Written evidence submitted by the National Audit Office (DTY0103)

About the National Audit Office

1            The National Audit Office (NAO) helps Parliament hold government to account for the way it spends public money. It is independent of government and the civil service. The Comptroller and Auditor General (C&AG), Gareth Davies, is an Officer of the House of Commons and leads the NAO. The C&AG certifies the accounts of all government departments and many other public sector bodies. He has statutory authority to examine and report to Parliament on whether government is delivering value for money on behalf of the public, concluding on whether resources have been used efficiently, effectively and with economy. The NAO regularly investigates health and care spending and outcomes, including the financial sustainability and organisation of the NHS, adult social care and public health.

Introduction

2            This briefing note to the Health and Social Care Committee's inquiry into NHS Dentistry updates data and analysis in the NAO's 2020 memorandum - Dentistry in England - using publicly available data for the period up to 2021-22. The NAO submitted the 2020 memorandum to the Health and Social Care Committee in February 2020, in response to a request of support from the then Chair, during the 2017-2019 Parliament. The 2020 memorandum covered the commissioning of NHS dentistry services, financial flows relating to NHS dentistry, the dentistry workforce, and access to NHS dentists.

3            This briefing note updates key information and charts from the 2020 memorandum to provide the latest available position for the Committee's inquiry. It provides information on, and is structured into, four overall areas:

• NHS dentistry funding and patient charges;
• NHS dental activity;
• NHS dentistry workforce; and,
• Satisfaction with NHS dentistry.

NHS Dentistry Funding and Patient Charges

4            The 2020 memorandum showed a reduction over time in the central funding of NHS dentistry and above-inflationary growth in patient charges for NHS dentistry. These trends have continued up to the latest available accounts for NHS England (2021-22).

NHS Dentistry Funding

5            Dentistry is funded by a combination of payments from NHS England (via the NHS Business Services Authority) and patient charges. The total cost of NHS dentistry in any given year is determined by the amount of activity that is contracted and delivered, minus the income from patient charges. Our 2020 memorandum showed that total funding for NHS dentistry (NHS England costs and income from patient charges ) decreased by 12% in real terms (i.e. after allowing for inflation) from 2014-15 to 2018-19. The majority of this reduction was the result of an accounting change in 2014-15 and 2015-16. After adjusting for the accounting change, total NHS funding for dentistry decreased by 4% in real terms between 2014-15 and 2018-19.

6            This drop was entirely accounted for by the reduction in costs to NHS England. The costs of NHS England to total NHS dentistry funding fell by 10% in real terms over the period. Meanwhile, the contribution from patient charges increased by 12%.

7            There are three further years of NHS England accounts to consider in this update (2019- 20, 2020-21 and 2021-22). These include the period during which most dental practices were closed to limit the transmission of COVID-19. Specifically: "on the 25 March 2020 dental practices were instructed to close and defer routine, non-urgent dental care, including orthodontics and establish remote urgent care services to limit the transmission of COVID-19… Due to the… restrictions the totals regarding activity, patient numbers, finances and treatments are much lower than traditionally expected for the final quarter of 2019-20 and the entire 2020- 21 financial year." 1 The marked impact on income from patient charges in 2020-21 and their partial recovery in 2021-22 are shown in Figure 1.

1 https://digital.nhs.uk/data-and-information/publications/statistical/nhs-dental-statistics/nhs-dental-statistics-annex-5- data-quality#impact-of-covid-19

8            In the three years since 2018-19 the reduction in income from patient charges has been largely offset by increases in cost to NHSE, particularly in 2020-21. However, the total amount of funding available for NHS dentistry in 2021-22 was 5% less than the pre-pandemic average (2014-15 to 2018-19).

Patient charges

9            Primary care dentistry is recorded in Units of Dental Activity, which are paid to dentists whenever they provide NHS treatment. There are four bands of treatment based on the complexity and urgency of treatment required, and these attract different patient charges. Some categories of patients (including children, pregnant women and new mothers, and those in receipt of low-income benefits) are exempt from charges, along similar lines to prescription charges (a difference is that over-60s get free prescriptions but do not automatically get free NHS dental check-ups and treatment). The current bands of patient charges, for those who are not exempt, are shown in Figure 2:

NHS Dental Activity

12        There are several ways to measure NHS dental activity. According to all these measures, NHS dental activity decreased markedly as a result of the COVID-19 pandemic.

Total number of NHS patients seen in England, 2019 and 2022

13        In our 2020 memorandum we noted that 22 million adults were seen by an NHS dentist in the 24 months up to 30 June 2019, and 7 million children in the 12 months up to 30 June 2019. The number of people seen by NHS dentists has reduced since the start of COVID-19. In the 24 months up to 30 June 2022, only 16.4 million adults were seen by an NHS dentist (a reduction of 25% compared with the 24 months up to 30 June 2019). In the 12 months up to 30 June 2022, 5.6 million children were seen by an NHS dentist (a reduction of 20% compared with the 12 months up to 30 June 2019).

Total NHS dentistry activity in England, 2011-12 to 2021-22

14        Total NHS dentistry activity decreased by 6% between 2011-12 and 2018-19, the last full year before the COVID-19 pandemic. Figure 4 shows the absolute reduction in dental activity in 2020-21 and 2021-22, which equates to a 71% and a 31% reduction respectively against the 2018-19 level.

Change in dental activity by patient type and band

15        The overall reduction of 31% in dental activity between 2018-19 and 2021-22 is unevenly distributed by patient type and band of treatment. Figure 5 shows that the greatest reduction has been across band 1 treatments (examinations, diagnosis and advice) for all types of patients and that there is growth only in urgent treatments for non-paying adults and children.

Contracted NHS dental activity compared with delivered NHS dental activity

11              Our previous memorandum examined the difference between contracted NHS dental activity and what dentists actually delivered in 2018-19. We did this by matching postcodes in the contracting and activity datasets. Figure 7 shows the situation in 2018-19 and gives an update for 2021-22. The contracted amounts are similar in these years, in 2018-19 there were

86.7 million contracted UDA's and in 2021-22 there were 87.0 million. The total amount delivered in 2018-19 was 83.1 million and in 2021-22 was 57.1 million UDAs. As in 2018-19, there remains variation in the activity delivered compared with contracted amounts. In 2021-22, a higher proportion of practices were delivering less than 50% of what they had been contracted to deliver. The commonest amount to deliver was between 65% and 69%, whereas in 2018-19 this had been between 100% and 104%. Annex 1 shows separate charts for each year with their values, as well as a comparison between areas.

NHS Dentistry Workforce

17        In 2020, we noted that the UK had a relatively low number of dentists per head of population compared with other advanced European economies, and that England had the lowest number of NHS dentists per head of population in the UK. This assessment is unchanged by the latest statistics.

International comparison

18        Figure 8 shows the OECD statistics for the four European countries which are also members of the Group of Seven (G7). These four countries have all submitted statistics between 2013 and 2020. The UK, France and Germany show the same level of absolute growth (1 dentist per 100,000 population) but from different starting points. The UK reported a headcount of around 36,000 practising dentists in 2020 (excluding dentists who work exclusively in the private sector), equivalent to 5.4 dentists per 10,000 population. This represents a slight growth in the headcount of dentists compared to the UK population back in 2013, when it had 5.3 per 10,000 (around 34,000 practising dentists).

population than other UK nations. Updating the comparison requires several caveats, but the available information points to the same conclusion as in 2018-19. First, the necessary caveats for primary care dentistry in England are that the response to the COVID-19 pandemic included the closure of dental practices in England on 25 March 2020 and their reopening on 8 June 2020. NHS Digital has noted that this closure potentially meant that not at dental practitioners returned to primary care dentistry during 2020-21, which may have contributed to the decrease in the overall dental headcount figure for that year:

• In 2018-19 there were 24,545 dentists with recorded NHS activity in England.
• In 2020-21 there were 23,733 dentists.
• In 2021-22 there were 24,272 dentists.

For 2018-19, this means there were 4.4 NHS dentists per 10,000 population in England. For 2021-22, this had reduced slightly to 4.3 per 10,000 population.

20        Scotland has paused publication of its workforce statistics, but it reported 6.2 dentists per 10,000 population in 2018-19. Northern Ireland data for 2021-22 shows the same number of dentists per 10,000 population as in 2018-19 (6.0 per 10,000 population) and in Wales, there was a decrease from 4.8 in 2018-19 to an estimate of 4.5 in 2020-21.2 Based on the latest available data, relative to population England continues to have the lowest number of primary care dentists in the UK.

2 NAO estimate based on 2020-21 NHS Wales primary care dentist workforce information and ONS 2020 mid-year population estimate for Wales.

Patient satisfaction with NHS Dentistry

21        Of people surveyed through the GP Patient Survey in 2019, and who had tried to get an NHS dental appointment in the past 2 years, 85% responded that their experience of NHS dental services was good (either 'very good' or 'fairly good') and 7% that it was poor (either 'fairly poor' or 'very poor'). The proportion having a good experience decreased in the latest survey results, for 2022: 72% responded that their experience was good, while 16% described their experience as poor. Figure 9 shows the national responses.

Annex 1

1              Figure 7 in the main briefing compares the delivery of contracted NHS dental activity in 2018-19 and 2021-22. Figure 11 and Figure 12 below show the analysis for each year separately, with values.

in the delivery of contracted NHS dental activity in the constituencies with the highest and lowest percentages.

March 2023