Just how bad does it have to get?
Michael Watson details exactly what’s going wrong in NHS dentistry and what the Government needs to do to resolve it.
Over the past year we have observed a war of words over NHS dentistry, in Parliament, the media including national and local newspapers, the dental press and social media.
The reaction of Government has been to stand idly by and make complacent remarks to the effect that things are not as bad as all that and NHS England is doing its best.
The impetus of two years ago, after minister Alistair Burt MP told the BDA Conference that the number of child extractions is ‘a national scandal’, has been lost.
So, with the LDC Conference coming up this week, I decided to do a bit of digging to find out just how bad things were in NHS dentistry and found that they were much worse than I had thought.
NHS dentistry is not very high up the priority list of Government and to an extent you can understand why in the current circumstances of Brexit, the economy, defence, social mobility, education, social housing, social care and the NHS as a whole.
But two immediate problems in NHS dentistry are about to come into sharp focus for politicians that are both going to have a direct impact on access to NHS dentistry for their constituents, in other words – voters.
The first immediate problem is that for the first year ever (2018/19), 330 NHS dental practices have a band one unit of dental activity value (UDA), which is currently £21.60, but a practice’s contract value for a UDA might only be £20.
The unit of dental activity paid to a dentist is lower than the charge that patients pay, and which an NHS dental practice collects on behalf of the Government and which was put in place by Government in 1951 originally.
Since March 2016, patient charge revenue (PCR) has increased by 5% each year.
As a result of this, the amount of money going to the Government has risen from £739,453,773 to £783,350,077 between 2015/16 and 2016/17.
This has obviously had an impact on patients, as they are paying more for dental care every year.
This has also resulted in putting NHS dental practices in a position where to economically survive they are handing their NHS dental contracts back and carrying out low cost private dentistry for their patients.
This situation is directly impacting on patient access to NHS dentistry.
Government needs to remember an NHS dental practice’s financial viability is completely covered by the practice owner, unlike doctors’ practices, which are paid for wholesale by the Government, unless they are a partner.
At the end of the day, dental practices have to be financially viable – no-one lives on fresh air.
If UDA contract values remain capped except for a negligible rise, and if PCR increases 5% every year, practices will be left with no choice but to consider affordable, family, private dentistry.
Eddie Crouch, BDA vice chair in a recent article published in the dental press, stated: ‘With clawback in England jumping from £55 to £81 million in one year and 330 practices now having a UDA value below the band one charge a patient pays and with real problems in recruitment and contracts being handed back, when will NHS England acknowledge the crisis in NHS dentistry?’
In addition to this there has been the impact on NHS dental practices of the falling value in pound sterling due to Brexit with about 50% of all products and equipment that a dental practice uses coming from outside the UK.
In addition there has been the rising cost of regulation and inflation.
Solution – NHS dental practices’ contract values have remained as they were in 2006 except for the uplift of nominally 1%, in reality 0.7% per annum (since 2010) via the Doctors and Dentists Pay Review Board (DDRB), which has not kept up with PCR at 5% per annum.
To avoid more and more NHS dental practices falling into the forced situation of reducing NHS patient access, Government must match the DDRB uplift with the PCR uplift.
The next DDRB uplift is due to be announced in June or July, the Government should act swiftly.
This is even the private view of some members of NHSE.
This is a view shared by many organisations in dentistry, including the Associated Dental Groups (ADG) and the British Dental Association (BDA) – the latter of which recently suggested the need for annual contract uplift to reflect the percentage rise in PCR in a paper for the annual conference 2018 of the Local Dental Committees this week.
It is crucial that the full consequences of the current situation are realised and acknowledged by the powers that be in order for the necessary changes to be implemented.
Otherwise, NHS dentistry may be very different in the future.
The second immediate problem is recruitment, which falls into two parts, what politicians can address immediately if they have the will and secondly the element that needs addressing if there is to be a viable future for NHS dentistry.
The immediate problem is that 17% of the UK workforce consists of EU dentists and that they deliver 22% of NHS dentistry.
This rises up to 30% in socially deprived areas.
The Conservative Party made a manifesto commitment (in 2017) regarding dentistry and socially deprived areas, yet due to the Government’s migration policy, this commitment is now being frustrated.
NHS England is acknowledging this workforce problem, which has been highlighted by both the ADG and BDA.
According to the BDA evidence submitted to the DDRB in 2017 says: ‘Nearly half of practices that had sought to recruit an associate in England had experienced difficulties’.
This figure rose to two thirds of practices in the BDA’s survey of practice owners.
However, if we cannot solve the recruitment shortage and grow the pool of talent from which to draw, this will all continue to provide yet another barrier to the continued access to and provision of NHS dentistry.
Sarah O’Connor of the Financial Times (FT) highlighted that the arbitrary UK visa quotas are leading to perverse and damaging outcomes.
Current British migration policy puts too much emphasis on money instead of human capital and as a result is having a direct damaging effect on the NHS and the provision and access to doctors, nurses and dentists for the UK population.
Pulse, The Telegraph, The Times, The Guardian, Sun and Mirror have all run coverage of the similar situation for doctors, whose numbers are down by 1,000, a seven fold increase in practice closures, 445 practices closed or merged, 1.3 million patients forced to find new family doctors.
Solution – if the Government wants to have access to NHS dentistry it needs to ensure it has a workforce to deliver it and in the immediate near future this means dentists from the EU/EEA, as unfortunately since 1997 dental qualifications from Commonwealth nations have not been recognised by the regulatory bodies in the UK.
If press coverage and surveys are to believed, support for an easing of immigration restrictions for staff coming to work in the NHS is high, even among Brexit voters.
The Government should also note that while they debate about a visa quota system that is not appropriate, the very people in question may decide they will take their talent and abilities to another country.
The UK should not be so arrogant to believe we are the only destination of choice, the young dentists of today certainly do not see it that way.
To ensure the UK has the necessary number of dentists it needs to act swiftly and add dentists to the shortage occupation list ie excluded from the cap on tier two visas.
This is something that should be the case for all professionals working in the NHS.
Quite simply the UK needs them and we should not cut our nose off to spite our face.
The second part the recruitment problem is around the current 2006 contract which is a failure for patients, dentists and NHS England.
The prototypes were reviewed by the Department of Health in a document published 22 May, which highlighted them as having significant issues around the business model.
As it stands this is not sustainable and is also not meeting ‘the needs of high needs patients’.
Contract reform started in 2009 following a damning Parliamentary report on the current dental contract.
The next generation of dentists coming through are already risk-averse due to the increased litigation in the profession and a lot are lacking practical experience and confidence upon leaving dental schools.
The current NHS contract is so unattractive to a lot of young dentists that more and more are leaving for hospital work or private practice earlier than they used to.
In the past dentists did 10 years’ work in NHS dentistry before considering a move to more private work, today it is five years and in a number of instances 30 months.
This is contributing to the other challenge we are facing with NHS recruitment.
Most new dentists prefer to remain near or in cities.
On the east coast, the only main cities are London, Hull and Newcastle, and this is creating a workforce shortage from The Wash (Norfolk) to Whitely Bay (Northumberland).
What’s more, the issue is now moving in-land, with rural areas across the country struggling to recruit dentists and it is likely to get worse after Brexit.
Another part of the solution is the extension of the recently announced £10 million fund to retain doctors to dentists as well.
In order to find a solution, we now need NHS England to realise the scale of the problem and to work towards a realistic contract.
Solution – one of the solutions might be skill mix utilisation, increasing the role of dental therapists and extended duties.
Training of these members alongside dentists would be more affordable than the current primary focus being on dentists, offering a viable alternative to the existing NHS practice model.
However, for this to work we need direct access for dental therapists and a change in attitude among both the profession and our patients that facilitates such a change.
We also need a reversal of the cut to the Health Education England Budget for training dentists as more therapists could be part of the solution, the Government’s own strategic workforce planning group acknowledge it will take at least 10 years for sufficient numbers to be trained to make an impact.
It is good to see the setting up of a new medical school in Lincoln, it would be even better if this was accompanied by a dental school too, that could train dentists and therapists, to help address the east coast recruitment issue.
It is also crucial that politicians, NHS England and other governing bodies understand the profession’s concerns so that we can work together for solutions and as highlighted, some of these solutions are required sooner rather than later.
NHS dentistry only represents £4.5 billion approximately in a £114 billion NHS England budget.
The Minister Steve Brine MP in reply to a fellow MP on 8 May in Hansard highlighted that ‘the most recent figures show that 22 million adults were seen by an NHS dentist in the 24 months from January ’16 to Christmas last year and 6.9 million children visited a dentist last year.’
That is all very well and good but one thing should be remembered, those 22 million adults are also voters and if their access to NHS dentistry is falling in the near future due to the circumstances outlined here, then they may remember when it comes to the ballot box.
May 2022 appears some time away, but in the current political climate a general election may take place earlier than expected.
What is more, the dental profession may decide in light of the critical circumstances to highlight further this dire situation.
The Government needs not prevaricate any longer but to act swiftly, especially on the two immediate issues on the horizon.
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