NHS Dentistry: Recovery and Reform

Lord Markham Excerpts

Wednesday 7th February 2024 Lords Chamber

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Markham) (Con)]

My Lords, I start by declaring my interest that my wife, who is present today, is a dentist—although she is not currently practising. With the leave of the House, I shall now repeat a Statement made in another place by my right honourable friend the Secretary of State for Health and Social Care. The Statement is as follows:

“With your permission, Mr Speaker, I would like to make a Statement on our plan to recover and reform NHS dentistry. First, on behalf of the entire House and my department, I send our very best wishes to His Majesty the King. His decision to share his diagnosis will be welcomed by anyone whose life has been touched by cancer. I know that we are all very much looking forward to seeing him make a speedy recovery and resume his public duties.

Turning now to dentistry, thanks to a once-in-a-generation pandemic between 2020 and 2022, 7 million patients across England did not come forward for appointments with NHS dentists. Since then, we have taken decisive action to recover services. We have made reforms to the dental contract, so that practices are paid more fairly for caring for NHS patients with more complex needs. We have made sure that dentists update the NHS website regularly so that the public know that they are taking on new patients. This has delivered results, with 1 million more people seeing an NHS dentist last year than in the year before. However, we know that too many, particularly those living in rural or coastal communities, are still struggling to find appointments. This recovery plan will put that right by making NHS dental care faster, simpler and fairer for patients and staff. It is built on three key pillars, which I will address in turn.

First, we will help anyone who needs to see an NHS dentist to do so, wherever they live and whatever their background. To do this, we must incentivise dentists across the country to care for more NHS patients. That is why I am delighted to tell the House that for the coming year, we are offering dentists two new payments on top of their usual payments for care— £15 for every check-up they perform on NHS patients who have not been seen over the past two years, and £50 for every new NHS patient they treat who has not been seen over the same period—because we know that patients who do not have a relationship with a dentist find it harder to get care. That is not a long-term ambition: our new patient premium will be available from next month.

We are also increasing the minimum payment that dentists receive for delivering NHS treatments. This will support practices with the lowest unit of dental activity rates, or UDA, to provide more NHS care. However, we know that in many of our rural, remote and isolated communities, dentists themselves are in short supply. That is why, starting this year, up to 240 dentists will receive golden hello payments worth up to £20,000 when they commit themselves to working in one of those areas for at least three years. These dentists will give patients the care they need faster, make dental provision fairer and tackle health inequalities.

We are also delivering dentistry to our most remote regions without delay. This year, we will deploy dental vans to more isolated, rural and coastal areas. Staffed by NHS dentists, they will offer check-ups and simple treatments such as fillings. This model has been tried and tested successfully across many regions. For example, last year in Cornwall, a mobile van visited five harbours, treating more than 100 fishermen and their families. We will be rolling out up to 15 vans across Devon, Gloucestershire, Somerset, Norfolk, Suffolk, Lincolnshire, Cambridgeshire, Dorset, Cornwall, North Yorkshire and Northamptonshire. This move has been welcomed by Healthwatch, the Nuffield Trust and the College of General Dentistry. We will let patients know when vans will be in their area, so they can get the care they need faster.

These reforms will empower NHS dentists to treat more than 1 million more people and deliver 2.5 million more appointments. As the chief executive of National Voices, a group of major health and care charities, said:

‘This extra money … should help thousands of people who have been unable to see a dentist in the last two years to get the care they need’.


These reforms are just the beginning. This recovery plan will also drive forward reforms to make NHS dentistry sustainable for our children and our grandchildren.

That brings me to the second pillar: growing and upskilling our workforce for the long term. Our long-term workforce plan, the first in NHS history, gives us strong foundations on which to build. By 2031, training places for dentists will increase by 40% and places for dental hygienists and therapists, who can perform simple tasks such as fillings, will also rise by 40%. More dentists and more dental therapists will mean more care for NHS patients.

I am delighted to tell the House today that we are going further in three key ways. First, we will consult on a tie-in to NHS work for dentistry graduates, because right now too many are choosing to deliver private work over valuable NHS care. More than 35,000 dentists in England are registered with the General Dental Council, but last year almost one-third worked exclusively in the private sector. Training those dentists is a significant investment for taxpayers, and they rightly expect it to result in the strongest possible NHS care. That is why, this spring, we will launch a consultation on a tie-in for graduate dentists and how this could deliver more NHS care and better value for taxpayers.

Secondly, we will take full advantage of our dental professionals’ skills. Today, even though they have the right training, without written direction from a dentist, dental therapists cannot do things such as administer antibiotics. This year, we will change this, making life simpler for dentists and making care faster for patients. As the president of the College of General Dentistry has said, the

‘use of the full range of skills of all team members will enable the delivery of more care and make NHS dentistry more attractive to dental professionals’.

Thirdly, we will recruit more international dentists to the NHS. We have a plan to do this by working with the General Dental Council to get more international dentists taking exams and to get them on to the register sooner, and to explore the creation of a new provisional registration status so that, under the supervision of a dentist who is already on the register, highly skilled international dentists can start treating patients sooner, rather than working as hygienists while they are waiting to join the register.

I turn now to our plan’s third pillar, which is prioritising prevention and giving children a healthy smile for life. This begins by supporting parents to give their children the best possible start. That is why family hubs up and down the country will offer parents-to-be expert advice on looking after their baby’s teeth and gums. As those babies grow up, we will support parents and nurseries in making sure that, before every child starts primary school, brushing their teeth is part of their routine.

The evidence is clear: the earlier good habits are built, the longer they will last. Seeing a dentist regularly is vital for children’s health, but, since the pandemic, too many have been unable to do that. That is why this year we are taking care directly to children. We will deploy mobile dental teams to schools in areas with a shortage of NHS dentists. They will apply a preventive fluoride varnish to more than 165,000 reception-age children’s teeth, strengthening them early and preventing decay. Our Smile for Life programme has already been endorsed by the College of General Dentistry.

Six million people in England already benefit from water fluoridation. In order to go further in protecting children’s teeth, we will consult on strengthening more of our country’s water with fluoride. Again, the evidence is clear: in some of the most deprived parts of England, enhancing fluoride levels could reduce the number of teeth that are extracted because of decay by up to 56%. That is why, through the Health and Care Act, we made it simpler to add fluoride to more of our water supply. As a first step, this year we will launch a consultation on expanding water fluoridation across the north-east—an expansion that would give 1.6 million more people access to water that strengthens their teeth, preventing tooth decay and tackling inequality.

This is our Government’s plan to recover and reform dental care: dental training places up by 40%; 2.5 million more appointments; dental vans treating more patients; more dentists in remote areas; more dentists taking on NHS patients; better support for families and better care for children; patient access up and inequity coming down. It will make life simpler and treatment faster and fairer for patients and staff. We have taken the difficult decisions, and we have now delivered a long-term plan to make dental care faster, simpler, and fairer for people across the country”.

--- Later in debate ---

[Lord Allan of Hallam (LD)]

My Lords, from these Benches, I also echo our best wishes to His Majesty the King. We hope that he makes a speedy recovery.

In responding to this Statement, I also reach for that familiar phrase of it being a sticking plaster, before heading in the direction of dental metaphors. Rather than a scale and polish, it seems to me that this is something of a temporary filling when, as the noble Baroness, Lady Merron, says, NHS dentistry needs serious root canal work.

I feel for the Minister because I know he cares about dentistry and understands the scale of the problem. He has to sell the temporary filling hard in the hope that we will trust the Government to deliver on the more comprehensive course of treatment that is in the consulting on and exploring part of the document.

There are three elements in that long-term part of the plan on which I hope the Minister can comment further today or later in writing. First, we are told that the Government will ring-fence the £3 billion of NHS dentistry budgets from 2024-25 which have been underspent because of the lack of dentists willing to work at NHS rates. We cannot see this changing overnight, even with what is announced today. How will this ring-fencing work if an integrated care board has still not been able to get the take-up of the contracts that it wants? What kinds of things could they use these underspends for? Will these include additional local financial incentives on top of the ones we are discussing at a national level today?

Secondly, it is important to realise the benefits of people with dental qualifications moving to the UK. I know that the Minister would wholeheartedly agree. The policy document promotes the idea of a provisional registration of overseas qualified dentists while they are waiting for their full GDC registration. The phrasing in the Statement and in the document is quite hesitant. It talks about the Government working towards introducing legislation. Can the Minister give us more information about the complexity of the legislative changes that will be required and their likely timescale?

Thirdly, failures in emergency care both cause severe patient distress and additional work for NHS hospitals. The noble Baroness, Lady Merron, has already pointed out that many children are referred to hospital for emergency treatment. I looked at the description on the Smile Together website—a good service in Cornwall cited in the plan. It says that:

“Smile Together is commissioned by NHS England to provide urgent and emergency dental care to patients who would otherwise be unable to access treatment. Demand for this service is very high and the criteria set by our commissioners is very strict. We therefore offer emergency appointments that are independent of our NHS service”,


and people who call in who are unable to get an NHS appointment and do not wish to wait and try again the next day can basically go private. I am not sure we want to be in a situation where people needing emergency care are left hanging on the phone day in, day out, or face having to go for the private option. I hope the Minister can explain what the Government intend to do around emergency care. I hope he will agree that making sure people can get NHS emergency care will be better for both the patient and the NHS.

A temporary filling is designed to last a few weeks—or months at most—or perhaps until an election. We are grateful for the temporary relief it provides, but we know that more work is needed, and this has to be done urgently if we are to fix NHS for the long term.

[Lord Markham (Con)]

I thank noble Lords for their comments. First, the thing that brings us together is the desire on all sides to expand capacity. That is something that we are all behind. I hope that I can bring out the themes in this regard—the plans that we are talking about are designed to do exactly that.

The noble Baroness, Lady Merron, asked how the golden hellos will work. The idea is that it will be in the 12 most needy areas, and the ICBs will have the flexibility in how they attract people there. It might be existing dentists who they want to take from another area, or it might be private sector dentists or dentists who are just graduating. It is about making sure that they have the ability to bring those people into the areas of most need.

The mobile vans have proved quite successful already in areas such as Cornwall, where they have already been. They are designed to hit exactly those areas where it is hard to seed new dental practices, because there is a dental desert there, for want of a better word. Each of those vans alone should be able to do about 10,000 appointments a year, which is quite a sizeable number. Of course, what that does is put it in the areas of most need. The beauty of it—if beauty is the right word—is that, when you are talking about emergency-type situations, you will be able to tell exactly where they are.

The other thing that is important, with regard to all the payment mechanisms and how that will work, is that the dentists working in these vans are salaried. The idea is that we know that in those instances it is absolutely going to work in terms of the incentives. While we think that the patient premium absolutely will help in terms of access, and we know that the hardest one is getting them to see patients for the first time and that is what the additional £50 is all about, by bringing in these salaried people we can absolutely guarantee that those new people will be seen in those situations.

What I note from all this is that these are very concrete plans to create 2.5 million new treatments. I noticed that the noble Baroness, Lady Merron, mentioned the Labour plan of 700,000 extra, so I shall let noble Lords draw their own conclusions as to which one is more extensive. But to try to answer the question around ring-fencing, what this is all designed to do is to make sure that the contracted number of UDAs that we want to happen is delivered. Noble Lords will have heard me say before that the problem often is that it is not delivered because the dentists then go and try to sell to the private sector instead. So this is all designed to underpin that: first, by making it more attractive for those dentists to offer it to patients, in terms of the patient premium of £50, and the increase in the UDA price; and, secondly, by supplementing that with salaried staff, so you can absolutely make sure that it is being delivered in those circumstances. That is what we are trying to do—because we know that the UDAs are there in terms of the expansion, and we did see a large expansion last year. We increased the number of treatments from 26 million to 33 million, a 23% increase—so we have managed to do it. But we are talking here about wanting to do more of it, of course.

As for whether this is a temporary filling or a long-term fix, of course the long-term workforce plan is all about a long-term fix, making sure that we have the supply in place so we can supply the NHS services needed on a long-term basis. That is where we are talking about the 40% increase, and about making it easier to bring people in from overseas, to answer the question from the noble Lord, Lord Allan. As noble Lords know, I have a personal interest. I would not have a wife—or this particular wife—if she had not managed to become a dentist from overseas. But what I saw from all of that was that it is a two-stage process. It was one thing for her to be allowed to become a private dentist. I had to fill in the forms myself, and it was pretty hard. But it was an altogether new process then to become an NHS dentist. To be honest, the conclusion after all that was, “Why would I bother to do this? If I can already be a private sector dentist, why would I jump through a load more hoops to then become an NHS dentist?” It is designed to try to iron out those differences and not act as a disincentive in those situations.

To answer the question, those mobile vans, in terms of SMILE4LIFE, are there to make sure that they get people off on the right foot. The family hubs are for training would-be mothers about looking after gums and teeth. But also, crucially, it is about using those mobile services in the areas where they are most needed, putting in the fluoride varnish for 165,000 reception-age kids—so aged from four to five. That means really starting to get the right start to life in all this.

I hope that what we are seeing here is a comprehensive set of plans, expanding supply in terms of the golden hellos, mobile vans and increasing treatments, as well as the long-term workforce plan for increasing staffing. We are making it more attractive for dentists to provide NHS dental services in terms of the patient premiums. These will all start very quickly—in March, for instance. It is also about increasing the UDAs and making sure that our children get the right start to life, in terms of SMILE4LIFE, and making sure that their teeth are clean from a very young age.

There is a lot to do—I perfectly accept that—but I believe that what we have here is taking the right steps to achieve it.

[Lord Young of Cookham (Con)]

My Lords, I felt that today’s Statement deserved a slightly warmer welcome than it has received so far, particularly from the noble Baroness. At a time of enormous pressure on public expenditure, more resources have been found to target the people in the areas who need dental treatment.

I shall raise an issue that has not been raised in exchanges so far. The single most effective public health measure that the Government could take to reduce tooth decay, particularly among children, is to add fluoride to the water supply in those parts of the country where it does not occur naturally. The Health and Care Act 2022 transferred the responsibility from local authorities to my noble friend’s department. Since then, until today, nothing has happened. I welcome the announcement that there will be consultation on extending fluoride to the areas in the north-east where tooth decay happens to be at its highest. Can my noble friend give some idea of the timescale of that consultation and whether there are any plans to extend fluoride to other parts of the country where it is urgently needed as a public health measure?

[Lord Markham (Con)]

I thank my noble friend. He is absolutely correct that the benefits of water fluoridation are well proven. The consultation for the north-east of England, which will bring in 1.6 million people to this, is starting very shortly. The idea behind that is that we can really try to get moving quite quickly on that. I was surprised to learn that the level of water fluoridation in England today is only at about 6 million people. I know that a lot of people think that their water supply has fluoridation, but there is obviously a long way to go on that. The 1.6 million in the north-east is a good extension to that, but there is a lot more that we plan to do in this space.

[Lord Harris of Haringey (Lab)]

My Lords, I declare my interests as chair of the General Dental Council. I welcome the fact that this plan has now arrived—it has been a very long time coming. Of course, the council’s role is to maintain a register of dentists and ensure that all the dentists on that list are of an appropriate standard and fit to practise in this country. I am not going to comment on the level of investment, but I make the point that increasing the number of dentists on the register does not in itself increase the number of people who practise in the NHS. I think that the British Dental Association uses an analogy about a bucket with a hole in it. The point is that, if the situation is one in which dentists, whether they qualified here or abroad, feel that the rewards that they get from being an NHS dentist are insufficient, we will continue to see that drift away from NHS dentistry.

My specific point is about the question of overseas registration. The Statement highlighted the fact that 30% of those on the register are qualified from overseas. I should say that nearly 50% of those who joined the register in 2022 are from overseas, so that gives some idea of the direction of travel. To facilitate that, the GDC has trebled the number of places for people taking their ORE part 1 examinations. On the specific proposal about provisional registration, which the General Dental Council will welcome, I hope it is recognised that, if somebody is provisionally registered, they must be supervised. This will require a structure within both the NHS and private practice to make sure that there are adequate levels of supervision available and an adequate number of dentists to do that. Can the Minister tell us how that will happen?

[Lord Markham (Con)]

I thank the noble Lord, particularly for his great knowledge and work with the GDC. I absolutely accept the basic point about the leaky bucket, for want of a better phrase; we are losing a lot of dentists to private. At the end of the day it is about the economics, and clearly we need to make sure that doing NHS work pays. In part that is what the patient premium is designed to do, as is increasing the value of UDAs to £28. There is also an acceptance that we need to look at some of the more long-term measures to make sure that it is economic to do that. The salaried staff I mentioned earlier will help with that as well.

The noble Lord is absolutely correct—again, I have some personal experience of all this—about having that mentoring scheme. Even if a dentist has been operating overseas for a number of years, learning a lot of the techniques and methods here is very beneficial. It is absolutely recognised that such mentoring is required. On the detail of how that is being planned, I will set out in my letter to everyone how exactly that will be achieved.

[Lord Hacking (Lab)]

My Lords, I have been very reassured by the Minister’s Statement and by my noble friend speaking on behalf of my party. It is very good to hear that dentistry is at last being given much greater attention at National Health Service level. I welcome the type of detail that has been brought out in this short debate; for example, bringing more fluoride into our water supplies and the elementary thing of getting a child to clean his or her teeth with proper toothpaste as a morning act before going out to school or elsewhere.

Many years ago my wife, who is a qualified consultant, was in Pakistan with a team of English doctors and surgeons to demonstrate heart surgery. I, in a kind of parliamentary capacity, was asked to make a visit to a certain place, Murree. This involved going through a number of villages in Pakistan. Of all the infirmities among the villagers, and there were a lot, the most conspicuous were infirmities of the teeth. It was a nightmare to look at.

This is some reassurance. We are absolutely right to pay proper attention to dentistry, and I most welcome the Minister’s Statement and the words of my noble friend speaking on behalf of my party.

[Lord Markham (Con)]

I thank the noble Lord for his comments. I agree that we all too often see such circumstances. As many as half the children in A&E come in for reasons of problems with their teeth. That absolutely illustrates, in a similar way to the noble Lord’s experience in Pakistan, that it really is vital to get on top of these problems. The hope, and the plan, is very much that these are the first steps in making sure that we achieve that.

[Baroness Taylor of Stevenage (Lab)]

My Lords, I take the point from the noble Lord, Lord Young, about money being found for dentistry in straitened circumstances. However, in the past 14 years, a whole generation of younger children who are now around six to 10 years old have had almost no access to dental treatment, resulting in the poor health and dental health that we heard about from my noble friend Lady Merron and the noble Lord, Lord Allan. What efforts will the Government make to ensure that the backlog of dental treatment that those children need will be assessed properly, with the appropriate treatment given as quickly as possible? Otherwise, we will have further health problems in future as those children go into their teenage years.

[Lord Markham (Con)]

On the targeting and how we are using those mobile vans, the thinking is that they will be rolled out quite quickly—in about six months or so. We are absolutely looking to target those areas with backlogs, such as where we know that the distance to an NHS dentist is further than normal, where there is low access according to GP patient surveys or where there is a low number of dentists per patients. This is exactly set up to try to make sure that we are going into those areas where there is the biggest backlog. Turning up in those locations and allowing people to queue up and receive a service on that day allows access very quickly to the people who really need it. At the same time, when they are calling up because they might need dental services, we can tell them, “A mobile van will be in your areas in two weeks; we can book you an appointment now”. That is designed to really hit those backlog areas. I suspect—this is just me speculating—that such will be the success of these that this will a model that we will look to roll out more widely in future.

[Lord Young of Norwood Green (Lab)]

My Lords—