Written evidence submitted by The British Dental Association (RTR0101)
- The British Dental Association welcomes this opportunity to respond to the Committee’s inquiry and our evidence below sets out in more detail the following points:
- Despite the largely stable numbers of registered dentists, the headcount of the NHS primary care dental workforce has fallen by 3.9 per cent in the last year.
- There is a lack of data on the dental workforce in general. In particular, the NHS data only relates to the headcount figure, with no figures on whole time equivalents available.
- There are profound recruitment and retention challenges facing dental practices, with 9 in 10 NHS practices seeking to recruit a dentist reporting that they experienced difficulties. For those looking to take on a dental nurse, it more than 8 in 10 finding challenges recruiting.
- These challenges are caused by government funding and take-home pay falling in real terms, a failed NHS contract, current targets that are extremely demanding during the pandemic, and a general sense that dentists are not a valued part of the NHS.
- There is a need for workforce planning and for dentistry not to be siloed from the rest of the NHS. The ICSs provide an opportunity to do this, if dentists are represented in the new structures.
- The time it takes to undertake the dental degree should not be shortened. Any changes to the cap in dentistry must only be made in discussion with the dental schools and their capacity for educating more students, and must go hand in hand with increased funding.
- The Overseas Registration Exam (ORE) that allows overseas dentists to register with the GDC has not been fit for purpose for a number of years and the pandemic has meant that it has been closed since 2020.
- There are equally problems with the process for demonstrating that dentists with overseas qualifications satisfy the requirements to work on the NHS.
- It is of utmost importance that the promised consultation on changes to the recognition of qualifications processes takes place urgently to address the future once ‘quasi-automatic’ recognition of EU/EEA qualifications comes to an end from 2023, and that this results in workable systems for recognition.
- The British Dental Association (BDA) is the professional association and trade union for dentists in the UK. Members engage in all aspects of dentistry: general practice, community dental services, the armed forces, hospitals, academia, research, and our membership also includes dental students.
- We welcome the Committee’s decision to hold this inquiry. The British Dental Association has long-standing concerns about the recruitment, training and retention of the dental workforce, and these have been further exacerbated by the pandemic and its associated pressures: huge treatment backlogs, access problems, unreasonable contractual targets and, consequently, unsustainable, unattractive working environments.
- Over 38 million NHS dental appointments have been lost since the beginning of the first lockdown, and recruitment and retention challenges are undermining the restoration of NHS dental services as we tackle this unprecedented backlog.
- Every dentist and dental care professional (DCP) lost to the workforce, and every vacancy that remains unfilled, means potentially thousands more patients losing access to vital dental care. It is therefore crucial that the necessary reforms are enacted to improve recruitment and retention, dental training, as well as the processes for recognition of foreign dental qualifications if the dental needs of the population are to have a chance of being met.
Attractiveness of NHS dentistry
- To recruit and retain the dental staff necessary to meet the needs of the population, a fundamental shift in dentists’ perception of NHS dentistry as a career pathway must take place. Simply put, a career in NHS dentistry must be made more attractive.
- The number of dentists registered with the GDC has remained stable over recent years, with a fall in the number registered at the end of last year. As of 31 December 2021, there were 42,215 dentists registered. There were 1,079 dentists who did not renew their registration, representing a 2.56 per cent reduction in the number of dentists. It is important to note that this data simply reflects those maintaining a registration and it does not indicate the number that are practising clinical dentistry or that all of these dentists are working full-time. Therefore, these figures only give us part of the picture about the dental workforce.
- Despite the levels of overall workforce, there have been profound issues with recruitment and retention in the NHS, due to it being unattractive as a working environment. NHS Digital figures from 2020/2021 illustrated a fall in the headcount number of NHS primary care dentists in England by 951 (3.9 per cent), reducing the number to its lowest level since 2013/2014. Our recent research suggests that more than half of the remaining dentists are now likely to reduce their NHS commitment. Data from NHS England and NHS Wales analysed by the BBC indicates more than 2,500 dentists – the equivalent of up to 8 percent of the workforce - stopped treating NHS patients last year. In some areas like Portsmouth losses exceeded one quarter of the NHS workforce.
- Among high-street dental practices, there are profound difficulties filling vacancies for dentists; with 93 per cent of practices with the highest levels of NHS commitment that had tried to recruit reporting that they had found it difficult to do so. Historically, these challenges have been more severe in rural, coastal and many post-industrial communities, often with high levels of need. However, analysis of job application data suggests that these issues are also impacting on many urban areas.
- It is notable that our more recent research has found that private practices are experiencing greater difficulties in recruiting dentists than had previously been the case. This may be the result of dentists looking to reduce their overall clinical commitment, due to the particular pressures of working through the pandemic.
- Across the community dental services, a mainly referral salaried primary care service for vulnerable children and adults, the numbers of clinicians have been falling year on year. Since 2005/06 the headcount has fallen from just over 1,500 to 925 in 2019/20. In addition, vacancies are not being filled. In 2021, the BDA sent an FOIA request to all services who have a community dental service. In England 48/62 providers questioned had a CDS as part of their service. The data showed that between April 2020 and 2021, only 60 posts were filled out of 78 posts which were advertised.
- The key areas which require reform to increase the attractiveness of NHS dentistry are financial investment, appropriate contractual arrangements, and workforce morale. The current deficiencies in these areas, and means through which they can be improved, will be explored in this response.
- The past decade has seen a rapid erosion of dental budgets, with government investment into NHS primary care dentistry falling by about a third in real terms. Even before the pandemic this was only enough to cover the dental treatment of half of the population of England. The cuts have been so great that an estimated £879 million of additional funding per annum would be required simply to restore financial resources to 2010 levels.
- The contrast between England and devolved nations has been striking during the pandemic. Practices in England have not received any capital funding to purchase ventilation systems that were desperately needed to improve patient access while working within infection prevention and control guidelines. This is in contrast to the approach taken by Government’s in Northern Ireland, Scotland and Wales where cumulatively over £10 million has been committed to new kit. This is reflected in a wider lack of capital investment in dentistry over a long period that sends a message to dentists about the extent to which they are valued by the NHS.
- The funding constraints have necessarily led to falling wages. Dentists’ take-home pay has fallen by 40 per cent in real terms in the decade from 2010/11. The most recent uplift to General Dental Services (GDS) contracts and to pay for dentists in employed roles falls below inflation for this financial year, and therefore amounts to a pay cut.
- Given this situation, it is no wonder that we have found through our research that dentists are increasingly looking to move away from the NHS and increase the proportion of the time they spend on private work.
- An immediate and long-term increase of financial investment into NHS dentistry is necessary to avoid a further exodus of dentists from the NHS, and to ensure that the next generation of dentists perceive NHS dentistry as a viable and desirable career prospect wherever they choose to work. In particular, the BDA supports the introduction of commitment payments that rewards dentists for maintaining a high NHS involvement to demonstrate directly that this work is valued. A similar system currently operates in Scotland and has previously existed in England.
Unsustainable NHS contractual models
- The NHS general dental service contract is not fit for purpose, as acknowledged by the Health Select Committee in 2008. It is a significant contributing factor to the unattractiveness of NHS general dental practice. The contract requires dentists to work in a system governed by ‘Unit of Dental Activity’ (UDA) targets that prioritise activity over prevention. This has resulted in a highly-demanding and stressful working environment, where the threat of financial penalties and contractual breach notices for underachievement of targets have stretched dental professionals to their limits.
- The GDS contract divides dental treatment into bands that are worth a set number of UDAs. This system is profoundly unfair and demoralising, with the financial reward fundamentally misaligned to the work dentists put in. Under a band two course of treatment, for example, a complex, lengthy root canal treatment would return the same three UDAs as a simple filling. Conversely, a filling carried out as an urgent treatment would only return 1.2 UDAs; this has been especially problematic in recent months as dentists have been contractually bound to prioritise patients in need of urgent care, in turn making it even more challenging to generate the UDAs necessary to meet imposed thresholds. This fundamental flaw in the NHS GDS contract is yet another example of NHS dentists being inadequately rewarded for their work, and another factor motivating dentists to leave NHS dentistry.
- These challenging working conditions in NHS high-street dentistry have worsened considerably as a result of the pandemic. Not only did dentists work for many months under strict IPC guidance that required high-level PPE, but this strain was combined with the reintroduction of NHS targets in a way that has put practices under even greater pressure. In December 2021, NHS England imposed a new UDA threshold of 85 per cent of pre-Covid levels for quarter four of 2021/22. This was done despite the Omicron wave bringing significant levels of staff absence and patient appointment cancellations, and the fact that many practices had previously failed to meet the lower target in place for quarter three.
- To address recruitment and retention concerns stemming from the outlined contractual arrangements in the short-term, unreasonable UDA thresholds should be decreased to ensure that dentists are not pushed to burnout in their attempt to meet targets, or financially penalised if they fall short for reasons outside their control. In the long-term, UDAs must be abolished in favour of a capitation-based contractual model. A capitation-based contract will avoid the stresses associated with a purely activity-driven model of care in favour of the rewarding work of prevention, and ultimately increase the desirability of a career in NHS dentistry.
- Within community dental services, providers bid for a Personal Dental Service Agreement to deliver services in a similar way to high street services. While UDAs are nominal, the model is unwieldy for community dental services. Community dental services either based in NHS Trusts or Community Interest Companies will be required to deliver services to patients within a fixed cost envelope. Services are usually specialist-led and all dentists working within the CDS are employed under the Salaried Primary Dental Care Services terms and conditions of employment. With the move to integrated care services, we are looking at new and innovative ways to better integrate CDS services across NHS primary dental care and secondary dental care services as part of CDS dental system reform.
- Community dental services teams have struggled to keep pace with patient demand, which was limited by restrictions on high street services and the previous backlogs of vulnerable patients requiring significant care. Access to treatment under general anaesthetic for vulnerable adults and children has in many places ceased completely due to a lack of access to theatre space and is now being impacted by staffing pressures too. In England, the triage and treatment of patients is still subject to the current SOP which continues to ask for children and vulnerable patients to be prioritised which has two impacts. Firstly, that these two are the only patient groups seen by the CDS making it very difficult to decide who should and should not be seen within the service struggling for a staff and capacity. Secondly, referrals into the CDS have continued because GDPs are continuing to refer children and special care adults in pain as they are prioritising these patients under the SOP. The increasing strain of working under these circumstances is having a significant negative impact on the CDS workforce.
- The financial and contractual concerns outlined above have led to a situation where morale among dentists is at rock bottom. Our research has found that – among those who have an NHS commitment above 75 per cent - 80 per cent of dentists who are practice owners and 70 per cent of dentists working in dental practices said their morale was low or very low. The importance of ensuring that dental teams feel valued and respected should not be overlooked when seeking to address recruitment and retention concerns.
- Alongside action to address a decade of rapidly falling take-home pay and securing contract reform, a number of other measures can be undertaken to improve the morale of the dental workforce. To help to address the abuse received by the dental profession from patients, the Government and NHS should do more to inform patients of the strain that the sector is currently under as a result of the pandemic and how this impacts dentists’ abilities to meet the needs of their patients through no fault of their own.
- Further, NHS England should endeavour to show respect for the profession by announcing major changes to their contractual arrangements and working lives in a reasonable timeframe.
Integrated Care Systems
- As noted above, the voices of dentists should be given greater weight when considering what contractual arrangements are manageable and fair. As ICS structures are implemented over the next year, ensuring that dentists are adequately represented within ICS structures is one way in which dentists’ concerns and views can be amplified.
- There are many laudable aims in NHS England’s guidance on the ICS role in terms of workforce, specifically in terms of support and cultural change, but the new systems need to work with the profession at national and local level to understand and advocate for the changes that will make the most difference to their local populations. Systems need good advice and good data.
- We believe that, for the benefit of patients and the NHS, we must see wide clinical engagement and representation for dentistry at every level of integrated care systems, including from across primary and secondary care, as well as public health. ICS footprints are relatively small and it is vital that the wider networks are tapped into.
- We have argued that the crucial contribution dentists and their teams make to the local health and care systems must be recognised and reflected within the Integrated Care Boards (ICB). As it stands the Bill states that each ICB includes a member nominated jointly by those who provide primary medical services within the area and are of a prescribed description. In practice, this means that Board members will most likely be drawn from a medical general practice background (and it is certainly being interpreted in this way by systems when drawing up their constitutions). By ‘representation’ we do not mean a straightforward reporting back – simply that one part of primary care cannot possibly be expected to effectively represent the views, perspectives and distinct challenges facing other branches of primary care. There must be formalised roles for dentists (and other primary care sectors) in ICBs and Integrated Care Partnerships – their inclusion in strategic advice, planning and decision-making is too important to be left to arbitrary local decision.
- The NHS guidance refers to the ICS role in supporting the health and wellbeing of all staff. Though we know that the recurrent funding for occupational health for dentists sits with CCGs there is a lack of understanding of this, and we receive many reports where dentists have struggled to access the relevant services. If we are to talk of ‘one workforce,’ we would argue that systems should provide and fund an occupational health offer for dentists and their teams (indeed all primary care) – the benefits would outweigh the costs in the long run.
- Practice owners are struggling to recruit and retain dental nurses. Among those heavily-NHS practice owners who tried to recruit a dental nurse, 84 per cent reported that they had experienced difficulties doing so. Dentists cannot undertake clinical work without the support of a dental nurse and therefore this issue of being able to attract a dental nurse workforce has a direct impact on capacity to deliver patient care.
- Dentists report to us that their dental nurses are leaving the profession for other roles that offer comparable pay with less stress and pressure. The squeeze on NHS dental practice funding has impacted on the pay that can be offered to dental nurses and this coupled with the additional stressors of working through the pandemic have led to a reconsideration of career plans.
- The BDA is very concerned that the introduction of compulsory Covid-19 vaccination for all health workers engaged with CQC-regulated activity will impact on the dental workforce as a whole, particularly dental nurses. Our survey of high street dentists found that over 30 percent of respondents believed dental nurses at their practice would leave as a consequence.
- Improvements to dental nurse training schemes by creating more avenues for career progression is another way in which we might encourage individuals to become, or remain as, dental nurses, and there have been some moves into this direction through HEE’s Advancing Dental Care project.
- The BDA has also argued for some time that the statutory regulation of dental nurses, which came into force in 2008 after a two-year transition period, is now significantly contributing to the recruitment issues outlined above. Statutory regulation involves formal training, registration and compliance with professional requirements such as continuing professional development. Statutory regulation is costly for the individuals and creates problems for practices where, for example, deadlines for registration renewal or CPD requirements have not been met by the individual. We therefore believe that statutory regulation of all dental nurses may well be disproportionate and DHSC should consider whether it should continue in the same way. Statutory regulation may well be appropriate for dental nurses who have taken advantage of additional career opportunities which see them work more independently. We intend to feed back accordingly to the DHSC consultation on Healthcare regulation: deciding when statutory regulation is appropriate.
- We do not believe that there are adequate systems for workforce considerations in dentistry. GDC registration numbers denote how many dentists and dental care professionals are registered, but not how many are currently working in the UK or whether they are working in the NHS or on a private basis. As noted about, both the GDC and NHS Digital data provide us with the headcount of those registered and of those providing some primary care NHS dentistry, but this does not represent whole time equivalent numbers that would give a true representation of the workforce capacity.
- What is also not clear is the training and specialty workforce including dental academia. We are concerned that the NHS England is not committing to a full workforce analysis every two years. While the picture is obscured, sensible workforce planning that meets the needs of patients is not possible. We are very concerned for the future of the specialty workforce within the next 5 years. A full workforce survey is needed to ensure that recruitment and retention can be adequately prepared for over the next 5-10 years.
- The BDA has held a seat on the People Plan Advisory Board in recent years along with a number of other notable dental representatives. To ensure that the NHS People Plan can fully embrace dentists and their teams across primary and secondary care, the currently siloed systems across healthcare including the financial flows must be better integrated. This would ensure that dentistry can be part of the wider healthcare people plan, not semi-detached and on the too difficult pile for those that do not understand the complexity and nuance.
Dental education and training
- The time it takes to undertake the dental degree should not be shortened. Apart from already existing programmes for graduate intakes of individuals who have a medical or related science degree, this would not be workable. Dentistry is not a degree in which people simply learn a number of clinical tasks. The curriculum is extensive and covers much of the medical curriculum in addition to the dentistry-specific side, and is formative in nature. It takes time for the student to reach the expected level of expertise and understanding. In addition, reducing the time for education in dentistry would negatively impact the international validity of UK dental qualifications which would in turn affect the number of overseas students wishing to study in the UK, and the ability of UK graduates to participate in international education and research activities.
- Any changes to the cap in dentistry must only be made in discussion with the dental schools and their capacity for educating more students, and must go hand in hand with increased funding. Long-term planning is needed to ensure that there are physical resources (more clinics, bigger hospitals to train in) and more education staff to support expansion. The current funding envelope has no flexibility to support more students.
- Any expansion must also take into account the need for a greater number of funded dental foundation training places (DFT) which is a requirement for working in NHS general dental practice, and additional funded places for postgraduate training such as dental core training and specialty training.
- Beyond the issues already outlined about the contractual situation and morale in the profession, it is also important to note that there have been significant issues with international recruitment in dentistry for some time. There are several issues in this area.
- The General Dental Council’s Overseas Registration Exam (ORE) has not been fit for purpose for a number of years. The problems range from an inappropriate system for applying for places, a limited number of available places for the practical part, to the GDC’s outdated and rigid legislation, which means it cannot address some of its problems without government support and Parliamentary time that the regulator tells us has not been forthcoming for many years. The delays inherent in this system were exacerbated by the pandemic, which led to the complete closure of the ORE since early 2020. Over 2,000 dentists are currently waiting to sit this exam, and some (at least 132 individuals at December 2021 and likely to increase in 2022) have been caught up in deadlines stipulated in legislation, which mean that they cannot continue with the exam until that legislation is changed.
- There are plans for reform of the wider regulatory system in healthcare, and a specific DHSC consultation looking at changes to the recognition regime for non-UK dental qualification is imminent, we believe. However, this work is already delayed and should now be looked at with urgency, as the new proposals are not yet known and must be put into practice before the end of the year to avoid an even more severe bottleneck for the exam once European qualifications are no longer accepted for automatic recognition from 2023 (see below).
- In addition, we must raise the issue of dentists joining the performers lists in England and Wales. The process is such that any dentist wishing to join the list must undertake training that is akin to dental foundation training (DFT), usually for at least one year full time, in a general dental practice setting in order to become an NHS performer. The process is called performers list validation by experience (PLVE). However, the current PLVE requirements state that “HEE is not able to consider applications into PLVE from dentists who cannot provide clinical references relating to two recent posts (one of which will usually be a current post) each of which lasted at least three months (continuous period) without a significant break, or where this is not possible, a full explanation as to why that is the case and the names and addresses of two alternative referees. ’Recent’ is defined as ‘working within a dentist’s full scope of practice within the previous two years’.”
- Getting through the current ORE system takes more than two years for a large number of candidates due to the exam’s limitations even in ‘normal’ times. With the current delays due to the pandemic, the exam delays are also making it impossible for these dentists to then move forward into NHS general dental practice for the necessary training.
- Given the huge workforce issues in NHS dentistry, the lack of appropriate systems for dentists, most of whom are based in the UK and ready to work bar the need to be registered and accepted onto the performers list, there is a significant need to develop workable systems urgently while ensuring that patient safety is not compromised as a result.
- Within dentistry there are no ‘trusted training programmes’ in other countries and it would be inappropriate for the General Dental Council to assess overseas training programmes to become ‘trusted’ if this work was financed by registrants’ retention fees. There are some historic provisions for qualifications gained in a limited number of countries before the year 2000 to be registrable here, and until the end of 2022 a ‘quasi-automatic’ recognition process remains in place for dentists with qualifications from the EU/EEA. All other overseas-qualified dentists – and, from 2023, dentists qualified in the EU/EEA if change is not implemented - will have to sit the ORE as described above. It is of utmost importance that the promised consultation on changes to the recognition processes takes place urgently and results in workable systems for recognition.
 Dental treatment for people with special needs NHS.uk (accessed 18.01.22) https://www.nhs.uk/using-the-nhs/nhs-services/dentists/dental-treatment-for-people-with-special-needs/