NHS Dentistry and Oral Health Inequalities

Wednesday 25th November 2020 Westminster Hall

11:01

[Judith Cummins (Bradford South) (Lab)]

I beg to move,

That this House has considered access to NHS dentistry and oral health inequalities.

It is a pleasure to serve under your chairmanship, Mr Gray. I am delighted to have secured this debate on access to dentistry and oral health inequalities. I have spoken about this issue many times in this place, and it is more urgent now than ever. I will shortly turn to the effects of the coronavirus pandemic on dentistry in this country and, in particular, on access and oral health inequalities, but first I would like to set the scene a little.

In 2017, I held an Adjournment debate entitled “Access to NHS Dentists”. In that debate, I said:

“Millions of people each and every year are being left without access to an NHS dentist.”—[Official Report, 12 September 2017; Vol. 628, c. 812.]

I urged the Government to get on with dental contract reform and bring forward a coherent strategy to tackle the inadequacies and inequalities in the dental health system. That was three years ago, and of course no one could have foreseen the events of this year, but I am making the point at the outset of this debate that NHS dentistry in this country was already in a sorry state before covid struck. It was therefore extremely vulnerable to what has happened since March, the effects of which have been disastrous. The crisis in access that people were experiencing prior to March has been turbocharged. Solving it now requires the Government to dramatically change their approach to oral health treatment and prevention. In discussing the impact of covid on dentistry, I will focus mainly on England.

[Barry Gardiner (Brent North) (Lab)]

My hon. Friend is a student of the Old Testament, and she will know Proverbs 25, verse 19:

“Confidence in an unfaithful man in time of trouble is like a broken tooth”.

We are certainly in a time of trouble. It is not for me to call the Prime Minister an unfaithful man—

[James Gray (in the Chair)]

Certainly not. You must be brief.

[Barry Gardiner]

But the lack of support for dentistry and dental technicians has certainly resulted in a few broken teeth. What does my hon. Friend believe is the single most important thing that the Government can do to support dentistry and the oral health of the nation?

[Judith Cummins]

The single most important thing that the Government can do is reform the dental health contract with a view to more prevention.

During the initial period of lockdown, between March and June, all routine dental care in England was paused and urgent dental care hubs were set up to provide emergency treatment to patients. That period of closure has clearly led to an enormous backlog of patients requiring treatment. The British Dental Association estimates that in April and May only about 2% of patients were able to access dental care, compared with last year, and that between March and October 19 million appointments were lost. One local Bradford dentist told me:

“Our phones are ringing hot with new patients who have no dentist access, which has certainly been made worse by this year’s lockdown. On top of this we are facing significant staffing pressures, due to increased triage requirements and the need to thoroughly clean the practice between patients.”

Just yesterday, I was contacted by one of my constituents who has been trying to get a dental appointment for five months and is living with gum disease and toothache. That is simply unacceptable.

[Rachael Maskell (York Central) (Lab/Co-op)]

I am grateful to my hon. Friend for securing this debate and for all her campaigning work on dentistry services. In York, it is really challenging to get registered with an NHS dentist, let alone access their services. One of the things that has exacerbated that during the pandemic is access to personal protective equipment for people who are overseeing our oral health. Does my hon. Friend believe, as I do, that oral health has not been seen as an equal partner in the provision of healthcare? We seriously have to address that, including access to PPE.

[Judith Cummins]

I certainly agree with my hon. Friend about access to PPE and the fact that dentistry is very much seen as the Cinderella service of the NHS.

Clearing the backlog will be a considerable challenge. Even in the best of circumstances it would take years, but unfortunately we are not in the best of circumstances. As people who have tried to get dental appointments since June know, dentists are operating with considerably reduced capacity. About 70% of practices are operating at less than half their pre-pandemic capacity. The primary reason for that is the requirement for a period of fallow time after each appointment to allow any aerosols that may have been produced by treatments such as drilling or even scale and polish to settle, and then for a long deep clean to take place. The fallow period can be for up to one hour.

In October, the number of NHS treatments carried out was a third the level of the year before. In the BDA’s members survey published earlier this month, 87% of dentists in England cited fallow time as a top barrier to increasing patient access. That could be significant reduced. The number of patients seen could be increased by installing high-capacity ventilation equipment. However, the price of such equipment and ventilation is estimated to start at about £10,000, and the cost is considerably more for larger practices with a high number of surgeries.

The British Dental Association members survey shows that the majority of dental practices in England are not currently in a financial position to afford such an outlay for investment. However, the practices least likely to have had the appropriate equipment tend to serve the most deprived communities, and are also the least likely to be able to afford that investment, increasing oral health inequalities further. That vicious cycle of underinvestment in our most deprived communities feeds inequalities in health outcomes.

[Scott Mann (North Cornwall) (Con)]

I thank the hon. Lady for securing this very important debate. It sounds like Bradford has a similar challenge to Cornwall. We have had a longstanding shortage of provision for NHS dentistry in Cornwall, particularly around recruitment and retention. I had a very constructive meeting with the Minister on this issue recently. Can we work together across the House to put together a programme of work that the Government can adopt to ensure that places such as Bradford and Cornwall get proper NHS provision?

[Judith Cummins]

Of course, I welcome cross-party work on this. I am vice-chair of the all-party parliamentary group for dentistry and oral health. I would very much welcome the hon. Member as a member of the APPG, and look forward to sorting out dentistry, including NHS dentistry, once and for all, with a particular view to addressing the difficulties his constituents face.

I ask the Government to step in now and provide capital funding to invest in new ventilation equipment to help to reduce these fallow times. It is simply not good enough to say that dental practices must fund this themselves. We all know how precarious their funding is, and how hard it has been hit by the pandemic. This is a matter of public health, and it is the Government’s responsibility to safeguard and protect that. To avoid that responsibility would be a matter of gross negligence on the Government’s part.

In recent years, neither NHS England nor the Department of Health and Social Care has extended any capital funding to dental practices. The situation we now find ourselves in requires a change of approach. Local dentists have contacted me about the importance of maintaining temporary contract provisions that have been in place during the pandemic. Alan McGlaughlin, a dentist in my constituency, told me:

“Our fear is that NHS England may ask us to achieve more than the notional level of 20% of contracted targets for next year. This will be impossible due to allowable body flow in through the door and the cleaning and fallow periods required. I hope the NHS will allow for this issue and only then can we settle into a positive routine for the care of our patients.”

Can the Minister confirm that this target will not be increased, putting practices under impossible pressure?

Turning to secondary care, the pandemic has had a significant effect on waiting times for dental procedures in hospital. Thousands of children and vulnerable adults who require dental treatment under general anaesthetic are waiting in pain for treatment. There have been countless horrifying reports in recent months. The BBC has reported on a patient who suffered eyesight damage after not receiving treatment for a fractured tooth, which became an abscess. Meanwhile, the Daily Mail has reported the case of a seven-year-old girl who was left in severe pain for months after she was unable to get an appointment. Even before the pandemic, the waiting time for this kind of treatment was around one year. That is set to become significantly worse, given the backlog and reduced operating capacity.

I recently tabled a question asking for how many children planned dental admission to hospital has been suspended or cancelled since the start of the covid-19 outbreak. The Department responded that data was not available in the format requested. I find it simply unbelievable that the Department of Health and Social Care does not hold this information, so perhaps the Minister can answer that question. If she cannot do so today, I would welcome an answer later on.

As well as the pain and suffering that such delays cause patients, including problems eating, speaking and sleeping, they contribute to the impending public health crisis of resistance to antibiotics, as people require multiple courses of antibiotics while waiting for surgery. I understand that eight organisations, including the British Dental Association, Mencap, the Royal College of Surgeons, and the British Society of Paediatric Dentistry, wrote to the Secretary of State about this in mid-September, but have yet to receive a response, so would the Minister ensure that they receive a response as soon as possible?

I have focused on the practical problems that dentists and patients are facing as a result of the pandemic, but I would now like to turn to the effects that this is having on oral health inequalities. The covid pandemic has exacerbated socioeconomic, ethnic and regional inequalities across the country, and will worsen oral health inequalities too. According to the Association of Dental Groups, access to treatments for poorer patients has fallen by 39% over the past 10 years. Regions such as Yorkshire and the Humber have struggled for years with an acute crisis in access to NHS dentistry. I have raised this many times with various public health ministers, and while we have taken some small but important steps to improve things—especially when the hon. Member for Winchester (Steve Brine) was Minister—for which I am very grateful, the situation is still fundamentally inadequate.

Inequalities in access to dentistry inevitably lead to inequalities in oral health outcomes. A child in Yorkshire and the Humber is five times more likely to be admitted to hospital for a tooth extraction than a child in the East of England. In Bradford, 36% of children have tooth decay, compared with just 7% in the best performing area of the country.

[Robbie Moore (Keighley) (Con)]

I thank the hon. Lady for securing this debate. This has been a big issue for many of my constituents across Keighley and Ilkley, in terms of the outreach programmes that are done by dentists and hospitals, ensuring that those children with tooth decay get the appropriate education about how to treat and look after their teeth. Does she agree that the Government could provide more emphasis on that?

[Judith Cummins]

I absolutely agree that prevention work is key to solving much of our dental crisis, particularly for children. I am also concerned about the effect of the pandemic on the oral health of vulnerable groups, including pregnant women, people who have been shielding and people with dementia. They are highly unlikely to have received any dental care since March. Inevitably, problems will have built up. In the case of pregnant women, who under normal circumstances would be able to receive treatment for up to 12 months after the birth of their baby, will the Minister outline what provisions are in place to ensure they will be able to receive their NHS dental treatment free of charge despite the backlog in treatment?

Finally, I would like to make a few points about the long-term future of dentistry in this country. Dental practices across England—and with them the very fabric of dental care for millions of people—are facing an existential threat. We are at a crisis point for dentistry. Most British Dental Association members believe they can survive only for 12 months or less in the face of lower patient numbers and higher overheads. The Government could take several immediate steps to protect dental practices and improve oral health outcomes.

First, the Government should look at what immediate financial support can be given to dentists and dental practices. For instance, why are dentists among the only businesses on the high street that continue to pay business rates? Secondly, in terms of access to both primary and secondary care, dentistry is severely limited for the foreseeable future, and emphasis on investment in oral health and prevention is needed now more than ever.

The Government must now commit to investing in preventive schemes that are proven to work. That includes supervised tooth brushing for children, which the Government committed to consult on by the end of 2020. I would welcome the Minister’s assurance that that will still go ahead.

On the topic of prevention, I must mention the dental contract. For some time, there has been widespread, cross-party agreement that the dental contract needs reform. Units of dental activity have always been a poor way to measure meaningful dental health care. Their continued presence in the contract would be a disaster in the present circumstances. Despite the wider challenges the Government are facing, now is the right time to do this. Working with the BDA and others, Government must introduce a new contract that focuses on prevention, supports best patient care and improves access, especially for those who need it most.

I have spoken about the real challenges dentists are facing as a result of the coronavirus pandemic, but the problems in our dental health system reach back far beyond that. The pandemic has shown how fragile the system is and the effect on patients when it collapses. I urge the Government to invest in dentistry, prioritise prevention and work to close the inequalities that I have outlined. Anything less than that will let down the most vulnerable people, who need an NHS dental service that is fit for purpose.

11:19

[The Parliamentary Under-Secretary of State for Health and Social Care (Jo Churchill)]

It is a pleasure to serve under your chairmanship, Mr Gray. I congratulate the hon. Member for Bradford South (Judith Cummins) on securing this important debate. I know her long-standing and grounded interest, shared by many across the House, in helping individuals access better health care broadly and in particular for their oral health. She has much support, as my hon. Friend the Member for North Cornwall (Scott Mann) showed.

This is a challenge which, as the hon. Lady neatly articulated, has become much worse under the pandemic. I hope to go into more detail about the fact that dentistry has faced specific challenges while delivering what care it has been able to. There are particular long-standing concerns about access to dental treatment in Yorkshire, including the hon. Lady’s area. She gave credit to my hon. Friend the Member for Winchester (Steve Brine) for the work that he did with her, because flexible commissioning has been operated in that area, and it is agreed that most dentists would prefer to move in that direction. As she said, there are challenges with units of dental activity, and arguably an evolution towards capitation, looking at dentistry in the round, and highlighting prevention would start to address those. The Department, NHS England and NHS Improvement are committed to the growth of access to dental services. There have been a number of actions, and seeing them come to fruition in Yorkshire is helpful in understanding how they might benefit a wider population.

As I said, the pandemic had a significant impact on dentistry. That reduced drastically, as the hon. Lady explained, the number of patients whom dentists can safely see each day. The dental risks were new. At the start of the pandemic we stopped dentistry because of the risk of transmission being much higher, owing to the aerosol-generating procedures used. That applies to extraction, but there is even such a risk in scaling and polishing.

During spring, urgent dental care centres were quite rapidly set up. Up to 635 centres were set up across the country and the remainder of high-street practices were asked to deal with the three As—telephone advice, antibiotics and analgesics. I understand that that was a challenge for patients, but I am sure that the hon. Lady will agree that it was vital to ensure the safety of dentists, dental technicians, nurses and entire teams at the beginning of the pandemic.

[Barry Gardiner]

It is really good to hear the Minister giving a straight response to the questions raised by my hon. Friend the Member for Bradford South (Judith Cummins). She mentioned dental technicians. Is she as concerned as many of us are that because of the lack of work for them now, people are leaving that employment, and the skills base is being lost in such a way that it will be difficult to cope with the expansion of demand once we move from present circumstances beyond the epidemic?

[Jo Churchill]

I believe that the workforce, more broadly, is something we must look at properly in the round.

Aerosol-generating procedures present a high risk, as I said, and under initial guidance issued by Public Health England, infection control required that rooms should be rested for up to an hour, as the hon. Member for Bradford South said, to allow the airborne spray to settle. NHS dental practices were allowed to start offering services from 8 June providing that they had appropriate PPE and infection prevention and control measures in place.

In response to the hon. Member for York Central (Rachael Maskell) I would say that all NHS dentists can access the portal. Registration is voluntary, and 5,500—equating to about 81% of all NHS dentists—have signed up, and 50 million items of personal protective equipment have been dispensed. Making sure that our frontline services have what they require is vital, but the e-portal is being used, and I urge the remaining dentists to sign up.

There are more than 6,000 NHS practices in England that should now be offering face-to-face care, in other than exceptional circumstances. Guidance to practices has made it clear that during the difficult period they should prioritise care for vulnerable groups and then address the delayed routine check-ups; but that remains a challenge.

I recognise the comments that the hon. Member for Bradford South made about expectant mothers; I have asked my officials to look at that at speed, and I will come back to her on that. I am determined that we mitigate widening oral health inequalities as much as we can during this difficult period because, as we have alluded to, we know we had a problem beforehand.

NHSEI is keeping more than 600 urgent dental centres stood up to provide additional capacity in the system. My hon. Friend the Member for North Cornwall said he has problems too—and we have them across the country—so making sure that we have that universal coverage with UDCs is important. I must put on record my gratitude to dentists, dental nurses, technicians and all the team, because this has been a really difficult period. Dentists and their staff have kept vital care going through the initial peak, both remotely and in frontline urgent dental centres; many also volunteered to be deployed if needed on the frontline of covid services, and their contribution was very much appreciated.

It is important to ensure that NHS dentists are financially supported as businesses. NHSEI has continued to pay dental contracts in full, minus the running costs for downtime in the initial lockdown, whatever the volume of service to be delivered, and NHS dentists holding NHS contracts have welcomed that support. However, I am mindful that that support was for NHS dentists, and there are challenges in the private sector—and many practices are a mixture of both.

The focus now is on increasing dental provision as fast and as safely as possible. Key work has been done to establish ways to reduce room resting times, and that advice has been made available to the profession. I regularly meet with the chief dental officer, the BDA and other stakeholders, because it is vital that we keep looking at how we can get volumes up. That also means updating the existing dental infection prevention and control guidance, but it does not solve the challenge of delivering dental care at volume through the pandemic. It is an important step forward, but part of the problem is the variability in the estate, as the hon. Member for Bradford South alluded to—the different sizes of practices, where they are located, and so on. NHSEI is in discussion with the profession and is taking clinical advice on the expectations for delivery of services to the end of March.

I met the BDA and other dental stakeholders last week to progress conversations further, and I heard those messages. The challenge is to make sure that we can get the optimal amount of care for our constituents and patients while safely ensuring that dental teams can be protected, but we do need to see increased provision. I am keen to understand what further work can be done to solve the challenges in dentistry and how it faces the pandemic, and I have asked officials and NHSEI to look at potential solutions, including testing, increased use of ventilation and the financing thereof.

I understand the constraints under which the profession is operating and how vital services are. We know without doubt that oral health inequalities are likely to have increased over the period of the pandemic and NHSEI is working hard to ensure that caring for vulnerable communities is prioritised. Poor oral health can have a devastating impact on somebody’s quality of life, particularly a child’s, and dental disease is entirely preventable. In the Green Paper published in 2019 we committed to looking at those barriers, to fluoridation and to consulting on rolling out supervised tooth-brushing schemes in more preschool and primary settings. We are working as hard as we can to make sure we hit the consultation dates, but there are challenges.

[Rachael Maskell]

Will the Minister give way?

[Jo Churchill]

I am all but out of time.

Sugar plays a crucial role as well, and dental professions are important in healthcare more broadly: diet, spotting oral cancers, diabetes and so on. NHS England is working on a number of key initiatives to reduce inequalities for children, the elderly and the frail. I know that all dentists seek to put prevention at the heart of what they do, recognising that good oral hygiene and diet are the foundation of a lifetime of good oral health.

Through more flexible commissioning, dentists can be partially remunerated for carrying out initiatives such as outreach to schools, care homes and other settings—the homeless are often very compromised with their teeth as well. I hope that provides some reassurance that we are determined to tackle both the long and short-term issues with dental access and the continuing and very concerning inequalities around health, and I am happy to continue this conversation informally.

Question put and agreed to.

11:29

Sitting suspended.