There is a crisis in NHS Dentistry. A survey of NHS dental practices last year found that 91% of NHS practices were not accepting new adult patients, rising to 98% in ‘the South West, North West and Yorkshire and the Humber’. A total of 37% of local authorities reported they had no NHS places available at all and 79% of practices were not accepting new child patients either. Following on from this, in September 2022 an additional investigation claimed we are witnessing the ‘the slow death of NHS dentistry’, reporting that many parts of the country are ‘dental deserts’ where there are not enough NHS dentists to meet the needs of the population. Researchers contacted every dentist across Somerset and not one of the 25 they were able to reach had a single adult NHS appointment available. This leaves people reliant on private care which can be as much as 10 times more expensive than NHS care and is simply not an option for many people.
This will not come as a surprise to the many thousands of people who have been forced to look to DIY care because they were unable to find, or afford, NHS care. Indeed, this is not a new thing. For example, the 2009 Adult Dental Health survey showed that 1 in 5 people delayed dental treatment because of cost. In 2012 research from the charity Oral Health Foundation found that 1 in 5 people would remove their own tooth, or ask a friend to help, if they could not afford treatment, whilst in 2015 the Guardian ran an article on the rise of DIY dentistry. They focused on the sale of over the counter ‘kits’ to enable people to do their own emergency dental care including fillings and replacements for caps and crowns. More recent news reports talk of 3 year waiting lists for care, of people pulling out their own teeth, or filling down broken teeth following guides from videos on tiktok. And there is a knock-on effect on already stretched GP services with patients presenting at GP practices with abscesses, pain and broken teeth because they are unable to find a dentist.
This does not come as a surprise to NHS dentists either, who have long been fighting to improve access to NHS care. Whilst the NHS dentistry crisis was exacerbated by the COVID-19 pandemic, with as many as 40 million lost appointments across 2 years in England alone, dentists have been warning that the service is ‘underfunded and unsustainable’ for decades. Figures from the BDA show that over 3000 dentists have left the profession since the pandemic and the amount of NHS work being carried out by those with NHS contracts is reducing. The British Dental Association (BDA) state that of the 24,272 dentists with NHS contracts in England 15% are carrying out only one course of NHS treatment a month. A recent poll of over 2000 high street dentists found that almost half (45%) had reduced the amount of NHS care they provide since 2020 and three quarters said they were likely to reduce it more in the next 12 months. Workforce shortages are reaching crisis levels and positive change does not look likely in the near future. It takes a minimum of 5 years to train a dentist, with a further 2 years of supervised practice. And once trained the challenge of retaining them remains.
In all of this, what is new is the scale of the crisis and the potential impact both on the future provision of NHS dentistry and on the oral health of those who rely on it. Healthwatch England highlight a ‘twin crisis of access and affordability’ with 61% of people unable to afford NHS dental care and with basic treatment costing £23.80 and complex care costing £282.80.
Last month a Parliamentary inquiry into NHS dentistry was launched. The Inquiry is looking at access to dental care, the ongoing issues with the NHS dental contract and the need to recruit and retain more NHS dentists. In his evidence, Shawn Charlwood, chair of the BDA General Practice Committee stated that ‘The fundamental barrier has been funding. There is only enough NHS dentistry commissioned in this country for 50% of the population….Now can you imagine if this was general medical practice? There would be rioting.’. The funding is tied to the Dental Contract which lays out the amount of Dental Activity required by NHS dentists. For many dentists this is seen as the heart of the NHS crisis. The amount of work (Units of Dental Activity) required to be completed by NHS dentists, combined with the renumeration per activity and the shortage of NHS dentists, puts huge pressure on those who remain and makes private practice, or even leaving the profession altogether, increasingly attractive.
Dentists have been calling for the reform of the latest dental contract for well over a decade. Indeed, dentistry has sat slightly uncomfortably within the NHS from its inception in 1948. Unlike general medical services, dental services provided by general dental practitioners continued to be a mix of private and NHS care post 1948 and this has been, and remains, an uneasy balance. Once established NHS dentistry immediately proved popular with the public and the huge public demand for dentures, nicknamed the ‘denture dash’ meant that within the first 9 months of the NHS, 33 million artificial teeth had been supplied. To limit public spending, charges were introduced for dentures. This was followed by subsidised charges for NHS dentures, introduced in 1951, then charges (co-payments) to cover routine dental care up to a preset limit. Charges were made according to an itemized list of treatments. By 2006 over 400 treatments were separately itemized for charges. Whilst early NHS dentistry focused on treating a backlog of dental disease and decay, by the 1970s the focus was shifting towards public health measures such as fluoridation and oral health education. Somewhat perversely, this history of underfunding, exacerbated by the COVID-19 pandemic has resulted in NHS dentistry reverting to focus on the treatment of a backlog of dental disease and decay rather than prevention. The UDA attached to preventative care also makes this financially less attractive than private treatment for dentists, although this is addressed, to a certain extent, in the latest contract reform.
In July 2022 the latest reform of the NHS Dental Contract was announced with changes including a better recognition of the range and complexity of treatments currently included under band 2 and widening of the scope of practice for Dental Hygiene Therapists to enable them to carry out more complex treatments. This will result in an increase in remuneration for dentists treating more complex cases with the aim of making it more attractive to treat those who are most vulnerable with high needs. Many dentists remain sceptical that this will make any real difference however, as no new financial investment in dental care was announced at all and the exodus of dentists continues. The BDA sees the new contract as little more than tinkering around the edges of a service which is on the edge of collapse (REF).
To exacerbate the problem, the government has just announced that dental charges will increase by 8.5% from 24thApril 2023. This will mean a rise to £25.80 for basic treatment (like a check up), with £70.70 for treatments such as fillings, and £306.80 for a band 3 treatment such as dentures. In a press release following the government announcement at the end of last month, the BDA condemned the government’s decision to increase dental charges during a cost of living crisis. They state that raising the cost of NHS dental treatment is a cynical political decision which prioritises reducing government spending over tackling the barriers to access facing those most in need. Patients will be asked to pay more but none of the extra money will go into improving access to NHS dental services, and no additional funding has been announced at all to help NHS Dentistry to weather the crisis it is now in. Given this it is likely that DIY dentistry enabled by tik tok guidance videos will continue.