Ninth Report - NHS dentistry

We believe there is a crisis of access in NHS dentistry. Many people are unable to access an NHS dentist or are travelling significant distances to get to one. Access varies across the country and is being experienced unequally by different groups. We believe everyone should be able to access an NHS dentist when they need one, wherever they live.

We welcome the Government’s ambition for everyone who needs an NHS dentist to be able to access one. This ambition must ensure access within a reasonable timeframe and a reasonable distance. The Government must set out how they intend to realise this ambition and what the timeline will be for delivery. It is vital that this ambition is the central tenet of the Government’s forthcoming dental recovery plan. Once the plan has been published, we will revisit the recommendations in this report to assess it against this criteria.

A lack of public awareness about NHS dental services and how practices operate is contributing to access issues. The Government and NHS England should roll-out a patient information campaign with the aim of improving awareness of how NHS dentistry will work and ensure the public are better informed about what they are entitled to. This should clarify common misconceptions, for example, about patient registration, recall periods, and NHS dental charges and exemptions.

Practices should abide by NICE recall guidelines of up to two years for most adult patients, recognising the need for more regular recall for some, but people should not automatically be removed from dentists’ registers of NHS patients without good reason. This should be monitored by NHS England to ensure it is being carried out. (Paragraph 19) The Dental Contract

We welcome the fact that to try and address the underspend, NHS England is applying a ringfence for 2023/24, to ensure that no ICB can divert funding away from NHS dentistry. We recommend that this ringfence applies permanently, and NHS England puts in place transparent scrutiny to ensure compliance.

We also welcome measures by NHS England to intervene on providers who are under-delivering on contracted NHS activity. We look forward to an update on how this work is progressing. We welcome this funding being used flexibly, however there cannot be further delays in doing so.

Fundamental reform of the dental contract is essential and must be urgently implemented, not only to address the crisis of access in the short-term, but to ensure a more sustainable, equitable and prevention-focussed system for the future. We are concerned that any further delay will lead to more dentists leaving the NHS and exacerbate the issues patients are experiencing with accessing services. (Paragraph 50) 34 NHS dentistry

We welcome the Government’s recognition of the need for dental contract reform. The Department and NHS England must urgently implement a fundamentally reformed dental contract, characterised by a move away from the current UDA system, in favour of a system with a weighted capitation element, which emphasises prevention and person-centred care. This should be based on the learnings from the Dental Contract Reform Programme and in full consultation with the dental profession.

We believe patient registration under a reformed capitation-based contract will better enable those patients who currently can’t access a dentist to be able to do so.

We uphold the recommendation from our predecessors’ 2008 report into Dental Services, that the Department should reinstate the requirement for patients to be registered with an NHS dentist. (Paragraph 55) Workforce

The Government states that the number of NHS dentists has increased over the past year. However, while the headcount has gone up over the past year, it has gone down over the past three years, and moreover headcount alone does not reflect how much NHS work these dentists are undertaking. We heard repeatedly that a lack of dentists and dental care professionals undertaking NHS work is the main driver behind both lack of access to appointments for patients, and the underspend in primary care dentistry.

The Government and NHS England should commission a dental workforce survey to understand how many full-time and part-time-equivalent dentists, dental nurses, therapists and hygienists are working in the NHS, and how much NHS and private activity they are undertaking, alongside demographic data such as age and location.

The Government and NHS England must improve the routine data that is collected on the number of NHS dentists and the wider dental team, and the levels of NHS activity they undertake, as well as data on demand, to assist with workforce planning and identifying gaps in provision. This must be addressed in the forthcoming dental recovery plan. Until such a time, the Government should focus on statistics which show the levels of NHS dental activity.

Any contract reform now will almost certainly be too late for those dentists who have already left the NHS or are considering doing so in the near future. The Government must urgently introduce incentives to attract and retain dentists to undertake NHS work. These should include, but not be limited to, the reintroduction of NHS commitment payments, incentive payments for audit and peer review, and the introduction of late career retention payments. The development of a careers framework should be considered, including on-going education, supervision and support. This should form part of a wider package, accompanied by a communications drive, to entice professionals to return to NHS dentistry.

The Government, NHS England and ICBs must ensure that the reformed contract ensures that full use is made of the skills of the whole dental team. (Paragraph 73) NHS dentistry 35

We support the implementation of the work of the Advancing Dental Care Review. Centres for Dental Development could have the potential to change how we approach training dentists in the UK to meet the needs of the populations who most require care. However, these are in their early stages and their outputs will need to be assessed. We also recognise that incentives are required in the short-term to address the immediate challenges with supply and demand.

The backlog of applications for the Overseas Registration Exam is unacceptable and resolving this represents an opportunity in the short term to increase the number of dentists working in the NHS, and therefore create more appointments to enable patients to access much-needed services.

The Government must work with the General Dental Council to ensure the backlog of applications for the Overseas Registration Exam is cleared in a timely manner, and to speed up changes to the process of international registration for new applicants seeking to work in the NHS.

We are concerned that the absence of explicit mention of the dental contract in the Long Term Workforce Plan reflects the lack of priority given by the Government and NHS England to contract reform. We believe it indicates a lack of recognition of the urgent need for reform before any other workforce initiatives can be implemented.

Given the varying views expressed regarding a tie-in for new graduates into NHS dentistry, we urge NHS England and the Government to ensure full consultation with professionals and representative bodies, as they seek to explore the potential merit of such a policy, although its success depends on fundamental contract reform, and should be accompanied with a careers framework. (Paragraph 92) Integrated Care Systems

The dental profession should be represented on Integrated Care Boards to ensure they have the necessary expertise to inform decision-making around contracting and flexible commissioning. This should include wider engagement with the profession locally, for example through Local Dental Committees and Local Dental Networks.

We contest the Department’s rejection of the recommendation in our ‘Integrated Care Systems: autonomy and accountability’ report, and reiterate that they should centrally gather information relating to the membership of ICBs, including the specific role of members and their area of expertise. We also recommended the Department should review that information with a view to understanding whether the policy of keeping mandated representation to a minimum is the right one and whether any specialties are especially under-represented. We believe this is particularly relevant in the case of NHS dental services.

We welcome the initiatives outlined by the Chief Dental Officer to help ICBs commission dental services in a way that best meets the needs of their local populations. NHS 36 NHS dentistry England should provide evidence of the effectiveness of these initiatives, so that ICBs can see for themselves which options they could most usefully pursue and best practice is spread.

In light of the current national contracting arrangements, NHS England must provide clarity to ICBs about what flexibilities they have with regard to commissioning NHS dental services and targeting resources according to the needs of their populations.

ICBs have been delegated responsibility for commissioning dental services by NHS England. They offer an opportunity to improve access locally, better integrate services around patients and address inequalities.

By the end of July 2024, every ICB should have undertaken an oral health needs assessment, in consultation with service users, patient organisations and the profession. NHS England should provide support to ICBs to undertake this, including sharing examples of best practice and learnings from other ICBs. NHS England must also ensure each assessment is sufficient to meet its intended purpose. (Paragraph 122) NHS dentistry 37