Written evidence submitted by the Association of Dental Groups (RTR0010)

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 workforce: recruitment, training and retention in health and social care .

2. 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.

3. 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. We welcome this inquiry as we believe that addressing recruitment and retention remains the most important step in dealing with the backlog and future demand for oral healthcare, be it NHS or private dentistry.

Workforce planning and investment is needed to address the recruitment crisis

4. Our submission is that recruitment into dentistry and the allied professions will be facing a “perfect storm” by the end of 2022 as we continue to recover the backlog of oral health needs created by Covid-19. We are seeing evidence from our own members workforce survey and NHS data that long standing dentists and other members of the team are now retiring early or exiting NHS dentistry due to the pressures of ways of working and the unfit nature of the current NHS contract. The UK has also historically relied on dentists with overseas qualifications, now comprising 23% of the registered workforce[1]. Reform of overseas recruitment is urgently needed before the ending of mutual recognition of qualifications from EEA countries in December 2022. If nothing is done the difficulties in getting access to NHS dental care will get worse and the damage to oral health by the pandemic will be permanent for many more patients.

5. We believe it is vital that long term dental workforce planning is now embedded within the NHS and we support the amendments tabled in both the Commons and the Lords to this effect in the Health and Care Bill. Improvements in the oral health of the population since the 1990s began to plateau before the pandemic and geographical inequalities are now widening[2] as we also anticipate more complex care needs for an aging population. We would note the action taken by the previous Labour Government from 2004-06 which not only invested in new dental schools domestically but launched a more immediate national recruitment campaign to bring in extra clinicians from both home and abroad. This approach has much to recommend it.

6. It is important to appreciate that modern dentistry in the UK is a mixed economy and private dentistry meets much of the population need that is not met by the NHS. NHS dental services delivered treatments for approximately half the adult population in 2019[3] and this is complimented by private provision which for many provides better preventative care and access to an affordable alternative particularly for more complex treatments not readily available on the NHS. Above inflation rises in NHS patient charges[4] for the past 5 years mean the cost differentials have significantly narrowed. Recruitment to NHS dentistry is particularly acute but all our members, many of whom provide a mix of NHS and private treatment, report recruitment difficulties for dentists and other members of the dental team, particularly in rural and coastal areas of England.

UK recruitment pathways into dentistry

7. The last major investment in UK dental training was made in 2004 as part of an expansion in medical and dental training places and the subsequent establishment of new dental schools at Peninsula Dental School (Plymouth) in 2006 and University of Central Lancashire (UClan) in 2007. At the same time a recruitment campaign, “Project 1,000”[5] was launched by the then Secretary of State for Health, John Reid, aimed at recruiting a total number of 1,000 extra dentists both at home and from abroad. Since then, no further significant investment in the dental workforce has been made. In 2012, a Strategic Review of Medical and Dental intakes[6] in England was published by the Higher Education Funding Council (HEFC) subsequently merged into the Office for Students (OFS). Now nearly a decade old, it recommended no change in student intake levels, but a 3 year rolling programme of reviewing them, adding that the complex system dynamics of the dental workforce meant that the quality of data available made workforce planning difficult.

8. The ADG and many others welcomed the lifting of the “cap” on medical and dental school places in September 2020 and the subsequent extra places in 2021[7]. The dental intake target figures published by the Office for Students for 2021/22 in England are 983.[8] The ADG has recommended to Government a national recruitment campaign with higher targets to recruit more dentists and we are disappointed that Government Ministers have indicated they wish to reimpose a cap on places in 2022. We believe that another review is now needed of medical and dental intake numbers as part of longer term workforce planning.

9. Advancing Dental Care Review. Published in September 2021[9] the Advancing Dental Care Review Final Report commissioned by Health Education England (HEE) sets out a ”blueprint for reforming the postgraduate dental training structure and developing and optimising the skills of Dental Care Professionals (DCP) through the education and training pipeline” We share the view that “current training models are outdated and siloed” and believe a number of recommendations are of relevance to the inquiry;

• Co-ordination and distribution of postgraduate training posts so that they are better aligned to areas with the highest level of oral health inequalities.

• Centres of Dental Development. To help overcome the difficulties in recruiting in certain areas of the country, which is partly caused by the geographical imbalance of dental schools in England, “Centres of Dental Development” are proposed for the latter stages of undergraduate training. This will require capital investment but could address the lack of dental schools in East Anglia and Lincolnshire highlighted by local MPs[10].

• Dental Care professionals being able to use their full scope of practice in multidisciplinary teams. One of the most common examples is dental therapists who under the NHS contract are not able to open a course of routine dental treatment (such as fillings) and work to the level appropriate to their training.

• Apprenticeship routes into dental careers. Much modern oral health improvement does not require a fully qualified dentist. The report recommends the more flexibility around entry routes to widen access into the oral health profession.

International pathways into working in UK dentistry

10. In 2020 UK qualified new registrants with the General Dental Council (GDC) formed 66% - the remaining 34% of new registrants coming from EEA countries or other overseas routes to registration[11]. Dentists with overseas qualifications now make up nearly a quarter of all dentists on the register.  Following Brexit, mutual recognition of EEA countries qualifications (or as near as) has been maintained until the end of 2022[12] when new overseas registration or mutual recognition processes  are expected to be established to maintain recruitment from all overseas countries. It should be noted however, that even the current “holding arrangement” with EEA countries has caused friction in individual recruitment[13] and our members report a wider lack of understanding and concern amongst potential EEA applicants about what is required now to live and work in the UK. Even if the Government was prepared to invest in a significant number of additional new UK dental student places, and the education facilities to undertake their qualifications as desired by MPs in some parts of England, they will not be entering the workforce for another 6 years.  For this reason alone the UK will remain dependent on overseas clinicians to maintain the current workforce.
11. The recruitment of overseas professionals from countries outside the EEA has effectively halted since March 2020 as the examination they are required to take to register (the Overseas Registration Examination, commonly known as “ORE”) has been suspended during the pandemic period. The ORE is administered by the GDC and widely acknowledged to be no longer fit for purpose.  The GDC themselves describe the ORE as a “flawed system made worse by the pandemic.”[14]. New overseas recruitment pathways quickly need to be identified and the ORE, tightly prescribed in legislation, resumed and reformed. We welcome the intention of the Department of Health & Social Care (DHSC) to undertake a consultation which could facilitate this reform[15].
12. GDC figures estimate that there are currently just over 2,000 candidates[16] that have applied or are currently registered, often for several years, to complete the ORE process. Reforming the ORE to enable the GDC to conduct the examinations for these candidates and for successful applicants to register and enter the workforce would be a considerable step forward in addressing the recruitment crisis and one of the most cost effective for the public purse. This is not about expanding overseas recruitment but ensuring functioning pathways continue to exist to maintain the current workforce.

13. Once an overseas applicant has successfully passed the ORE and is registered with the GDC, they can enter private practice. However, to practice as an NHS dentist they have to complete Performers List Validation by Experience (PLVE) training to join the NHS Performers List. The PLVE assessment process is currently managed by Health Education England at a regional level. Each region runs PLVE differently, spanning application dates and processes. Although some steps have been taken to make improvements, one process for all regions would be much simpler resulting in a better candidate experience and improved recruitment. Standardising the quality threshold of PLVE is also highlighted in the “Advancing Dental Care Review” previously referenced. Steps should also be taken to speed up the process (we were given one example of trying to recruit via PLVE ongoing for 18 months and the candidate eventually abandoning the process).  Variation in PLVE is a significant obstacle to recruiting to NHS dentistry and it should be noted that if alternative arrangements are not made by the end of 2022 that EEA clinicians who chose to come to the UK would be obliged to go through the ORE and PLVE route as well. 

14. It is clearly not desirable for the ORE to be the sole route to registration in the UK for overseas applications and new mutual recognition process need to be agreed with countries where the GDC as regulator believes that standards meet ours .  The GDC has already commissioned research[17] into individual EEA state provision of dental education which identifies variance and we would anticipate mutual recognition to be at an individual state level in the future. We believe that the GDC should scope out further opportunities for mutual recognition globally with Commonwealth countries such as India. Before 2001 the GDC had a number of bilateral agreements with Commonwealth countries including Australia, Singapore, Hong Kong and South Africa whose qualifications met UK standards and potential agreements should be explored again. In the specific case of Hong Kong, removing barriers for dentists with British National Overseas Visas to work in the NHS would be the appropriate next policy step.

Other drivers contributing to the workforce crisis in dentistry

15. Many of the difficulties impacting NHS dentistry predate the pandemic and will hold back recovery unless they are addressed. Contract reform has been mooted for the past decade through the “prototype” contracts but not taken forward by DHSC. However, we welcome the renewed desire by Ministers as stated in the letter of 29th March 2021 to the profession for national contract reform[18]. Increasing the flexibility to target particular “local needs” will be key and align with the desire to see more integrated care systems. It is welcome that policymakers and NHSE are now considering dental system reform and trying to identify “quick wins” which can be made within existing contractual arrangements. However what is required is a new contract with a greater emphasis on preventative dentistry which will improve oral health outcomes. Meaningful reform away from the UDA model will enjoy the support of the profession.

16. As with many sectors, the impact of the pandemic has resulted in individuals reassessing their careers and changing employment. 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[19] in 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.
17. This has also 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[20] across all regions. To put this into context, this is the near equivalent of the whole dental student intake target for this year, and in the previous year’s data there was an increase of only 139 dentists with NHS activity[21]. We expect this steep decrease in those undertaking NHS activity to continue into 2022. It is clear that the pandemic experience and difficult ways of working over the past 18 months is resulting in a significant number of clinicians reassessing their life work balance and either choosing to move more of their work into private practice or leave the profession altogether. 

18. Vaccine uptake has been very positive in the dental sector.  ADG members encouraged all practice staff to be vaccinated at the earliest opportunity in the first phase of roll out. However In the short term the implementation of mandatory covid vaccination will result in staff churn in 2022. The Government’s own impact assessment models[22] a central scenario of 4% of dental teams could remain unvaccinated at the end of the grace period in April 2022 and use of temporary staff for up to two months in the same scenario. Group providers will be better able to manage support for staff concerned about vaccination and implementation but the British Dental Association (BDA) has highlighted in a survey of the profession that staff turnover could be much higher than Government estimates.[23]

19. The pandemic has highlighted the failing of the current system to be able to provide not only urgent, but routine care, particularly for patients not with an NHS dentist or living within one of the emerging “dental deserts” in England. The recruitment crisis in rural and coastal locations in dentistry in England is now widespread. Our members survey of 2021 identified the following counties as having acute difficulties;  Yorkshire and Humber, Norfolk, Suffolk and coastal Essex and Kent.  Hampshire and the Isle of Wight, Cornwall, Devon, Somerset, Staffordshire, Lincolnshire, Notts, Derbyshire, Herefordshire, Cumbria, Lancashire and Teeside.

Concluding comments

20. Recruitment into dentistry and the allied professions could be facing a “perfect storm” by the end of 2022 as we continue to recover the backlog of oral health treatments unless there is sustained commitment to the UK dental workforce and new agreements for the mutual recognition of overseas professional qualifications.

21. We believe that a review of dental schools intake by the OFS should form part of the work of longer term workforce projections which should be part of the Health and Care Bill. The ambition must be to take forward the development of new undergraduate and postgraduate education and training in those parts of the country where it is most needed, Lincolnshire and East Anglia being two such examples. The “Centres of Dental Development” provide a model to address this. HEE/NHSE should also work with service commissioners to deliver more dental foundation training opportunities in parts of the country where access is an issue.

22. Reform of the ORE to enable applicants to successfully pass it in a timely manner and bringing forward bilateral mutual recognition arrangements. This is vital to maintain overseas recruitment and avoid it being completely choked off at the end of 2022 when “holding arrangements” with EEA countries are due to expire.

23. An overarching recruitment campaign, learning from the success of Project 1000 to bring in a combination of overseas and UK dentists back into the NHS should be launched including the above policy proposals for provision in particular high needs parts of England.

24. Retention of the existing workforce will be intimately related to the prospects for reform of the current “UDA” dental contract. We welcomed the work of the Dental System Reform Advisory Group[24] last summer. In order to cease the flow of dentists exiting NHS activity a roadmap has to be set out by Ministers and NHSE in 2022 including not only “quick wins” identified by the Group which can be achieved without legislative change but the ambition for a new contract model to ensure the sustainability of NHS dental services in the decade ahead.

January 2022