Restoring Dental Health in England: Reactive Measures to Compensate for the Lack of Proactive Planning of NHS Dental Services
Long queues formed in the inner-city St Pauls neighbourhood of the southwestern English city of Bristol on the morning of Monday, 5 February 2024. The residents of this vibrant, multi-ethnic, and socially deprived area, currently being rejuvenated, had been without an NHS dental practice, ever since the last remaining provider closed in June 2023. The supplicants lined up in orderly fashion, seeking in-person registration at the new St Pauls Dental Practice on Ashley Road. At times, however, things got unruly and the police had to move in to restore order. The events in Bristol provided compelling visual confirmation for an escalating crisis in English dentistry.
There is indeed a serious lack of access to NHS general dental services, at least three decades in the making. In August 2022, a BBC investigation reported that nine in ten NHS dental practices across the UK were not accepting new adult patients, while eight out of ten were turning away children. The BBC’s researchers had surveyed 6,880 dental practices, in all of the UK’s 217 upper-tier local authorities, finding that the South-West, Yorkshire, the Humber, and the North West were the worst affected regions in England.
Poor access to general dental services disadvantages local communities in many ways. Untreated tooth decay progresses, causing prolonged pain, making eating difficult, and leading to absenteeism from school or the workplace. Preventable complications force sufferers to attend emergency departments and require the services of maxillofacial surgeons, thereby adding to the burden on an already overstretched NHS. Tooth decay is reported to be the single biggest cause for hospital admission in England for children aged between five and 17. Anecdotes abound of people taking matters into their own hands in desperation, resorting to liquid diets, experimenting with superglues, devising makeshift dentures, and even pulling out their own teeth with pliers. The cited reasons for the present crisis include a shortage of NHS dentists, chronic underinvestment in dental services, poorly considered government policies that disincentivise GDPs, Covid pandemic backlogs, and even mass immigration.
NHS dentistry dates back to July 1948, when dental services were first provided free of charge to all, to be provided by General Dental Practitioners (GDPs)-independent contractors who could set up in practice anywhere in the UK. GDPs were initially remunerated on a fee-for-service (FFS) basis, depending on the volume of work and type of service provided. The alacrity with which GDPs embarked on the task of extracting teeth or inserting fillings soon alarmed a cash-strapped government. Free dental treatment soon made way by 1951 for subsidised care. Patient Charge Regulations were introduced in 1952, requiring patients to contribute to treatment costs, guided by a Statement of Dental Remuneration. Subsequent reforms to NHS dentistry were intended to improve access, contain costs, and prioritise oral health over curative treatment. The NHS dental contract of 1990 retained FFS payments for adults, while children were paid for on a capitation (per capita) basis, rather than for actual work undertaken. To compound matters, NHS fees for GDPs were then cut back the following year.
GDPs are currently remunerated according to the General Dental Services NHS contract of 2006. To keep down costs, three bands of treatment were introduced in place of the Statement of Dental Remuneration’s four hundred items of treatment. Band 1, which included examination, x-rays, and scale and polish, attracted one Unit of Dental Activity (UDA), whereas Band 2, including restorations, extractions, and root canal treatments, attracted three UDAs, and Band 3, including crowns, bridges, and dentures, earned twelve UDAs. NHS activity was then capped at an agreed number of UDAs per year. In addition, GDPs were no longer required to provide emergency care for their patients. The contract speeded up the exodus of NHS dentists to an expanding and lucrative private sector, free from public sector bureaucracy.
In an election year, and in the face of an untenable and unsustainable situation, the UK government has been forced to act. The Department of Health & Social Care launched the NHS Dental Recovery Plan on 7 February 2024, supported by £200 million of government funding. It is hoped that this will create 2.5 million more NHS dental appointments and provide 1.5 million extra treatments over the coming year. It will become easier to identify NHS dental practices on the NHS website or by use of the NHS App. Meanwhile, ‘new patient payments’ will be introduced, and standard fees for GDPs will be topped-up. Up to 240 GDPs, representing 1 per cent of the workforce, will be tempted by a one-off “golden hello” payment of £20,000 to work for three years in underserved areas, often referred to as “dental deserts.” Dental vans will provide mobile dental services to rural and coastal areas of need. A ‘Smile for Life’ programme will advise parents and parents-to-be about dental care for their offspring, while dental teams will target nurseries and schools with fluoride varnish treatments and supported tooth-brushing. Water fluoridation will be rolled out across the country, in collaboration with local authorities.
This mishmash of financial incentives for GDPs, preventative measures to improve oral health, and widened access to dental services may just be a case of too little, too thinly spread out, and too late. Retention of GDPs in the NHS has been hindered by a contract that does not adequately reward their efforts, as reimbursement by UDAs does not adequately compensate for multiple visits or the length of time spent at a single sitting for any given treatment. It is unfortunate that dental hygienists and dental therapists do not practise autonomously and offer their services directly to the public, independent of GDPs. While private dentistry may be in the ascendance and provides good quality, innovative treatments to well-heeled and insured people, those most in need of dental care, and also most at risk of serious complications such as oral cancer, have been let down, unable to find and then access NHS services. NHS dentistry warrants recovery and reform, but the government’s efforts, although welcome, may not be enough to reverse the decline of an important sector of healthcare. Workforce planning, contract reform, adequate reimbursement for complex dental procedures, and structural changes are awaited.
Ashis Banerjee