Written evidence submitted by The Faculty of Dental Surgery the Royal College of Surgeons of England (CBP0022)

 

Summary

 

  1. The Faculty of Dental Surgery at the Royal College of Surgeons of England welcomes the opportunity to submit evidence to the Health and Social Care Committee’s inquiry into clearing the backlog caused by the pandemic. The focus of this submission is on the need to tackle the backlog of care within dentistry, drawing on the findings of a recently published survey of our members. We recognise that the Committee’s focus is on elective care, emergency care, General Practice, mental health and long-COVID but would be keen for it to examine the challenges facing dentistry in detail, potentially by revisiting an inquiry into NHS dentistry which began just before the last general election but could not be completed.

 

  1. The findings of our survey suggest a significant backlog has developed in dentistry, with 37% of our members in England saying this will take at least a year to clear – this rises amongst those working in NHS hospital practice (41%), NHS general practice (49%) and community dental services (62%). Our members are also seeing fewer patients than before the pandemic, creating a risk that the backlog will continue to grow as new patients come forward for treatment. We are particularly concerned about the impact of long waits on children and vulnerable adults such as patients with special educational needs.

 

  1. The majority of our members (52%) highlighted the requirement to leave a period of “fallow time” between patients after finishing an aerosol generating procedure as a barrier to treating more people. Social distancing requirements (48%), limited availability of theatre and surgery space (30%), inadequate ventilation (27%) and staff shortages (26%) were also cited by significant numbers of respondents. Fallow times have been a key part of maintaining safe, COVID-secure environments during the pandemic but do limit dentists’ capacity to see patients, so the requirements should be kept under constant review and if evidence emerges justifying a change this needs to be communicated as quickly as possible. Improvements to ventilation in dental settings can also help reduce fallow times – capital funding to support better ventilation has been announced in Wales, Northern Ireland and Scotland, but not to date in England.

 

  1. Tackling the backlog also requires a sustainable dental workforce which can meet patient need now and in the future. However, our survey suggests pressures on the workforce are building in a number or areas. 28% of respondents say they will reduce the number of sessions they work in the next five years, 16% plan to retire in this period, and 11% intend to leave the profession before retirement age.

 

  1. There has been a significant fall in dental attendance during the pandemic, which makes preventing oral health problems more important than ever. There was strong support amongst our membership for a range of preventative initiatives. It is now vital that Government fully delivers on previous policy commitments to restrict junk food advertising, expand community water fluoridation initiatives, extend the provision of supervised tooth brushing schemes in England and update the School Food Standards.

 

Introduction

 

  1. The Faculty of Dental Surgery at the Royal College of Surgeons of England (“the Faculty”) welcomes the opportunity to submit evidence to the Health and Social Care Committee’s inquiry into clearing the backlog caused by the pandemic. The Faculty is a professional body committed to enabling dental surgeons to achieve and maintain excellence in practice and patient care. We represent around 5,000 specialist dentists who provide patient care in primary, secondary and community care settings, as well as holding key public health roles. We also campaign on public policy issues relevant to dentistry such as the need to tackle child tooth decay, which has been the leading cause of hospitalisations for five to nine year olds for a number or years.[1]

 

  1. In this submission we highlight the backlog which has developed within dentistry as a result of the disruption caused COVID-19. When the pandemic first struck, routine dental services were suspended, and treatment was only available for those experiencing a dental emergency through a network of urgent care centres. Routine treatment was allowed to resume in England on 8 June 2020, although dental professionals continue to operate under infection prevention and control protocols to limit the risk to themselves and their patients from COVID-19.

 

  1. One year on from the resumption of routine treatment, the Faculty recently undertook a survey of its members to understand the scale of the backlog that has built up, and the challenges that they are still facing in providing dental care. The results of this survey, presented here for England, form the basis of this submission.[2]

 

  1. We recognise that the Committee has indicated that this inquiry will focus on elective care, emergency care, General Practice, mental health and long-COVID. However, there are particular challenges facing dentistry as a result of the pandemic, and we would be keen for the Committee to examine these in detail. Shortly before the last general election the previous Health and Social Care Committee began an inquiry into NHS dentistry, although this could not be completed before the dissolution of parliament and ultimately did not report. Since then the challenges facing dental professionals and their patients have only become more acute. The Faculty therefore believes there is a strong case for the Committee to revisit the issue of NHS dentistry, potentially through a new inquiry. We would be happy to work with the Committee on this, if a new inquiry was something it was interested in taking forward.

 

Dental backlog

 

  1. A significant care backlog appears to have developed within dentistry as a result of the pandemic. In the Faculty’s recent survey of dental specialists, 37% of respondents from England told us that they anticipated that it would take them at least a year to clear the backlog of patients currently waiting for treatment.[3] Half of this group – 17% of all respondents from England – told us it would take at least two years.

 

  1. There was also variation in the scale of the backlog across different types of dental setting. The proportion of respondents who said it would take at least a year to clear the backlog was higher than average amongst those working in settings such as NHS hospital practice (41%), NHS general practice (49%) and community dental services (62%). It was considerably lower amongst those working in private practice (11%).[4]

 

  1. The challenge posed by the dental backlog is reinforced by NHS England’s latest patient waiting times statistics, which provide data about the number of patients waiting specifically for an oral surgery procedure. This shows that 21,461 patients were waiting a year or more for oral surgery in June 2021 (this represents 7% of all those waiting at least 52 weeks for an elective surgical procedure). Furthermore, 389 patients were waiting two years or more for oral surgery (7% of all those waiting at least 104 weeks for an elective procedure).[5]

 

  1. Moreover, the results of our survey also suggest that the Faculty’s members are able to see considerably fewer patients than before the pandemic, due to constraints on patient throughput (we discuss these in more detail in the next section on barriers to treatment). Just 17% of respondents in England told us that they currently see more than ten patients per session – by comparison, 46% of our members were able to see more than 10 patients per session before the pandemic.[6] Consequently, there is a risk that the existing backlog of patients will continue to grow, as new patients coming forward for treatment cannot be seen as efficiently as before.

 

  1. In addition, there has been a notable fall in dental attendance during the pandemic, meaning there is potential undiagnosed need which has yet to present. The latest NHS Dental Statistics for England show that in the 12 months to 30 June 2021, just 33.7% of children aged 0-17 saw and NHS dentist – this compares to 52.9% of children in the 12 months to 30 June 2020. There was also a decline in the number of adults who visited an NHS dentist (measured over a two year period). 42.0% of adults saw an NHS dentist in the 24 months to 30 June 2021, compared to 47.9% in the 24 months to 30 June 2020, and 50.9% in the 24 months to 30 June 2019.[7]

 

  1. Patients waiting for dental treatment are often in pain, making it difficult to eat and sleep, and delays to procedures can lead to a deterioration in their condition and ultimately mean more complex treatment is required. The Faculty is particularly concerned about the impact of long waits for treatment on children and vulnerable adults, such as patients with special education needs. 26% of our members in England told us that the majority of patients on their waiting lists were children – this was particularly pronounced in specialities such as orthodontics and paediatric dentistry, which generally treat younger patients.

 

  1. Addressing the backlog in elective surgery has rightly been identified as a key priority as health services recover from the pandemic. However, the Faculty urges Government and policy makers not to lose sight of the significant challenges that dentistry also faces as a result of COVID-19, and the impact that long waits for dental care have on the health and wellbeing of dental patients.

 

Barriers to treatment

 

  1. In order to understand the challenges that our members are encountering in delivering dental care, we asked them about the main barriers they face to seeing more patients. The majority (52%) of respondents in England highlighted the requirement to leave a period of “fallow time” between patients after completing an aerosol generating procedure (these are dental procedures which create airborne particles, such as those involving the use of dental drills or scaling and polishing devices). Other factors cited by our members included social distancing requirements (48%),[8] limited availability of theatre or surgery space in which to undertake procedures (30%), inadequate ventilation in the dental setting which can prolong fallow time between patients (27%) and staff shortages (26%).[9]

 

  1. A review by the Scottish Dental Clinical Effectiveness Programme, which has informed infection prevention and control guidance across the UK, has advised that a minimum fallow time of 10 minutes should be left between patients after an aerosol generating procedure is completed. However, this is dependent on the mitigations that are in place, and a longer period may be required if ventilation in the dental setting is poor or suction is not used during the procedure.[10] Our survey found that 35% of Faculty members in England are managing fallow times of at least 20 minutes, with 11% saying they leave at least 30 minutes between patients after completing an aerosol generating procedure.[11]

 

  1. Fallow times are a key part of the measures that have been put in place during the pandemic to ensure safe, COVID-secure environments for dental professionals and their patients. However, it is clear from the findings of our survey that they also significantly limit dentists’ capacity to see patients. The Faculty therefore believes that the requirements around fallow times in dental settings should be kept under constant review, and if evidence emerges which justifies a change this must be communicated to the dental profession as quickly as possible.[12]

 

  1. In addition, supporting dental settings to implement mitigations enabling them to reduce fallow times, such as improvements to ventilation, is also crucial. Capital funding to enable dental practices to upgrade their ventilation systems has been announced in each of the devolved nations. The Welsh Government announced £450,000 of support for dental practices in December 2020,[13] the Department of Health in Northern Ireland announced £1.5 million of funding in February 20201,[14] and the Scottish Government agreed to commit £5 million to enable ventilation systems to be upgraded in June 2021.[15] To date no equivalent funding has been announced in England. The Faculty urges the Governments of all four UK nations to continue to do all they can to support dental settings to improve ventilation as part of the recovery of services, as this represents a key enabler of patient throughput.

 

Workforce

 

  1. Tackling the backlog in dental care also requires a sustainable dental workforce that can meet patient need now and in the future. Our survey has highlighted that for many of those in dentistry, the experience of working through the pandemic has been the most difficult of their professional lives, and concerning workforce pressures are building in a number of areas. 28% of respondents in England indicated that they are planning to reduce the number of sessions they work over the next five years, and 25% said they would reduce the amount of NHS work they undertook. Furthermore, 16% suggested that they would retire during this period, and 11% said they planned to leave the profession before retirement age.[16] It is therefore vital that we support those who are considering leaving the profession in the coming years, as well as dental professionals at an early stage in their careers whose development will have been significantly impacted by the pandemic.

 

Prevention

 

  1. Given the significant fall in dental attendance highlighted in paragraph 14, stopping oral health problems from occurring in the first place has become more important than ever. Our survey demonstrated widespread support amongst the Faculty’s members for a number of preventative measures such as limiting the availability of sugary food and drink in schools (90%), extending the provision of supervised tooth brushing schemes in nurseries and primary schools (83%), expanding community water fluoridation initiatives (83%) and restricting advertising for high sugar products on TV (77%) and online (73%).[17]

 

  1. Prevention has been a key focus of health policy in recent years, and the Government has made a number of welcome commitments around oral health. In particular, the 2019 Prevention Green Paper stated that the Government would seek to remove funding barriers to water fluoridation, and consult on plans to extend supervised tooth brushing programmes to the 30% most deprived 3 to 5 year olds by 2022.[18]

 

  1. The Faculty therefore welcomes the inclusion of provisions around water fluoridation in the Government’s Health and Care Bill, which will streamline the process for introducing community fluoridation schemes by granting the Secretary of State for Health and Social Care direct powers to do so. This year’s Health and Care White Paper also confirmed that the Government will take on the capital and revenue costs associated with any new and existing community water fluoridation schemes.[19] However, to date little progress has been made in meeting the commitment to expand the provision of supervised tooth brushing programmes. The Prevention Green Paper indicated that a public consultation would be launched on these proposals in 2020, but this has yet to take place. While we appreciate that the COVID-19 pandemic will have disrupted plans in this area, we urge the Government to bring forward this consultation as soon as possible and set aside funding for the scheme in the Comprehensive Spending Review. There is strong evidence that these initiatives have a significant impact on reducing child tooth decay, and deliver a positive return on investment.[20]

 

  1. Furthermore, interventions aimed at reducing children’s sugar consumption also play a major role in improving oral health. The Faculty is pleased that the Government has announced plans to introduce a 9pm watershed for advertisements for products that are high in fat, sugar and salt, as well as new restrictions around online paid-for advertising – it is vital that these proposals are now implemented in full.[21] In addition, the Government has previously committed to take action to reduce the amount of sugar that children consume while at school by reviewing the School Food Standards.[22] We recognise that it has been necessary to pause this work during the pandemic,[23] but believe it should now be progressed at the earliest possible opportunity.

 

Contact

 

  1. For further information about this response please contact the Royal College of Surgeons of England’s public affairs team at publicaffairs@rcseng.ac.uk

Sept 2021


[1] According to NHS Digital’s Hospital Admitted Patient Care Activity data 23,529 children aged between five and nine were admitted to hospital because of tooth decay in 2019-20 (the latest year for which figures are available), making it the leading cause of hospitalisations for this age group by some distance.

[2] The survey took place between 10 June 2021 and 25 July 2021 and received responses from dental surgeons working in England, Scotland, Wales and Northern Ireland. The figures cited in this submission are for England-only. The full results can be read in our report A resumption of dental services – one year on.

[3] In total, 266 Faculty members based in England responded to this question in our survey.

[4] In total we received 82 responses from members working in NHS hospital practice, 68 responses from members working in NHS general practice, 26 responses from members working in community dental services and 65 responses from members working in private practice (all based in England)

[5] NHS England, Consultant-led Referral to Treatment Waiting Times Data, June 2021 (Incomplete Commissioner dataset)

[6] In total, 266 Faculty members based in England responded to this question in our survey. Comparisons with the number of patients who could be seen before the pandemic are taken from a previous survey of the Faculty’s members undertaken between 18 August 2020 and 9 September 2020, the results of which were published in October 2020 in our report A resumption of dental services?: Dental surgeons’ experiences of delivering care since 8 June 2020

[7] NHS Digital (2021) NHS Dental Statistics for England – 2020-21 Annual Report (figures accessed using data dashboard tool)

[8] While national social distancing restrictions were lifted in England on 19 July 2021, physical distancing is still required in dental settings as part of infection prevention and control protocols.

[9] In total, 265 Faculty members based in England responded to this question in our survey.

[10] Scottish Dental Clinical Effectiveness Programme (2021) Mitigation of Aerosol Generating Procedures: a Rapid Review (Version 1.2), p. iv

[11] In total, 266 Faculty members based in England responded to this question in our survey.

[12] We note that after our survey closed a minor update was issued to infection prevention and control protocols in August 2021, removing the requirement to leave fallow times between patients from the same household.

[13] Letter from Minister for Health and Social Services (8 December 2020)

[14] Department of Health, Health Minister announces grant funding to improve dental patient throughput (19 February 2021)

[15] Letter from Chief Dental Officer for Scotland on Scottish Government policy on ventilation in dental premises (9 June 2021)

[16] In total, 265 Faculty members based in England responded to this question in our survey.

[17] In total, 264 Faculty members based in England responded to this question in our survey.

[18] Department for Health and Social Care (2019) Advancing our health: prevention in the 2020s

[19] Department for Health and Social Care (2021) Integration and Innovation: working together to improve health and social care for all, p. 60-61

[20] Marinho et al, Fluoride toothpastes for preventing dental caries in children and adolescents (Cochrane systematic review, 2003); Public Health England (2016) Return on investment of oral health improvement programmes for 0-5 year olds 

[21] Department of Health and Social Care, New advertising rules to help tackle childhood obesity (24 June 2021)

[22] HM Government (2018) Childhood obesity: a plan for action – Chapter 2, p. 10

[23] Department of Education, Written Answer: School Food (26 April 2021)