NHS Dentistry in England

Derek Thomas Excerpts

Wednesday 22nd June 2022 Westminster Hall

[Derek Thomas (St Ives) (Con)]

I beg to move,

That this House has considered NHS dentistry in England.

It is a privilege to serve under your chairmanship, Mr Stringer. I am delighted to bring this debate to Parliament and to combine it with a petition that has been signed by more than 10,000 members of the public. The petition calls for

“an independent review of the existing”

NHS dental

“contract and a radical rethink of the way in which dental services are delivered.”

We may not need an independent review to tell us that NHS dental services need a radical rethink; we all know that they do.

NHS dentistry is a huge concern for all Members here today, and the number of us present reflects what a huge concern it is for our constituents. I already had a good indication of how significant the lack of dentistry was across my constituency, but to grasp the detail and the scale of it, I posted a survey at the beginning of the year asking constituents about the problems they had faced in accessing NHS dentistry. Within a day, it had received more responses than any other survey I had run—more than surveys on bus services, post office closures, noise pollution, or whether the Cornish flag should appear on a Cornish numberplate.

The picture that came out of my survey was shocking. Nearly half of respondents had been waiting more than three years for an appointment. Tim has had temporary crowns awaiting replacement for eight years; the teeth underneath have rotted away. Robert’s solution was to wait until a tooth was

“beyond repair and intolerably painful before getting an appointment with the emergency dentist to have it extracted. Last time they removed three in one go.”

Other people tried DIY solutions. Looking up how to make temporary fillings on YouTube was commonplace. Mark pulled out his wisdom tooth himself.

Other constituents have given up completely. They do not show up on the waiting lists because they have given up on waiting. Lauren told me:

“I don’t use the right side of my mouth to chew as it’s sensitive and causes me pain but it is too difficult to get an appointment so I am having to live with it”.

Anna racked up three times her usual phone bill trying to get through to the appointments line before she gave up. One constituent comes from a family of seven, of whom only the youngest has ever seen a dentist, and only then because he went to hospital for urgent surgery; the oldest is 20. Patients who can afford to go private do so, but so do patients who cannot afford it. The fees for Anthony’s private dental care represent a tenth of his pension; that is not affordable. The fees that Megan paid to remedy just one of her abscesses equated to a month’s rent. She has just had a baby, and cannot afford to pay another two months’ rent for the other two abscesses.

The situation is particularly grave in Cornwall. Last week, NHS England and NHS Improvement presented a report to Cornwall Council showing that in 2020-21 only 24% of the dental activity commissioned in Cornwall was delivered. In 2021-22, it has increased, but only to 59%. By the end of this month, we should be returning to 100% of normal activity, but that is simply not happening in Cornwall. The total number of adults with access to an NHS dentist dropped from 188,000 in June of last year to 155,000 in December.

[Sir John Hayes (South Holland and The Deepings) (Con)]

I congratulate my hon. Friend on securing the debate. Things are clearly not as they should be in Cornwall, but in Lincolnshire they are even worse. Greater Lincolnshire has three of the four worst dental deserts in the United Kingdom, according to the Association of Dental Groups, with just 38 dentists per 100,000 people. Finding a dentist in Lincolnshire is like finding the holy grail. It is vital that we have more dentists, for the reasons my hon. Friend set out. People deserve better.

[Derek Thomas]

I completely agree. My right hon. Friend will know that in Cornwall we are very competitive; we always want to win, but I do not want to win this competition. This tragedy for both Cornish residents and his constituents highlights the fact that something needs to be done urgently. I thank him for his intervention.

[Damian Green (Ashford) (Con)]

I am very grateful to my hon. Friend for giving way again and allowing me to continue this tour of woe around the country. I can tell him that the situation is equally bad in Kent; it is almost impossible in Ashford to find an NHS dentist. My frustration and that of my constituents about this is compounded by the lack of response of the health service generally. The clinical commissioning group refers me to NHS England, and NHS England—the Minister may take note—just does not reply. I have before me an email I sent seven weeks ago regarding someone who could not find a dentist, but there has not even been a reply from NHS England. From top to bottom, this system needs complete reform.

[Derek Thomas]

I appreciate that intervention. In my case, NHS England, and commissioners for the south-west have been fairly good and engaged with the challenge. However, it is a tale of woe, as my right hon. Friend says. Perhaps we can all commit to coming back to this place in a year or two to commend the Minister and celebrate the fact we have a new contract that addresses exactly the challenges that we are all quite rightly highlighting today.

[Dr Dan Poulter (Central Suffolk and North Ipswich) (Con)]

I congratulate my hon. Friend on securing this debate. He is right to highlight this national challenge. We have substantial challenges with access to NHS dentistry in Suffolk. Part of that, as our right hon. Friend the Member for Epsom and Ewell (Chris Grayling) said, relates to the quality of the commissioning and monitoring of contracts by the local commissioner. Will my hon. Friend join me in urging the Minister to put pressure on local commissioners to take this issue seriously? Also, does he agree that we need to ensure that dentists who are commissioned to perform NHS services do actually provide the services that they are commissioned to provide? Some of them are not doing so at the moment.

[Derek Thomas]

I thank my hon. Friend for that intervention. He is right to say that there are commissioned units of dental activity that are not being delivered. There are all sorts of reasons for that, which I hope to cover in my speech. Ultimately, however, we need to look at the contract itself and consider whether it actually works for patients. The contract was introduced by the Labour party in 2006. We know that it does not work today and is in urgent need of reform, which I will come on to in my remarks.

[Jim Shannon (Strangford) (DUP)]

Will the hon. Gentleman give way?

[Derek Thomas]

I will make a little progress first and then I will give way to the hon. Gentleman.

We have heard about other examples and concerns elsewhere, but in Cornwall we do not have the capacity to assess the patients in the backlog, let alone to treat them. This is not just about dental health. Dental examinations pick up the early warning signs of mouth cancer, or poor periodontal health associated with diabetes, for example. I should declare an interest, Mr Stringer, as the chair of the all-party parliamentary group on diabetes. It is estimated that 60,000 people with type 2 diabetes had their diagnosis missed or delayed because of the cancellation of dental examinations.

I will now give way to the hon. Member for Strangford (Jim Shannon).

[Jim Shannon]

I know that this debate is about NHS dentistry in England, but may I say—regionally—that the problems are just as real in Northern Ireland as they are anywhere else? My concern is that there is no access to NHS dentistry any more in Northern Ireland; either people pay for dentistry, for example through a subscription, or they do not get it.

Does the hon. Member agree that dental care should not be restricted to those who have the money to pay? The impact of this situation will clearly fall on those who see dentistry as being the bottom of the list when it comes to paying? People in the poverty trap who feel the pressures of rising prices will be even more detrimentally affected than ever. Does he feel that now is the time for Government all across the United Kingdom of Great Britain and Northern Ireland—although I appreciate that the Minister who is here today does not have responsibility for Northern Ireland—to do something specifically for people on the breadline?

[Derek Thomas]

I thank the hon. Gentleman for his intervention.

It is probably fair to say that although the responsibility lies with the Minister here today, it is not her responsibility, or even in her power, to ensure that every member of the British public can access NHS dentistry, simply because NHS England, or indeed any part of the NHS, does not commission enough dentistry to cover the whole population. Perhaps the Minister will clarify today the Government’s expectation regarding access to NHS dental care, and say whether there is a right for everybody, whoever they might be, to access that care. However, it is a very important point that has been raised. It surprises people that we do not commission enough dentistry to meet the needs of every one of our constituents.

It is not enough to blame the pandemic, although it has certainly not helped. I was raising the state of NHS dentistry in Cornwall before we had a single case of covid in this country. Over two years ago, I spoke about the difficulty of recruiting and retaining dental staff. At Prime Minister’s questions two years ago, I raised the shocking results of the lack of access to NHS dentistry for children in Cornwall. I also told hon. Members that these inequalities needed to be addressed quickly and creatively.

Outside this House, I have been working to improve access to dentistry in the constituency, most recently by getting the council to overturn a decision not to allow electrical works to proceed in St Ives that would have delayed the opening of a new dental surgery until the autumn. I have been meeting the regional health commissioners and Cornwall’s public health officers to discuss dentistry on a regular basis, and I cannot fault their speed and creativity. Their south-west dental reform programme has been working hard to improve access by helping to reopen a surgery in Hayle and in St Ives, piloting child-focused dental practices, and developing its own evidence-based workforce plan, but the Government must lead the way. Resolving these oral health inequalities is not just this Minister’s responsibility; it will require a cross-Government approach.

NHS England has launched a drive to recruit dental professionals to the south-west, but a key challenge in Cornwall, and maybe other parts of the country, is finding housing for those who want to take up a job in dentistry. I am working on that issue with the Department for Levelling Up, Housing and Communities. The national food strategy was a wasted opportunity. We could have extended the sugar tax, which has successfully incentivised the reformulation of sugary drinks. That would have helped oral health as much as health in general. I shall continue to argue for a national food strategy that is truly strategic, even if the Government have made a tactical withdrawal from tax rises to support public health.

The Minister has responsibility for the dental contract. In oral questions in January, she agreed that the contract was

“the nub of the problem”.—[Official Report, 18 January 2022; Vol. 707, c. 195.]

She said in February,

“there is no doubt that the UDA method of contract payments is a perverse disincentive for dentists. The more they do, the less they seem to be paid. I for one certainly do not underestimate the problems that that causes dentists, and I can see why many hand back their NHS contracts.”—[Official Report, 7 February 2022; Vol. 708, c. 780.]

I could not have put it better myself. I have asked dentists in my constituency if they would prefer to see increased budgets or reform of the UDA contract, and they asked for reform.

There are two main issues with the dental contract, both of which are not just obstacles to dental health but actively create problems for the future. First, the current system does not focus on prevention. When units of dental activity are the sole measure of contract performance, there is no incentive for preventative work; nor is there an incentive to make the best use of the whole dental team’s skills when the practice cannot make a claim for payment for a course of treatment purely because it was initiated by someone other than a dentist.

I made sure that the title of the debate referred to NHS dentistry not NHS dentists. We need to recognise the contribution of the whole team of dental professionals —dental nurses, hygienists, therapists and technicians—and use them. Again, this is about not just saving money, but using professionals in the best way we can. Yesterday I spoke to a dental nurse who works with people in care homes. If she wants a resident to switch to a high-fluoride toothpaste, she has to get a dentist to prescribe it. Our regional dental commissioning team has been running a pilot to take supervised toothbrushing conducted by dental nurses out to the community. Given that more five to nine-year-olds are admitted to hospital for tooth decay than for any other reason, this work should be at the heart of NHS dentistry, not something that is topped up by flexible commissioning.

Second, the UDA method does not properly reward dental practices for their work. A dental practice is faced, in effect, with a UDA cap for an entire course of treatment, which means when a patient has complex needs, the money involved does not even cover the overheads of the practice. The predictable result is that dental practices are moving away from NHS work. Around 3,000 dentists in England have stopped providing NHS services since the start of the pandemic. Every time a dentist leaves the NHS and is not replaced, approximately 2,000 people lose access to dental care. If you cannot do the arithmetic in your head, Mr Stringer, 3,000 times by 2,000 is 6 million, so 6 million patients have lost access to a dentist just over the course of the pandemic. For every dentist leaving the NHS, another 10 are reducing their NHS commitment by a quarter on average; that is another 500 patients losing access to an NHS dentist. According to the British Dental Association, 75% of dentists plan to reduce the amount of NHS work they do next year.

The fewer dental practices there are doing NHS work, the more pressure the remaining practices are under. A recent BDA members survey found that nine in 10 owners of dental practices committed to NHS work found recruitment difficult, with 29% of vacancies going unfilled for more than a year. That is nationwide, but one provider in Cornwall told me that their surgeries were unused 52% of the time due to shortages of dentists and nurses. The vast majority said that it was the UDA contract that was the biggest factor in their recruitment difficulties. The Minister said last week that the Government are serious about reforming the dental contract, but I want to press that point. It is not enough to be seriously planning a reform; we must be planning serious reform. Tweaks to the existing system are not enough when the contract is fundamentally flawed.

I have focused on the contract because we need the Minister to focus on the contract. Other Members will no doubt raise the issue of recognising overseas qualifications, passing the section 60 order that would give the General Dental Council discretion over qualifications, maintaining the mutual recognition of professional qualifications with Europe and extending that to the Commonwealth, and expediating the process for experienced candidates to register with the NHS. Dental care professionals need to be allowed to initiate treatments. The issue of funding will come up—for a catch-up programme of overseas registration exams in the short term, and university places in the long term—but it is striking how many of those proposals are cost neutral. We could even save money by catching mouth cancer in the early stages when it is more easily treated.

To quote the Minister, the contract is the nub of the problem. I urge her to commit to a firm date when we will see the end of units of dental activity, and a better contract focused on prevention and increasing access.

[Graham Stringer (in the Chair)]

I have indications from six Members who wish to speak. I intend to call the Opposition spokesperson at 3.40 pm. You can do the arithmetic—it is fairly straightforward—I do not intend to impose a time limit unless Members indulge themselves.

--- Later in debate ---

[Derek Thomas]

First, I thank and commend the Minister for her response and for the way in which she has engaged with this subject since taking up her role. I have found her determination to get this matter right really refreshing, because this has been a long battle.

I thank all colleagues, from all parties, for their contributions and for going into things—not just the problem but the solution—in great detail. I will leave the shadow spokesperson, the hon. Member for Enfield North (Feryal Clark), out of that assessment, because I do not think that that came across from her at all.

I wish the Minister all success with trying to get a new NHS dental contract. We know that getting new contracts can be very tricky and fraught with problems, so I wish her the very best, on behalf of all of our constituents, who urgently need good dental care.

Question put and agreed to.

Resolved,

That this House has considered NHS dentistry in England.