We could have told you so!

‘A pessimist is simply an optimist with experience’

Ehud Barak

‘A pessimist sees the difficulty in every opportunity; an optimist sees the opportunity in every difficulty’

Winston Churchill

Readers may have read about the House of Commons Health and Social Care Committee Ninth Report on NHS Dentistry (2022–2023) (herein referred to as the Committee) that was published in mid-July 2023.¹ However, I don't imagine that many readers will have read its 46 pages, so I will help with that by providing a precis of the main findings, along with some comments, as you might expect! While some readers may have put NHS dentistry behind them (with the numbers doing that increasing daily), I feel that spending some time on the contents of the report will convince those who have left that they have done the right thing, and, for those thinking about it, I hope to provide food for thought.

First, who wrote it? Answer, 11 cross-party MPs, mainly from England (one from Scotland), chaired by Steve Brine, the (Conservative) MP for Winchester. The report starts by identifying the problem of access, with recent research indicating that 22% of the population is not registered with a dentist, some because they could not find an NHS dentist, and others because they could not pay the cost of the treatment.² And, while the report is focused on England, the Committee considered that the problems with access exist across the UK, and that access problems have significant variation around the country. The Committee concluded that:

‘there is a crisis of access in NHS dentistry, with many people unable to access an NHS dentist or are travelling significant distances to get to one’.

We already knew that! They reiterated that everyone should be able to access an NHS dentist when they need one, wherever they live.

Chapter 2 of the report deals with the Dental Contract. Much of this provides historical information, mentioning the 2009 Steele review, which recommended transitioning ‘from dental activity to oral health as the outcome of the NHS dental service’, and the establishment, in 2011, of new contract prototype research involving 100 dental practices undertaking ‘pilots’. I have previously written about the abrupt ending of these in March 2022, and the unfair way in which dedicated dentists were treated.³ Let alone the cost, which in a Freedom of Information request by my MP, Preet Kaur Gill, was stated to be almost £10 million, that being made up of £8 million revenue (which I take it to mean the cost of treatment) and almost £2 million in capital (which covers things like development and maintenance of IT systems, admin support of the pilot and prototype dental practices, project management etc). The Committee concluded that the Department of Health and NHS England must urgently implement a fundamentally reformed dental contract, characterized by a move away from the current UDA system. We already knew that!

Regarding patient registration, which was abandoned in the 2006 new contract, the first incarnation of the Health and Social Care Committee on Dental Services (2007–2008), recommended the reinstatement of patient registration as a means of monitoring access and encouraging long-term continuing care, arguing that ‘dental care is most effective when delivered over time and as part of a trusting dentist–patient relationship’, the theme of my previous editorial.⁴ Fifteen years later, this has not happened, with the latest Committee recommending upholding the previous recommendation, that the Department should reinstate the requirement for patients to be registered with an NHS dentist. We already knew that!

The chapter on the dental workforce makes challenging reading, insofar as the conclusion is that no one knows how many dentists actually work in NHS dentistry! They know how many have a dental contract, but not the hours worked. One witness to the Committee, Dr Sandra White, stated:

‘We do not even have workforce data. We have headcounts, but we do not know how many are part time, full time, NHS or private. We do not even know if they are in this country, and yet we have the headcount. We really need some robust workforce data to have a robust workforce strategy’.

Is this not a massive oversight for any organization, let alone one charged with providing healthcare? Quite logically, the Committee concluded that:

‘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’.

Regarding recruitment and retention, readers within the NHS and without, already know the answer. The Committee expressed concern that any reform will almost certainly be too late for those dentists who have already left the NHS or are considering doing so in the near future. We already knew that!

The Committee suggested that the Government must provide other incentives to attract dentists to undertake NHS work, concluding that 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. They added that:

‘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’.

Perhaps the Committee should also have mentioned the significant shortfall in funding for NHS dentistry over the past decade, and more?

Overseas recruitment was also discussed, or rather, the unacceptable backlog of candidates wishing to sit the ORE (1700 in March 2023) with the Committee recommending that:

‘the Government must work with the General Dental Council (GDC) 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’.

In that regard, a recent announcement from the GDC has confirmed a 20% increase in the number of examinations next year.

The big surprise (which I didn't see coming) was not that the number of dental school places would increase by 40% in 2031/2032 (the delay being needed, I guess, to increase facilities and faculty in dental schools in order to cope with the increase), but that:

‘NHS England will explore measures with the Government such as a tie-in period ‘to encourage dentists to spend a minimum proportion of their time delivering NHS care in the years following graduation’.’

This is not a new idea. This happened in other parts of the NHS 50 years' back, when training was linked to NHS service provision for a period of time. The Committee concluded that:

‘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’.

Places to be a fly on the wall at such consultations between the profession's representatives, the Government and the universities are already fetching a high premium!

NHS England published their long-awaited ‘NHS Long Term Workforce Plan’ on 30 June 2023, but there was no mention of the dental contract in this. The Committee reflected upon the lack of priority given by the Government and NHS England to contract reform (We already knew that!), adding that:

‘we (the Committee) believe it indicates a lack of recognition of the urgent need for reform before any other workforce initiatives can be implemented’.

We already knew that!

Until recently, NHS England was responsible for commissioning dental care services to meet local needs and priorities, managed through its local area teams. The Committee discussed the newly formed Integrated Care Boards (ICBs), who assume the commissioning of primary care medical services, and some pharmacy, dental and optometry services. Yet another change to NHS structures, something that seems to happen on a regular basis. Will it improve anything? Not for dentistry, because there is no statutory requirement for a dentist to sit on these Boards. However, in that regard, the Committee recommended that the Department (of Health) should review whether any specialties are especially under-represented (on these Boards) saying:

‘We believe this is particularly relevant in the case of NHS dental services’.

Finally, on 25 April 2023, it was announced that there would be a Recovery Plan for NHS Dental Services. However, at the time of writing, the plan has yet to be published. The Committee recommended that:

‘the Plan must have the scope and ambition required to immediately address the crisis of access people across the country are experiencing. This should be accompanied by the necessary funding and a plan for swift implementation’.

A good idea, but…

What are the chances of implementation of the findings of this report? When these Committees commenced examining dentistry in 2008, few patients and few dentists were complaining about NHS dentistry. There was a steady supply of dentists from Europe willing to work within the NHS Regulations, therefore access was not much of a problem, and they were content (I did not use the word happy) with the fees. This is no longer the case: we are now relying on the ORE to supplement the UK dental workforce, and, as mentioned, there is a substantial bottleneck with that. How things have changed. There is now (almost) daily coverage of the problems of NHS dentistry. Is it all, too little, too late?

Many of the difficulties alluded to in this Committee's report have been obvious to thinking dentists in the UK, to me^5,6 and other commentators (I think of the wise words of Stephen Hancocks⁷ and David Westgarth,⁸ among others.) In that regard, Stephen Hancocks has beaten me to it (my excuse being that he has 2 weeks between editorials, and I normally have 4 weeks, but for this issue, 6!): on writing about this Report.¹ In his own most eloquent way,⁹ he stated that:

‘the upsurge in private practice to fill the void of the NHS provision is daily evidence that not only fills MPs in-boxes but does also get care completed’,

adding words about government indifference. He wrote nothing to dispel the gloom.

Hopefully, vigilant readers will have noticed the italic words ‘We already knew that!’ throughout this Comment. Dentists who were in touch with, or worked within the NHS Regulations could have told Parliament what was wrong with the NHS system of payment because they have known the problems for years. I even wrote about it before the new contract was introduced!¹⁰ I am not normally a glass half-empty person, but I have become, like the words quoted above, a pessimist, at least with regard to NHS dentistry. This Committee's report has done nothing to change me to an optimist.