Written evidence submitted by the British Dental Association (DEL0252)
1. 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.
2. We welcome the Committee’s decision to hold this inquiry. Dental services face existential challenges during the current pandemic with most NHS and all private general dental practices unable to provide normal patient care and only able to offer advice, analgesics and where appropriate antibiotics which only buys time until definitive, and inevitably more complex can be provided. For those with urgent need practices may refer to Urgent Dental Care systems (UDCs). With tooth decay and gum disease being among the most common diseases experienced by both adults and children, and with tooth extractions the most common cause of paediatric General Anesthesia admissions, we are very concerned about the pain and deterioration in the nation’s oral health that is happening now and the potential loss of thousands of NHS and private practices who find themselves with insufficient income to sustain themselves through a prolonged period of lockdown and different ways of practising after these practices and clinics resume regular care .
3. The public deserves timely access to appropriate dental services, close to home and appropriate to their needs. This requires a stable, sustainable service that is properly resourced to prevent and treat dental disease.
4. The BDA would be pleased to give oral evidence if it would be helpful to the inquiry.
5. With the current suspension of non-urgent dental treatment and dental public health/practice-based prevention programmes, we anticipate a very substantial burden of untreated dental disease and an overall worsening of the nation’s oral health as the UK emerges from the peak of the pandemic.
6. there will also be further build-up of demand due to ongoing measures to limit COVID-19 transmission as dental practice resumes, which will severely restrict the number of patients that can be seen each day.
8. Due to the financial impact of the lockdown restrictions on private dental practices leading to likely closures, and because the wider economic effects will lead to reduced disposable income for patients, we would anticipate additional demand for NHS services in future.
9. In the face of an extreme shortage of dental appointments, it would be anticipated that initially treatment would take priority over practice-based prevention and check-ups. This could drive an even further increase in dental disease for the future.
10. Crucially, we expect pre-existing inequalities in oral health to become even more marked, as the loss of treatment and preventive services during the pandemic will have disproportionately affected people from disadvantaged and vulnerable/shielded groups. These patients have a higher baseline level of dental disease (ADHS, CDHS, PHE survey of five-year-olds), are likely to have experienced greater difficulty in accessing/travelling to urgent care hubs, and are the key targets of public health programmes. The latest PHE oral health data for five-year-olds, show almost a three-fold difference in prevalence and a more than ten-fold difference in severity of dental decay between those in more and less deprived areas; the pandemic may well increase this already unacceptable disparity. Before lockdown, preventive programmes including fluoride varnishing and supervised toothbrushing for children were targeted at disadvantaged and vulnerable groups, and we would expect these people now to feel the greatest effect of their cessation. In addition to the lack of treatment and preventive services, other consequences of the pandemic restrictions are likely to drive oral health inequalities:
11. Sugar consumption is a risk factor for dental decay and polling by the Obesity Health Alliance indicates that people report increased snacking on sweet foods during the lockdown Concerns have also been raised about food poverty, including the impact of school closures and difficulties in accessing the voucher scheme established for children entitled to free school meals. The rising numbers of adults and children experiencing poverty/reliance on benefits will have further effects on diet and oral health outcomes.
12. As well as diet, tobacco and alcohol consumption are major risk factors for oral cancer with patterns of use likely to be affected by the lockdown; they are also strongly linked to socio-economic inequalities. As routine dental appointments provide a key opportunity for early detection of oral cancers, improving survival rates from 50 to 90 per cent, we are extremely concerned that the lack of capacity for dental appointments for the foreseeable future will cause an increase in oral cancer mortality that will disproportionately affect disadvantaged groups.
13. We strongly urge the Committee to recognise that prevention must be prioritised, with substantial investment, to address the burden of dental disease, reduce inequalities and relieve the pressure on treatment services that will be otherwise unable to cope with demand. Modelling by PHE clearly demonstrates that preventive measures for oral health generate a return on investment. Many of the risk factors for poor oral health are shared with systemic conditions including obesity, cancers, diabetes and cardiovascular disease, meaning that there will be a synergistic benefit of investment in prevention. Continued funding and commissioning of epidemiology programmes to understand oral health needs and trends is also important.
Testing and vaccination
14. We would recommend that a role for dental practices as official providers of COVID-19 testing and (when available) vaccination be considered. This would help people to access these services locally, the c. 22,000 practices potentially achieving a significant throughput to support the government’s mass testing effort. The General Dental Council has confirmed that testing would be within the scope of practice of dentists, and we are aware that a similar proposal has been made in the USA.
Patient access to general dental practice services
15. It is highly unlikely that demand for dental services will reduce longer term – in fact inability to access care during the lockdown means there is likely to be more demand than ever on NHS and or private dentistry in primary care.
16. Access to NHS dental services was fragile prior to the pandemic. BDA analysis of the Government’s 2019 GP Survey indicated that over 1.4 million adult patients had tried and failed to access dental care, with a further 2 million estimated not to have tried in the belief they would be unable to secure an appointment. Furthermore, 130,000 adults reported that they were on waiting lists and over 700,000 cited cost as a barrier to seeking care, the pre-pandemic level of unmet dental need was over 4 million people, or nearly 1 in 10 of the adult population.
17. The recent NHS Digital statistics show that in the 24 months ending December 2019, 49.6 per cent of adults were seen by an NHS dentist and the in the previous 12 months 58.4 per cent of the child population. Over recent years approximately half of the population has received NHS dental care. Given levels of unmet need we cannot realistically expect demand for services to fall below this level.
18. As of March 2020, all routine dental care was stopped. Only in the last month have UDCs become active and start seeing urgent patients.
19. Many high street practices are offering patients remote dental consultation with a Three As approach (advice/analgesia/anti-biotics). For many patients this is not enough and securing access to urgent care remains difficult, owing to restrictive criteria and PPE shortages.
20. Due to the COVID 19 infection control and deep cleaning requirements – UDC surgeries are only seeing 8 patients a day (1 per hour) compared with approximately 30 a day pre-COVID in NHS practice with more in orthodontic practices due to shorter appointment times. Should the same restrictions apply to high street practices on re-opening the result would be radically reduced capacity. For practices that have multiple surgeries that can see multiple patients concurrently, it is likely that the capacity will be reduced to one or two surgeries being open (one receiving patients while the other is deep cleaned). The threats to private dental practice services are described below.
Patient access to community and hospital dental services (referral services)
21. Dental services are provided by the Community Dental Services (CDS) for vulnerable patients, and the Hospital Dental Service (HDS) who see patients in dental and other major hospitals on referral across a number of different specialties
22. CDS dentists are now working in UDCs but many CDS patients cannot access ‘routine care’ via CDS dentists which for many will cause discomfort and distress. Patients using the CDS are vulnerable adults and children (with complex medical history and/or learning disabilities).
23. Waiting lists for extractions for children and adults under a GA usually carried out by CDS dentists are already unacceptably long. The pandemic will have created an even bigger demand and accompanying backlog than the 2 year wait already being experienced by some children/adults. Post pandemic there may be reduced capacity within GA lists due to deep cleaning, social distancing measures. We are enormously concerned that treatment will be delayed further given the pressure that is already building on hospital theatres and ward staff.
24. Across all Hospital specialties some services have continued as before during the crisis others will have suspended all care entirely.
25. For Oral and Maxillo-Facial Surgery (OMFS) departments trauma and severe infection management have continued as before. They have provided telephone triage and urgent dental service as required and teams have been part of the overall primary/secondary care response albeit dependent on the availability of PPE.
26. Orthognathic surgery has been suspended and will be re-introduced when elective surgery is restarted. Again, there will be a backlog of cases needing operations and this will be a challenge for surgical teams (theatre and ward teams).
27. Oral cancer clinics have continued throughout the closure but there will be patients who have not been screened and referred as their dental practice was closed. Some patients may have been referred by their GP. There will however be a backlog of surgical treatment for oral cancer patients and this will depend on access to other hospital services in demand (radiographs/pathology) and depend on staff and theatre/ICU availability. There will also be a backlog of patients needing radiotherapy.
28. There will be a back-log of patients requiring oral surgery that will have been in (sometime intolerable pain from toothache and infection) and with potentially life-threatening infection who will require treatment amidst a growing back-log.
Orthodontics and restorative dentistry
29. Both these specialties have continued in some hospitals dealing with ‘emergencies’ only. These patients would already have been under the care of the hospital and for these patients there would have been a detriment by waiting for normal service resumption. However, both these services will face back-logs.
30. Many hospital dentists have been redeployed to support the wider COVID effort. Many of our members are working in intensive care units or geriatric departments, roles which they will have been trained to do but until the need for them in those areas reduces, a normal service will have trouble resuming without destabilising the wider NHS. While this has been a positive way to support the wider NHS, working in such settings may have a lasting impact on these individuals’ mental health. Hospital dentists working in intensive care units will have seen the devastating effects of COVID in an environment very alien to their daily lives. In the short, medium and long term, mental health support must be available for all NHS staff and volunteers who have worked in this environment.
31. Backlogs in all hospital dental specialties means a huge impact upon patient care – the most serious being the ‘missed’ oral cancer patients who present late meaning a poorer prognosis. Hospital dental services are a vital part of the patient journey. There must be a careful balance in bringing back these vital services without destabilising the rest of the NHS effort and managing a backlog of significant cases created by the absence of routine dental care since March.
32. Looking forward we feel that consideration should be given to specialists supporting primary care services locally with treatment of patients affected by the pandemic. Any wider consideration of integration would enable a decrease of onward referrals and would help with the growing number of patients waiting for secondary care dental treatment.
33. We are very concerned that there must be sufficient capacity in primary and secondary dental care to meet treatment need at a time when initially patient throughput will be diminished owing to the need to control infection transmission and social distancing requirements.
34. As described in the next section private and NHS/private practices provide a substantial amount of dental care and treat millions of patients and the cessation of all non-urgent dental care has left many of these dentists and practices without income. On return, the potential permanent closure of some general dental practices - particularly private practices – because of the financial impact will lead to a diminished service and aggravate current access problems.
35. In early April 2860 owners of UK dental practices (24.3 per cent of an estimated total of 11,800). Answered a BDA survey on financial sustainability in the pandemic. With all routine care suspended 71.5 per cent of practices reported they could only remain financially sustainable for 3 months or less. Less than a third (28.7 per cent) estimated they will be placed to restore pre-pandemic levels of patient access. The majority of UK practices are mixed, delivering both NHS and private care in varying proportions. Practices performing a greater share of private work appear most exposed, with 75 per cent of those with low or no NHS commitment (0-25 per cent NHS) stating they will face imminent difficulties in the next three months, falling to 60.7 per cent among those with the highest NHS commitments (75-100 per cent NHS). A month after the survey was conducted examples are beginning to surface on bankruptcy/closure with associate dentists (who provide the bulk of clinical care), losing their jobs.
The role of private dental practice
36. Private practices have been particularly badly hit by the effects of the lockdown; left with little or no income in this period, while a range of fixed business costs remain in place. This dire situation is only compounded by these small businesses being excluded from the Small Business Businesses Rate Relief Scheme and difficulties accessing the Coronavirus Business Interruption Loans.
37. While associate dentists have had their NHS incomes guaranteed at normal levels, most private associates will be ineligible for any Government coronavirus income support. The Chancellor indicated that the £50,000 profit threshold for the Self-Employed Income Support Scheme was intended to exclude those with very high earnings. However, our research found that 60 per cent of associate dentists excluded from the Scheme earn less than £75,000 a year. It is not clear to us why an employee earning £51,000 would be eligible to receive £2,500 per month under the Coronavirus Job Retention Scheme, but a self-employed person is not eligible to receive the same level of support.
38. There are around 5,000 purely private practices, but many dental practices with an NHS contract will also rely on private work for a significant proportion of their income. As such, private dentistry accounts for more than half of the spend on high street dentistry; an estimated £4.4 billion of the £7.8 billion spent in 2017-18 was on private dentistry. Many practices who provide both NHS and private dentistry use their private incomes to subsidise their NHS work. If private dentistry is left to collapse, as looks very possible at present, this will have a disastrous effect on the overall provision of care to patients and to the viability of NHS dentistry.
39. Some private practices provide much needed homes for referral of complex dental problems not easily available in the NHS. If some of these practices disappear this will put more strain on NHS resources.
The new normal
40. It is unknown when non-urgent face to face to face dentistry will begin again. We are part of discussions with NHS England on this issue and we are about to survey our members to ask for their views on the best way to return for both patients and the profession. What does seem certain is that there will be a gradual return to routine dentistry and what the profession needs is a clear plan of action from the NHS so dentists and practices can prepare. Financial stability for practices is also needed if patient numbers seen will be much lower than previously but practices still need funding to stay open and provide a service. There is a strong likelihood that the service will be more PPE intensive (greater overheads and supply chain issues). There will be considerable ongoing concerns about PPE availability given global demand and the impact of that demand on cost. Without support such moves could fatally undermine the business model on which NHS practice currently operates.
41. The lessons learned in general medical practice regarding technology and video consultations will not apply to dentistry.
42. To safeguard the nation’s oral health support is necessary for dental practices during the pandemic and to preserve them in the future. We would see as priorities:
1) Clinical priorities need to focus on prevention
2) NHS England needs to produce a clear action plan in consultation with the BDA
3) Providing adequate financial mitigation packages for dentists
4) Extension of business rates support/support for self employed
5) General dental practices could act as testing centres pending a resumption of practice
6) Consideration given to PPE supply and cost, for example could PPE be exempt from VAT for a limited period?
7) Longer term support in line with any new dentistry operating model