Professor Raman Bedi reflects on the crisis in NHS dentistry 20 years ago and his role as the chief dental officer for England during a time of major turbulence in NHS dentistry.
Let’s start in 1999 and the famous pledge made by Tony Blair the then Prime Minister for all to have access to an NHS dentist.
Robin Wild was the CDO in England from 1997-2000 (Gelbier, 2005).
He attempted to persuade ministers to reform the GDP contract and commission a national dental workforce review. We hear this again in 2021!
Robin worked hard in advocating for the workforce review. And only in his last days in office in 2000, the process started and a dental manpower review commenced (Gelbier, 2005).
It is clear that we need regular and robust manpower assessments, not just simply counting the number of dental professionals on the register, but an in depth understanding of the challenges in recruiting dental professionals to provide universal dental care in England.
This led to the Prime Minister pledge in 1999. How did that happen?
Robin was clear that the poor access to NHS primary dental care would best be resolved by reforming the NHS fee scale. As well as recruitment of dental professionals possibly from overseas.
However, the political solution was to create large access centres. So £100m investment was provided to improve access by opening 50 ‘access centres’.
Tony Blair said that there would be guaranteed access to NHS general dental practitioners within two years. He announced this policy at the 1999 Labour conference.
The crisis in access to dental care was, in the minds of politicians, resolved by grand designs and not with basic principles of reform. Namely changing the NHS contract and ensure we have an adequate workforce.
Robin Wild, soon after the announcement of the pledge, resigned as CDO and it was a great loss to the profession (Gelbier, 2005).
Dame Margret Seward was appointed as CDO for England in 2000. Dame Seward was an inspiring leader, both dynamic and a strategic guide.
She was appointed initially for one year, on three days per week. But I often reflect that she achieved more than most who held that position.
What approach did Dame Seward take?
Margaret had great political awareness.
She knew that the Prime Minister pledge was irreversible – even though most of us knew that this was a band-aid solution. So Margaret started to re-engage with the profession.
She started a series of national working groups to look at reforms of NHS dentistry. This work resulted in the landmark publication in 2002: Options for Change (Department of Health, 2002).
All this underlined her strategy of meaningful engagement with the wider profession. It is really clever – and showed me the importance of consultation.
You took over the CDO mantle from Margaret Seward in October 2002.
Yes, and whilst Margaret was a lone person in the CDO office, I had the privilege of appointing a deputy CDO and a senior dentist within the CDO team. I always say it took three men to replace Margaret Seward.
When I took over the office it was clear that the whole NHS was moving towards local commissioning. This better placed it to respond to local needs.
My task was to embrace the findings expressed in the Options for Change publication with the government’s commitment to local commissioning.
I was determined that NHS dentistry’s first priority went to children, young people and seniors. (Gelbier, 2005). And so I would therefore revisit the principle of a core dental service.
The challenge of implementing local commissioning was that to be effective, we would need to close the General Dental Service (GDS). This was a major undertaking and finally ended in September 2005.
The pillars to reforming NHS dentistry were the same as expressed by Robin Wild – alter the contract and construct a dental workforce review.
Yes, although we did a number of things like review the salaried dental service, reform prison dentistry and implement the section 60, which reshaped the GDC. The fundamental change was to change the NHS dental contract and implement a robust workforce strategy (Gelbier, 2005).
Local commissioning implementation meant fundamental changes like closing the GDS and implementing a new contract for delivering NHS primary dental care. However, you couple this with a national dental workforce report.
I picked this up again. The first primary dental care workforce report since 1987 was published in July 2004.
This report led to an immediate recruitment of 1,000 full-time equivalent dentists from overseas. A 25% increase in dental undergraduate numbers, which meant 170 additional students started training in 2005. And providing £80m investment for existing dental schools and the creation of two new schools (Gelbier, 2005).
I openly documented these changes in my report NHS Dentistry – delivering the change (2004) (Department of Health, 2004).
This is really interesting – but what about the NHS dental crisis in 2021.
Well, I have outlined some principles for addressing the NHS dental crisis almost 20 years ago.
These principles now sit within a new landscape and the COVID pandemic has made changing NHS dentistry even more difficult.
Politics invariably makes the situation more complex. One of the government’s top priorities is that of implementing a ‘levelling-up’ agenda. We can show how NHS dentistry reforms can help this policy
Whilst remuneration models have dominated the conversation since 2008, the issues we face are not solved simply by exchanging UDAs for another activity metric.
Our advantages are that Sara Hurley and her team are the most capable group of dental leaders I have witnessed. They absolutely recognise gamut of system issues. As well as contractual relationships that need trust and reform if we’re to build a foundation for sustainable NHS dentistry.
Pre-COVID the dental contract reform was progressing slowly, too slowly I think for Sara. The reform was limited in its ambition.
With the announcement of dental system reform, I detect her influence. The adoption of a far more ambitious approach is very apparent.
We need the wider perspective on how cash allocated to NHS dental care stays in the sector and investment in digital connectivity for dentistry.
The CDO’s advocacy for HEE’s Advancing Dental Care has paid dividends; it underpins a re-invigorated workforce strategy. It will significantly increase workforce capacity and capability with opportunities for progression.
However, if the strategy for the NHS is to make best use of the entire dental team in delivering care, it will also require regulation changes. Never a swift process.
I am confident that Sara’s team will have anticipated this and are actively working with NHS and Department of Health and Social Care to deliver the complementary strand of activity.
It will be a vital part of the system reforms that will address shortfalls in NHS access and oral health inequalities.
However, the NHS dental agenda has not changed, whether now or 20 years ago. We need reorganisation, recovery and refocus.
- Reorganisation of the NHS dental contract and funding
- Recovery that will be managing waiting lists and workforce shortages. Surely one agenda item will be to allow dental therapists to open a NHS course of treatment
- Refocus. This is probably the most important, particularly after the COVID experience. To grasp the opportunity to build an NHS dentistry that is truly fit for the future.
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