King’s Lynn have active dental decay.
UEA submitted a bid to HEE in 2005 to establish a new dental school in the region but was not selected. Earlier this year, the Norfolk and Waveney Medical and Dental Workforce and Quality Advisory Group noted that there were a number of issues for dental treatment capacity in the region, which mostly centre around recruitment and retention of staff.
Norfolk and Norwich University Hospitals (NNUH) has recently identified that the lack of dental services in the region is impacting A&E admissions and causing significant financial burden to the NHS. There has been an increase in dental related incidences such as patients presenting with overdose of analgesics due to tooth ache.
Whether increasing or redistributing the number of dental undergraduate places, universities would also work with regional HE and FE colleges as part of regional dental development centres to develop specific Access to Dentistry courses and wider programmes to support professions allied to dentistry. This would strengthen previous steps to increase the availability of dental care across the whole of the UK.
What role should ICSs play in improving dental services in their local area?
How should inequalities in accessing NHS dental services be addressed?
Analysis of regional expenditure shows large variations in levels of funding and activity per head of population. This data shows greater amounts of total and per capita spending in the Midlands than in other regions and the lowest amounts in the South-West and the East of England.
There are also variations between constituencies in the delivery of contracted NHS dental activity in 2018-19. The median level of delivery by constituency is 96% of the contracted level. Dentists overall in 10 out of 533 constituencies in England delivered more than 110% of contract value, and dentists overall in 109 constituencies delivered less than 90% of contract value.
There are fewer dentists per 100,000 of population in West Norfolk and North Norfolk than England and East. Great Yarmouth and Waveney, Norwich and South Norfolk have more dentists per 100.000 of populations and consequently each dentist in these areas have a lower population per dentist than England and East. Whilst there has been a small increase overall in the total number of dentists, there has been a decrease in North and South Norfolk and Norwich. NHS Dental Statistics: 2018-19, Second Quarterly Report shows that access rates in West Norfolk are much lower than Norfolk, East and England.
With a high rate of dentists leaving the NHS every year with West Norfolk having the worst distribution of practising NHS dentists per 10,000 population, data demonstrates that these differences are likely because dentists willing to work within the current NHS contract are not evenly distributed across England, and the resulting shortfalls in provision are more notable in more remote areas. For example, West Norfolk has one of worst primary care dental activities (Units of Dental Activity (UDAs) per head of population) and these differences are likely to be explained by the shortage of dentists overall and in some cases the availability of private dental care to meet local needs. West Norfolk also has the highest unsuccessful percentage of patients when trying to get an NHS dental appointment.
Whilst greater numbers of professionals allied to dentistry and upskilling provide advantage, it is not evident that these actions alone will support an increase in dental provision within rural and coastal areas, neither will the improvements to the NHS contract. Our early study indicators, based particularly on the advantage demonstrated by retaining medical students within the region, would be to re-allocate places for undergraduate dental education or increase the number of undergraduate dental places through the development of new regional schools where there is most need to increase opportunity for current NHS dentists (retention), new academic training posts (attraction) and undergraduate students that are recruited and retained within the regions (growth).
Does the NHS dental contract need further reform?
NHS England and NHS Improvement considers that dentists willing to work within the current NHS contract and terms and conditions of service are not evenly distributed across England, and that the resulting shortfalls in provision have been most notable in more remote, rural areas. Further reforms should focus on how changes to the contract affect remote areas and how to level up access across the UK. Many other opportunities that have been considered, including increasing the ease of internationally qualified dentists to move to the UK are beneficial, but evidence has shown that this only supports areas where there is already the highest levels of availability and not necessarily remote regional areas which could have the detrimental impact of making the regional gap wider.