Written evidence submitted by The Healthwatch England (FND0013)

 

About Healthwatch 

  1. Healthwatch England is the independent, statutory and national champion for people who use health and care services. We were launched in 2013 – along with a network of 153 local Healthwatch – to ensure that those who run local health and care services understand and act on what really matters to people. Our remit covers all NHS services and publicly funded adult social care services in England.
  2. A local Healthwatch operates in every area of England, commissioned by every local authority. At a national level we provide guidance, training and support to the local Healthwatch network and collate the evidence they collect from communities to help track trends in the public’s experiences of services.
  3. We exist as a sub-committee of the Care Quality Commission but are operationally independent from the regulator and hold direct relationships with our sponsor department, the Department of Health and Social Care (DHSC).
  4. Healthwatch England is also a statutory consultee on the NHS Mandate, usually produced annually by DHSC.

Submission overview

  1. This submission covers:
    - a summary of previous evidence we shared with inquiries by the National Audit Office (NAO) and Health and Social Care Committee (HSCC) into, respectively, the NHS Dental Recovery Plan and NHS Dentistry;
    - commentary on the three key lines of PAC’s inquiry (the dental contract, falling dental numbers, and spending on dentistry), which reference new public polling we carried out during 2024 to help measure the impact of the recovery plan and public understanding of the way NHS dentistry works, as well as other latest evidence from people and the local Healthwatch network.
    - a summary of our key policy recommendations for the future of NHS dentistry.

Our role in the National Audit Office and parliamentary inquiries on dentistry

Health and Social Care Committee inquiry on NHS Dentistry

  1. Healthwatch England gave oral and written evidence to the HSCC’s inquiry on NHS Dentistry in 2023. We described that while difficulties accessing NHS dental appointments had been raised with us since we were launched, the problem was exacerbated during the pandemic. It was now the second highest reported problem to us (after GP access).
  2. Our evidence also showed that that the NHS dental crisis was also a social justice issue, exacerbating inequalities already experienced by certain parts of the population. Some people could not afford NHS dental charges, or to travel long distances to out-of-area practices that had NHS availability, and private treatment was out of their financial reach. Children were starting school having never seen a dentist and were being sent to hospital in record numbers for teeth extractions. Women entitled to free dental treatment under maternity exemptions, could not experience this benefit because they could find no dentists able to take them on during the eligible period.
  3. We called for the system to be reformed so people could register and stay with a dentist in the same way as they did with GPs.
  4. We welcomed the HSCC’s inquiry report in July 2023 that recommended that ‘the Department should reinstate the requirement for patients to be registered with an NHS dentist’.
  5. Healthwatch England was invited to return to the HSCC for a one-off session in March 2024 to give evidence, following the launch of the Dental Recovery Plan by the (previous) Government. We highlighted that people living in ‘dental deserts’ were driven to desperate DIY measures, which in one case had led to a person overdosing on borrowed painkillers because of untreated dental problems. We also called for better promotion of new NHS appointments for people not seen in the past two years, being offered through the recovery plan’s new premium payment to dentists.

National Audit Office inquiry

  1. We attended a roundtable held by the NAO to inform its investigation into the NHS Dental Recovery Plan. We shared our concerns that it had transpired that funding for the plan had not been new, as initially suggested by DHSC, and that it was unclear how the DHSC and NHS England (NHSE) were evaluating the plan’s success.
  2. We were also still unclear whether the new Labour Government would retain any elements of the Dental Recovery Plan, and how it planned to deliver its election pledges to provide an extra 700,000 urgent dental appointments on the NHS, through its own ‘Dental Rescue Plan’.
  3. The NAO’s report, published in late November 2024, was the first time we had seen any DHSC or NHSE figures on the impact of the new patient payment, despite us raising questions in our regular meetings with officials. The report’s confirmation that the payment had failed to deliver, in its first seven months, over and above the number of appointments offered to new NHS patients compared to the same period last year, was similar to our own conclusions. These were made after we conducted new research aiming to evaluate the early impact of the plan, details of which were published a few days before the NAO report, and which is referenced more fully below.

Our evidence for PAC’s three lines of enquiry

The dental contract

  1. Healthwatch England has consistently called for reform of the dental contract, given the twin crisis of access and affordability experienced by the public. In particular we want to see a permanent link restored between patients and dental practices.
  2. Despite nearly 20 years passing since people lost their right to register with an NHS dentist, when a new NHS dental contract was introduced in 2006, people still misunderstand this system. The contract moved to paying dentists per ‘unit of dental activity’, which meant that practices had no long-term obligation to keep seeing patients on the NHS unless they were undergoing active treatment or completed treatment was still under guarantee. People were ‘free’ to shop around for care at any dentist when seeking new NHS check-ups or treatment.
  3. But a nationally representative poll of 1,981 adults we commissioned in September 2024, showed that over two-thirds (68%) of respondents mistakenly believed they had the right to register with an NHS dentist as they did with an NHS GP. This misconception was held more (73%) by younger adults (18-34s) compared with people aged over 55 (64%), people from ethnic minority backgrounds (73%) compared with people from White backgrounds (67%) and people with a disability or long-term condition (72%) compared with those without (66%).
  4. These misconceptions can result in conflict between patients and dental practices when dentists choose to give up the NHS contract to focus on private work. This has become increasingly common, according to British Dental Association survey findings reported in 2023, that found one half of dentists in England (50.3%) had reduced their NHS commitment since the start of the pandemic, and by 27% on average.
  5. Because people mistakenly think dentists work like GPs, and know that GPs can’t remove them as patients (except in limited circumstances), then they can be distressed when a dentist ‘de-lists’ them and think that a practice has breached their ‘rights’.
  6. Even when patients understand that dental practices operate differently from GPs, they are often disappointed to lose a relationship with a trusted and known health professional if their dentist gives up NHS work. And unlike with GP practices, they don’t get guaranteed help from an integrated care board to place them with a new practice seeing NHS patients – they are left to find this themselves, often without success, as illustrated in this story shared with Healthwatch South Tyneside:
    “I have been registered at the [name removed] Dental Care practice for over 50 years and I have always regularly had check-ups and treatment when necessary. I was notified by [the practice] in April this year that with effect from 1st August the practice was only offering Private Treatment Plans. I have been unable to find a dentist in South Tyneside willing to accept me as an NHS patient.” 
  7. This misunderstanding about the way the NHS dental system may also be preventing people from adequately preparing for the potential loss of their regular NHS dentist, through alternatives such as dental insurance. These alternatives will be limited though, to those who receive workplace insurance, or those who earn enough to fund private treatment.
  8. In our September poll, we also asked people their preference from a range of theoretical options on how they wanted to access NHS dentistry in the future. The most popular option, selected by 54% of respondents, was ‘to be able to register with an NHS dentist as a permanent patient in the same way as they can with an NHS GP’. Only 27% supported an option describing the current situation of having ‘the flexibility to seek an appointment at any NHS dentist each time, including those outside my local area’.
  9. We believe our evidence, and the unpopularity of the contract with the dental profession, shows why fundamental reform is required, particularly to give people the right to permanently register with a practice.

Falls in the numbers of dentists

  1. We have heard from other stakeholders that the overall number of qualified dentists in England is not the key problem – it’s the number of those willing to take on NHS work, and to work in the most under resourced areas. Our polling and other evidence from the public illustrates the problems that this causes.
  2. Our September 2024 poll was the second of two polls, carried out six months apart, asking mainly the same set of questions about people’s access to NHS dentistry. This was our attempt to provide initial evaluation of the Dental Recovery Plan. The first polling was carried out for us at the beginning of March 2024, when the plan’s new patient payments were first introduced.
  3. The proportion of people who said they’d attended an NHS dentist appointment in the past two years stayed the same – at 60% - from March to September. We know now from the NAO report that the number of new patients seen was not any higher than the previous period the year before, despite the new incentive payment offered to dentists of £15 or £50.
  4. A breakdown of the polling figures showed access was lower in already known ‘dental deserts’ of the South West and Eastern regions and slightly higher in urban areas like London and the West Midlands. This affects existing and new residents, as this story shared with Healthwatch Norfolk, describes:

‘Not able to register as an NHS patient with a dentist in or near Norwich since moving to Norwich in March 2022. None accepting new NHS patients. As a result, am still travelling to Wakefield in West Yorkshire where I was already registered for dental care.’
However we hear from many people without their own car, good public transport links or the funds to pay for either, that travelling out of area to receive dental care is not an option.

  1. While it is encouraging to hear that dentists are taking up the ‘golden hello’ schemes introduced through the recovery plan, it still remains difficult for patients to get timely information on whether local practices have begun to see more new NHS patients. The Find a Dentist tool on the NHS website – for which practices are contractually required to keep their access details up to date – has changed its wording, from ‘accepting new NHS patients’ to ‘accepts new patient when availability allows’. Local Healthwatch tell us the public is confused by this and still have to ring around practices to check. The Find a Dentist tool is not linked to live practice appointment systems and even the NHS 111 helpline service – which is supposed to locate urgent dental care for people without a regular practice - often refers people incorrectly to practices without capacity because it doesn’t hold centralised, up-to-date information on availability. We have even heard in some areas of urgent appointments being funded through local incentives schemes, going unfilled, because patients don’t know how to access them.

 

 

The current picture on Government spending to support access to NHS dentistry. 

  1. We have previously raised concerns about lack of transparency on spending of NHS dental budgets by integrated care boards, which makes it harder for local stakeholders – including local Healthwatch, MPs and councillors - to inform local people, when or if, any improvements to NHS dental access will occur, and trying to hold ICBs to account over efforts to adopt flexible commissioning of dentistry services.
  2. The Dental Recovery Plan pledged to ‘strengthen oversight of funding’ by requiring NHSE to meet with and collect monthly returns from all ICBs to establish current and planned spend. But many local Healthwatch tell us they have been unable to get this data from their ICBs and we have seen in previous years, this information only being made available via Freedom of Information requests.
  3. NHSE’s 2025-26 planning and operational guidance sets a national target to deliver the Labour manifesto commitment of 700,000 extra urgent dental appointments. But at the same time, NHS England’s revenue, finance and contracting guidance for 2025-26, states that ‘exceptionally, the unspent [ringfenced dental] allocation may be returned to NHS England’. This raises the prospect of yet again, underspent budgets being used to balance wider NHS budgets.
  4. The finance guidance also newly proposes allowing ICBs to relax the ringfence around their dental budget to spend it on other local NHS services, if they can demonstrate that they’re delivering their share of the 700,000 extra urgent appointments and improving dental access more generally.  This appears to confusingly suggest that full dental budget allocations can more than meet the aspirations to improve access to urgent dental care, when evidence from patients suggests the contrary.
  5. It also appears strange that ICBs have still yet to be told what their expected contribution to the 700,000 target will be, more than six months after the Government came to power.

Patients’ concerns with NHS dental charges and affordability

  1. The final evidence we are submitting concerns people’s awareness of and views on NHS dental charges. In our September 2024 poll, one in five (20%) people who’d seen an NHS dentist in the past two years, said they had had difficulties finding information about NHS dental fees. Similarly, 19%, believed they were charged more than advertised NHS dental charges.  Younger people, 18-34, and people from ethnic minority groups were more likely to believe they were charged more for dental care
  2. Meanwhile, one in seven (15%) of people who had seen an NHS dentist in the last two years felt pressured to pay privately.  This story shared with Healthwatch Lancaster describes a scenario that causes anxiety for people on low incomes:
    ‘I'm on benefits and can access free dental treatment because of this. I was sent an appointment for a scale and polish which the dentist has done for many years, this time it was the dental nurse, and I was told that they would be doing it from now on. After the appointment they charged me £58 and told that this is no longer a free treatment.
    However, no one told us this beforehand and it was a lot of money to find. Charges should be made clear before any treatment/appointments, as if I'd known I wouldn't have gone.’
  3. In a separate cost-of-living poll we conducted in January 2024, we found that 21% of people were put off going to the dentist because of cost, up from 15% in a similar poll in 2023.  People experiencing the greatest financial pressures were more likely (40%) to avoid the dentist, compared to just seven per cent who were ‘very comfortable’.
  4. We were disappointed that NHS dental charges rose by four per cent in 2024, especially after they had risen by a record 8.5% the year before.
  5. People who are not entitled to free dental care on medical or income grounds, can apply for partly funded help towards NHS dental costs through the NHS Low Income Scheme. But we believe this scheme requires much greater promotion by the NHS to reach all those who could be eligible.

Our recommendations

In conclusion, Healthwatch England seeks a range of reforms to radically improve the public’s access to NHS dentistry, particularly for those already experiencing wider health or socioeconomic inequalities. In particular we call for:

January 2025