The Pandemic highlighted the dissociation of dentistry from the rest of the healthcare service. Dental practices were closed, to reduce the spread of Covid, but required to continue paying for staff at the same level if they had an NHS contract, despite most practices operating in a mixed financial economy and unable to operate privately.
Remuneration was offered to NHS dental practices in return for targets of basic oral healthcare activity being met. This was conditional, however, on the whole practice team being signed up and possibly being redeployed into the Nightingale hospitals. Thus, the whole team being treated as though they were within the NHS system, but without being in receipt of the same benefits as their colleagues in general healthcare. When reopened to offer face-to-face care, many dental staff found it difficult to travel to work, have their children attend school, and obtain access to the first wave of Covid vaccinations, as they do not have NHS passes, resulting in confusion over their “key worker” status.
The change of working patterns brought about by the pandemic resulted in a shortage of dentists willing to return to the dental “treadmill” that is the current UDA contract. This led to the Department of Health and Social Care “clarifying” how dental hygienists and dental therapists can operate under the NHS contract. A patient may now visit a dental hygienist or therapist for an oral healthcare check, that may lead to a diagnosis of oral disease. If so, the dental hygienist or therapist may go on to plan the treatment for the patient and undertake what is needed, within their permitted scope of practice, to help the patient attain oral health. This has been possible in the private dental sector since 2013, and the intention now seems to be to subsidise the loss of dentists with an increase in dental hygienists and dental therapists providing the same work, but without access to NHS benefits that dentist associates receive.
All of this has taken place not only in the context of the global pandemic, but also in the context of NHS structural reform. A reform that has decentralised commissioning arrangements and brought them closer to the local level. Integrated Care Boards (ICBs) have now been tasked with delivering improved access and care in dentistry within the context of their wider remit to reduce health inequalities and improve health outcomes. They are required to do this while constrained by the same NHS dental contract that has been discredited since its inception in 2006.
While the move to ICBs represents an exciting opportunity to integrate dental care with other pathways, the problems that existed before responsibility devolved to ICBs still exist. The difficulty of recruiting dentists to work on NHS contracts has not changed, nor is there any sign that it will if the contract is not substantially revised as the British Dental Association (BDA) is demanding. The BDA suggest a move towards a capitation-based system with prevention at its heart. This preventive care is the primary domain of the dental hygienist, dental therapist, and of a dental nurse with additional skills.
These oral healthcare professionals are perfectly placed to educate, motivate, and empower patients to manage their oral health themselves, starting with the basics of effective daily toothbrushing, as recommended by the Oral Health Foundation during this year’s National Smile Month. Any member of the dental team can coach a patient into better oral hygiene and health, but it does not need to be a dentist who does this. It doesn’t even need to be done face-to-face; with the digital platforms and technology that are available now, the patient does not even need to attend a dental practice and use a chair in surgery time, to receive this support.
Proposals to enhance or enlarge the NHS dental workforce are misguided at best and disingenuous at worst, however. The “clarification” provided late last year for increased utilisation of the dental therapist workforce did not come with any incentives to take on this work, nor consideration for how these professionals are already engaged. It can safely be assumed that all of the almost 5,000 dental therapists on the dental register are already working. While some may be working in the NHS in the salaried sector, the majority will be working privately, mostly within the scope of a dental hygienist. The incentives for this cohort to move to NHS work while the UDA contract remains unreformed are not clear. They are being asked to provide the same work as a dental associate, potentially taking on additional risk, and adding stress to their working day, but without access to the NHS pension or other NHS benefits.
If a dentist will not work for the current UDA values, why would a dental hygienist or therapist do the same work for less remuneration and different benefits, when they are already working privately?
And what of their patients? If a dental hygienist or dental therapist is already working with a busy diary of patients who need appointments to maintain or stabilise their oral health, even if they were keen to undertake NHS work in this way, when would they do it? And where? It may be that there is not the time available in the day to see additional patients, nor the surgery space or chair time to do so. With no comprehensive assessment of the available dental estate it is impossible to understand potential capacity.
These questions, and the questionable ethics behind them have not been answered. Nor indeed has an answer been provided to the shortage of dental nurses. A dentist requires a dental nurse to provide care, if a dental therapist is providing the same care as the dentist ordinarily would, then they will also require a dental nurse. Much consideration has been given into exploring the reasons why dentists are leaving the NHS, but a similar exploration has not been undertaken for dental nurses to see why they are leaving dentistry, and why it is seemingly not an attractive profession for a trainee to enter. If this backbone of the dental workforce is not properly supported then there is no dental care. Without the clerical support staff to answer the telephones and make appointments for patients, the clinical team cannot work. Every individual within a general dental practice has a part to play, they are interdependent, and essential for the smooth running of a practice.
The only members of the dental team with access to NHS benefits are dentists, and this access has long been identified as a key incentive to provide NHS care. It is clearly no longer enough of an incentive. If dental nurses, dental hygienists, and dental therapists contribute to NHS care, but are expected to do so without even that incentive then it is hard to see how morale cannot suffer and how a new way of working can be delivered.
To see a thriving NHS dental service requires real investment, not token gestures to provide a cut price service at the expense of professional integrity. Dental care within the NHS must be properly considered to be within the NHS. Beyond improving pathways and information exchange, this means treating the dental professions with the same courtesy and respect that their peers in the rest of the NHS receive. If dentistry is part of the NHS, then the whole dental team must be treated as part of the NHS family.
