Written evidence submitted by the Association of Dental Groups (CBP0014)

Introduction

 

  1. This submission from the Association of Dental Groups (ADG) responds to the Health and Social Care Committee call for written evidence for its inquiry into clearing the backlog of care caused by the pandemic period.

 

  1. The Association of Dental Groups (ADG) is the trade association for large dental providers in the UK. Our members include 20 of the largest groups of dental practices in the country, representing over 10,000 clinicians delivering NHS and private dentistry to more than 10 million patients every year. 

 

  1. ADG members represent corporate, group and community interest companies delivering a wide range of oral healthcare, be this commissioned through General Dental Contract (GDS) services or local authority and community oral healthcare programmes.  Our response comments on three of the questions posed by the inquiry; What is the anticipated size of the backlog of oral healthcare?  What is the capacity and staff available to address the backlog? and how might NHS dentistry change to address the backlog?

 

 

What is the anticipated size of the backlog of oral healthcare?

 

  1. A number of estimates of the backlog of oral healthcare have been made which we have referenced below.  In December 2020 the ADG published commissioned research[1] using government data to estimate the number of patients who would be waiting for treatment compared to throughput in a normal year in England.  For ease of reference for parliamentarians the data was aligned to parliamentary constituencies and figures for members of the Health Select Committee are given below.

 

Constituency

Normal throughput by December 2020

“Central” scenario of patients waiting at December 2020

South West Surrey

17,738

9,484

Peterborough

21,430

11,761

West Lancashire

20,485

10,611

Bosworth

20,887

10,601

Ealing North

25,062

14,981

Coventry North East

25,896

14,245

Luton North

19,590

10,986

Watford

25,716

14,139

Sevenoaks

16,571

8,973

 

 

  1. The ADG’s central assessment of patients untreated who would have usually had care in England by December 2020 was just over 10 million.  The British Dental Association (BDA) estimated that in November 2020 19 million fewer dental procedures  (not patients) had been delivered in England compared to the previous year.

 

  1. Further concerning data for England was published in the February 2021 NHS Dental Statistics Biannual report for England 2020-2021.[2] The statistics reveal that overall, 3.6 million children were seen by an NHS dentist in the 12 months up to 31st December 2020, which equates to 29.8% of the child population. This compares to 7 million children seen by an NHS dentist in the 12 months up to 31st December 2019[3], which was 58.4% of the child population. The British Dental Association (BDA) estimates that up to 9 million children could now have gone without care they would have previously received pre-pandemic.[4]  Data for Scotland published in February 2021[5] indicated that between May and December 2020 the number of children seen was a quarter of the previous year’s average.  Northern Ireland data published in June 2021[6]  showed a 57% fall in children receiving treatments on the previous year. Although not directly comparable this data confirms the overall dramatic effect of the pandemic on oral healthcare for children during 2020.  Taken together with the suspension of supervised toothbrushing in schools and other early year settings, the loss of preventative care, advice and good habit forming to prevent dental decay for a cohort of young children across the UK over the past two years is a hidden consequence of the pandemic.

 

  1. It should be noted that the causes of the “backlog” are several and evolving.  The complete closure of England’s dental practices in the first lockdown (except for a network of 600 urgent care centres) had the most significant impact on providing routine treatments and appointments.  This continues to be compounded by the reduced capacity that dental practices are operating under the infection prevention and control guidance (IPC) since reopening.  NHS delivery targets are currently set at 60% of normal activity and our feedback is that current IPC requirements are constraining practices from achieving much more than this level (see also paragraph 8).  Since reopening in July last year it has taken time for patients to regain confidence and as with GP services we have seen people presenting for care in 2021 who in normal circumstances would have presented earlier.  Before the pandemic NHS dental services only provided care to approximately 50% of the adult population and 60% of 0-17 population[7].  For this reason the role of private dentistry in whole population oral health should not be overlooked.  Some patients will have gone private who previously were seen on the NHS, although of course private dentistry is subject to the same IPC restraints. However, we fear that many of the most vulnerable and low income groups will have not sought any treatment at all.  We have evidenced during 2020 a rise in “DIY dentistry”[8] which will now add to an “overhang” of oral healthcare from 2020/21 in all four nations of the United Kingdom. 

 

What is the capacity and staff available to address the backlog?

  1. Upon reopening of service in July 2020 IPC guidance stipulated a “fallow time” of 60 minutes between AGP treatments to allow potentially infectious droplets and aerosols to clear from the air.  Following the work by Scottish Dental Clinical Effectiveness Programme (SDCEP) which led to publication of “Rapid Review into the Mitigation of Aerosol Generating Procedures[9] this has been reduced by several ventilation mitigations and the current “fallow time” requirement can be lowered to 10 min with 10 air changes an hour or 30 minutes without additional ventilation with a range of times between depending on ventilation and additional mitigating factors such as high volume suction or rubber dam [10]. A number of minor revisions to increase throughput have subsequently been made.  However, this still considerably curtails the capacity of the NHS estate and will inhibit recovery of the backlog of outstanding care. Many dentists have had to undertake building works to premises and install ventilation equipment without financial support. It should be noted that compared to many other countries the UK’s requirements for ventilation and fallow time still remains at the higher end of the scaleIPC guidance will continue to constrain clinicians ability to treat the pre-pandemic volume of patients.

 

  1. Many of the other difficulties impacting NHS dentistry predate the pandemic and will exacerbate recovery unless they are addressed.  Contract reform has been mooted for the past decade through the “prototype” contracts but not taken forward by the Department of Health & Social Care.  However, we welcome the renewed desire by the current Minister as stated in the last letter to the profession for national contract reform[11].  A new contract with a greater emphasis on preventative dentistry which will improve oral health outcomes is likely to enjoy the support of the profession and staunch the outflow of clinicians reducing their NHS commitment or leaving the NHS due to dissatisfaction at current ways of working within the UDA model.  Increasing the flexibility to target particular “local needs” will be key and align with the desire to see more integrated care systems.

 

  1. One of the more welcome unintended consequences of the pandemic has been the lifting of the “cap” on medical and dental school places for both September 2020 and 2021[12].  The ADG has recommended to Government a national recruitment campaign with higher targets to recruit more dentists.  However,  it takes over five years to fully train an NHS dentist and continued funding will have to be provided for future foundation training.  The pressures on the whole NHS workforce are well understood by this Committee and it hardly needs saying that if the cap on dental school places falls back in coming years it will demonstrate a lack of political commitment to investing in the future health and social care workforce.  This is one reason why it is paramount that the Health and Care Bill  should require an annual workforce report to Parliament.
  2. The overseas workforce is also at risk of drying up.  In 2020 UK qualified new registrants with the General Dental Council (GDC) formed 66% - the remaining 34% of new registrants from EEA countries or other overseas routes to registration[13]Now that Brexit has been completed, mutual recognition of EEA countries qualifications falls away at the end of 2022 when new overseas registration or mutual recognition processes are expected to have been established to maintain recruitment.  The flow of overseas professionals from other countries during 2020/21 has effectively halted as the examination they are required to take to register has been suspended during the pandemic period.  New overseas recruitment pathways quickly need to be identified and existing overseas registration examinations resumed and streamlined.
  3. As with many sectors, the impact of the pandemic has resulted in individuals reassessing their careers and changing employment and the impact of this can be seen in difficulties to recruit dental nurses and other members of the dental team.  The 2020 registration report published by the GDC[14] this August showed overall registration remained stable, but Dental Care Professionals (DCP) non-renewal or voluntary removal increased by 5%, confirming that some members of the team are now choosing to exit the profession.
  4. Our submission is that recruitment into dentistry and the allied professions could be facing a perfect storm in 2022 as we try to recover the “overhang” of oral health needs.  We are seeing evidence from our members workforce survey that long standing dentists and others are retiring early or exiting NHS dentistry due to the pressures of ways of working and the unfit nature of the current contract (this churn will not be picked up yet by GDC registrant figures) and overseas recruitment is unlikely to make good the shortfalls.  This means the difficulties in getting access to NHS dental care could get worse before it gets better, and the damage done by the pandemic may be permanent for many.

 

  1. This has been borne out by NHS statistics published on 26th August 2021, which show a decrease of 951 dentists with NHS activity in England in 2020-21[15] across all regions.

 

How might NHS dentistry change to address the backlog?

  1. Healthwatch England, the patient watchdog has carried out two surveys on patient access when they observed that complaints regarding access to dentistry rose markedly (fivefold from the previous three months) between July and September 2020[16] identifying the difficulties that dental practices were still facing in resuming routine care, and as a consequence, the difficulties patients were finding in accessing care.   A further review was carried out in May 2021[17].  These surveys have contributed to policymakers and NHSE now considering dental system reform and trying to identify “quick wins” which can be made within existing contractual arrangements.

 

  1. The pandemic has highlighted the failing of the current system to be able to provide urgently needed care, particularly for patients not with an NHS dentist or living within one of the emerging “dental deserts”.  As referenced above during the first lockdown a network of 600 “UDCs” were established but this was far from adequate.  The ADG put forward a detailed proposal to NHSE  that  through “flexible commissioning” emergency slots could be provided on a daily basis which could be done via NHS111 services seeking treatment, providing a more integrated service.  Allowing the whole team more flexibility to work within their scope of practice is another option that could increase access.

 

  1. Looking beyond quick wins that can be made all four nations have recognised the need for contract reform coming out of the pandemic.  Wales has led the way with the introduction of new a unit of measurement, “the ACORN”[18] which develops an annual individual plan for patients and has been widely welcomed as placing a more preventative emphasis on treatment and care.  Both Northern Ireland and England have also set up advisory groups to look at dental system reform within the current constraints of existing contracts and with ambition for legislative change.

 

  1. In the longer term, water fluoridation will be the single most effective “whole population” public health measure this Government could take to improve the oral health of future generations.  Thousands of children could soon require hospital operations (waiting times for dental anaesthetic have been seriously curtailed[19]) to remove unsavable teeth due to the pandemic.  Before the pandemic, hospitals in England were already carrying out an average 177 operations a day on children and teenagers last year to remove teeth, costing the NHS more than £40m[20]. Water fluoridation requires no behaviour change and the evidence shows it is highly effective in preventing dental disease. It is estimated by the British Society of Paediatric Dentistry (BSPD) that water fluoridation could reduce this by as much as two thirds in the most deprived areas[21].  It is a public health intervention of most benefit to those parts of the country the Government says it wishes to “level up”.

Concluding comments

  1. The dental profession has seen a wave of unmet and rising demand for care as a consequence of the three month cessation of provision which has to be the priority for NHS Dental Services and the profession in the next 12 months

 

  1. Recruitment into dentistry and the allied professions could be facing a “perfect storm” next year as we try to recover the “overhang” of oral health needs without sustained commitment to more UK dental school places and new agreements for the mutual recognition of overseas professional qualifications before the end of 2022.

 

  1. Existing IPC guidance will continue to constrain clinicians ability to treat the pre-pandemic volume of patients and needs to be under ongoing review.

 

 

 


[1] MPs write to Matt Hancock as research reveals worst-hit constituencies for access to dentists – Association of Dental Groups (theadg.co.uk)

[2] NHS Dental Statistics for England 2020-21, Biannual Report - NHS Digital

[3] NHS Dental Statistics for England 2019-20, Biannual Report - NHS Digital

[4] Press releases Support needed as 9 million children miss out on care (bda.org)

[5] Dental statistics - registration and participation - Statistics as at 30 September 2020 - Dental statistics - registration and participation - Publications - Public Health Scotland

[6] General Dental Services Statistics (hscni.net)

[7] Dentistry in England - National Audit Office (NAO) Report

[8] Dentists set for post-Covid ‘horror show’ as millions of Brits pull own teeth out during lockdown – Association of Dental Groups (theadg.co.uk)

[9] Mitigation of Aerosol Generating Procedures in Dentistry - A Rapid Review (sdcep.org.uk)

 

[10] COVID-19: infection prevention and control dental appendix (publishing.service.gov.uk)

 

[11] Letter template (england.nhs.uk)

[12] Extra places on medical and dentistry courses for 2021 - GOV.UK (www.gov.uk)

[13] Registration statistical report 2020 (gdc-uk.org)

[14] Registration statistical report 2020 (gdc-uk.org)

[15] NHS Dental Statistics for England - 2020-21 Annual Report - NHS Digital

[16] COVID-19 pandemic pushes NHS dentistry to crisis point, finds new report | Healthwatch

[17] Twin crisis of access and affordability calls for a radical rethink of NHS dentistry | Healthwatch

[18] Eich cyf (bda.org)

[19] Waiting-times-for-dental-treatment-under-general-anaesthetic-150920.pdf (bda.org)

[20] 180 operations daily to extract children's decayed teeth – Dentistry Online

[21] BSPD Press Release - White paper 8 Feb 2021 final.pdf

 

 

 

 

 

 

Sept 2021