Morale among NHS dentists is at ‘an all-time low and we are facing an exodus of dentists from the NHS’, the British Dental Association (BDA) warns. In its briefing, Reviewing the NHS Dental Contract published in December 2022, the BDA says chronic underfunding, the current NHS dental contract, and the added challenges posed by Covid-19 are to blame for problems with burnout, recruitment, and retention in NHS dental services.
The results from a BDA survey published on Monday (March 6) reveal more than half of dentists in England (50.3%) report having reduced NHS commitments since the start of the pandemic.
A further 74% of those who responded to the survey indicated they plan to reduce or further reduce NHS work with 43% indicating an intention to go fully private and 42% likely to change career or seek early retirement. More than one in 10 stated they intend to move to practice abroad.
The BDA says measures often put forward as solutions to the shortage of NHS dentists – such as training more dentists, or making it easier to bring in foreign dentists to work in the UK – might help in the short term, but represent ‘a sticking-plaster approach’. ‘Unless the underlying reasons why dentists are leaving the NHS in their droves are addressed, trying to bring in more dentists would be akin to trying to fill a leaky bucket,’ the BDA says.
‘Reform of the dysfunctional NHS dental contract is a matter of urgency – a reformed service won’t work if there is no workforce left by the time it’s finally introduced’, the BDA says.
According to the BDA the main issues with the 2006 contract are restrictions on the number of NHS patients a dentist can see and the rate of pay for treatments which see dentists ‘punished’ for taking on more complex patients.
‘The target system means dentists pay back for undelivered activity, even if they have been working flat out delivering NHS care,’ says Eddie Crouch, chair of the BDA.
Dentists are commissioned to deliver a set number of units of dental activity (UDAs) which caps the number of dental procedures they can perform each year. In recent years an increasing number have not achieved the UDA target and have therefore lost out financially.
If a dentist does deliver more than they have been commissioned to, they are not paid for the extra work and added to that they must pay for any materials used, laboratory work and other overheads. ‘Recent changes to the contract does allow over delivery of up to 10% of the contract but very few will be in this position,’ says Mr Crouch.
The BDA also highlights that dentists are being ‘punished’ for taking on new patients with high needs. In November 2022 the government raised the number of UDAs (the average UDA value is £25) from three to five for treating three or more teeth and seven UDAs for complex molar root canal treatment,. However, less complex work is still rewarded at the same rate as treatments that can take hours – effectively continuing to punish dentists for taking on new patients with high needs, says the BDA.
A key ask in the BDA’s briefing is that dentistry should not be treated as an afterthought in the reform of the healthcare system. ‘Changes to primary care commissioning in the Health and Care Act 2022 must not lead to further cuts to the already extremely overstretched NHS dental budgets, and dental services must be represented in the governance structures of the integrated care systems (ICSs),’ the BDA says.
With NHS dental services coming under the remit of integrated care boards (ICBs) on 1 April, Mr Crouch, says ‘it’s important that the voice of dentistry is actually heard’.
‘If you were to ask the profession whether they thought having ICSs were an improvement or not, you would probably see a fair split between those who see this as a threat, and those who view it as an opportunity to commission more flexible services,’ he says.
While financial incentives to recruit and retain NHS dentists have met with varying degrees of success, the solution to the workforce crisis is contract reform, says Mr Crouch. ‘If the contract is not changed urgently then the situation, which at the moment is terrible, will become worse.’
He encourages ICSs to talk to local dental committees and networks in their areas to work collaboratively ‘to make the best of what we can’. ‘There are people out there with innovative ideas about how services can be improved within existing budgets. But we need significant contractual changes to back up that innovation.’
There are more than 44,000 dentists registered with the General Dental Council in the UK as of December 2022. They don’t all work in primary care on the high street, but the majority, around 35,550 do. Some work in community dentistry, academia, and hospitals, such as in oral surgery and maxillofacial surgery.
Dentists UK: 44,000 (Dec 22)
High street dentists/General dental practitioners (GDPs) UK: 35,550
Dentists in England: Unknown
Number of NHS dentists (GDPs): 24,272 (2021/22)*
Dental practices in England: 7,084
Hospital dentists: 2,697 (2020/21)
Dentists in private practice UK: 7000 (2020/21)
Dentists in private practice England: Unknown
Purely private practices: Estimated at 3,500
All practices: Around 12,390
Dental practices accepting NHS work in England: In August 2022 the BBC found 9 in 10 practices were not taking on new adult NHS patients and 8 in 10 not taking on new children.
*In 2022-22 they were 24,272 dentists who performed NHS activity in England, lower than levels seen in 2017/18. There is no whole time equivalent (WTE) data collected, so this data gives equal weight to those doing one NHS check-up a year as an NHS full timer. The BDA surveys show for every dentist leaving the NHS 10 are reducing NHS commitment. This goes unseen in official data.
Pay and training
According to the BDA 1,500 dentists qualify across the UK every year. Becoming a dentist involves at least five years’ study at dental school, followed by one or two years of supervised practice.
There is a ‘massive shortage of dentists who would wish to work in NHS system because they do not think the work is well remunerated,’ says Mr Crouch adding that dentists have seen a 30% net reduction in income during the last decade.