NHS Dentistry: Lincolnshire

John Hayes Excerpts

Wednesday 20th October 2021 Commons Chamber

[Dr Caroline Johnson (Sleaford and North Hykeham) (Con)]

Smiles are very important. When we smile, it makes us happier and it makes those around us happier, but unfortunately many of my constituents are struggling to smile because they have problems with their teeth and just cannot get an NHS dental appointment. That has left some of them in very significant pain and discomfort.

Many constituents have contacted me to share their experiences: people waiting years to access NHS dental care; children unable to access NHS orthodontic care, with a choice between hugely expensive private treatment and doing without; service families posted to Lincolnshire struggling to get an appointment. Figures show that just 41% of adults in Lincolnshire have accessed NHS dental care in the past two years, and less than a third of children have accessed it in the last year.

Access to specialist treatment is even more limited. Lincolnshire has gone from having three full-time consultants in orthodontics, based in Boston, Grantham and Lincoln, to just one permanent consultant two days a week, based in Lincoln. Unlike neighbouring counties in the east midlands, Lincolnshire has no specialist dental services either in paediatrics or in restorative dentistry, which means significant travel out of county for patients who require more specialist help.

It is therefore perhaps not surprising that 80% of Healthwatch complaints in Lincolnshire relate to problems with access to NHS dental services. I would like to speak about how we could improve the situation for my constituents.

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

The circumstances are just as bad as my hon. Friend suggests. Indeed, Lincolnshire is the worst served of any midlands county, with the lowest proportion of dentists in the population. There are detrimental effects on children, as she said, and it is the poor who tend to suffer most. Finally, given her professional expertise, I wonder whether she could comment on those who have undiagnosed conditions that a visit to the dentist might reveal, notably oral cancer.

[Dr Johnson]

My right hon. Friend is a big champion for his constituents and for ensuring that they have good dental care. My hon. Friend the Member for Louth and Horncastle (Victoria Atkins), who cannot be here this evening, is also vigorously campaigning to improve access to dental care in rural areas such as her constituency, particularly in Mablethorpe, where urgent care has now been restored and where she is committed to seeing non-urgent care renewed.

The journey to being a dentist begins at university dental schools, which are heavily over-subscribed. The Government trained 21% more dentists in 2018-19 than in 2008-09. It was forward-thinking of them to increase the number of dentists; given the increase of only 7% in population, one would have expected it to result in more dental care. However, that has not happened in practice, for two reasons: partly the increase in part-time working and flexible working, but particularly the dramatic increase in the number of dentists working in the private sector as opposed to the NHS. What is the Minister doing to increase the number of dental students still further? What is she doing to ensure that they are trained particularly in areas of low provision?

I note that there is currently no university dental school in the east midlands—or in East Anglia either, in fact. It is well known that people often stay where they train; it is therefore perhaps not surprising that there are fewer dentists in Lincolnshire. Does the Minister agree that, building on the success of the Government’s investment in opening a new medical school in Lincoln to train more doctors, we should build an east midlands dental school in Lincoln, creating a centre of excellence locally for specialist services and thereby increasing the number of local dentists being trained?

There is already a precedent for opening dental schools in under-served areas: the last school was opened in Plymouth to serve a deficit in the south-west. Following the establishment of Lincoln Medical School, the addition of an adjunct dental school would be a welcome addition to Lincolnshire and the surrounding area. It would boost training and skills opportunities for young people in Lincolnshire and the wider east midlands and increase the retention of new local dentists, while helping to address access to routine NHS dental care and specialist care for patients. I also ask the Minister what efforts are being made to increase local specialist provision for paediatrics and restorative dentistry.

Following their university careers, graduates become foundation trainees, and we need to look at where we place our foundation trainers and trainees. Newly qualified dentists need to work in a foundation job to get an NHS provider number, but they can work in a private practice without one. That is something of a disincentive for people to work as NHS dentists. We also need to consider where the postgraduate training takes place. For example, there are currently six full-time training places at Grantham Hospital, just outside my constituency, but this year it has been given only two new graduates to fill those places. That is creating a reliance on temporary and overseas staff to deliver services, but it also means that there will be fewer dentists trained locally and therefore fewer dentists for the population.

Does the Minister agree that all new dentists should work their foundation year in the NHS, as doctors do, and does she agree that, given that trainees often stay where they train, the foundation places in areas of low provision should be filled first? Would she consider “golden hellos”, such as those provided in some medical specialties in areas with low provision, to attract more dentists to under-served areas?

At the heart of the issue of NHS dentists moving into the private sector is the current target-based dental contract that was introduced by the Labour Government in 2006. It was widely considered unfit for purpose even before the pandemic, which has only served to highlight its flaws, and I am aware that the Government are rightly looking to replace it. The present system effectively sets quotas on the number of patients whom a dentist can see. NHS dentists are commissioned to deliver a set number of units of dental activity—UDAs—which caps the number of dental procedures that they can perform in a given year. If they deliver over 4% more than they have been commissioned to deliver, they are not paid for the extra work; moreover, they have to bear the cost themselves of any materials used, any laboratory work, and all other overheads. That penalises dentists who treat patients in the greatest need.

The contract also penalises dentists who under-deliver on the activity that they were commissioned to deliver, perhaps owing to difficulties in filling a practice vacancy. In addition, it pays a set amount for particular types of treatment, regardless of the number of teeth that need to be treated. For example, a dentist would be paid three units of dental activity—worth an average of £75 —for one simple extraction, but would also be paid £75 for an entire course of treatment including six fillings, three extractions and a root canal treatment, which would not be enough to cover their overheads. That means that the system effectively punishes dentists for taking on new patients with high levels of dental need.

There is also—believe it or not—a huge variation in the value of UDAs. I said that the average was £75, but in fact, across England, dental practices are paid anything between £15 and £45 per unit of dental activity delivered, with an average value of £27.50. In Lincolnshire and Leicestershire, the value is between £18 and £38, with an average value of £25. For example, in Spalding, Lincolnshire—in the constituency of my right hon. Friend the Member for South Holland and The Deepings (Sir John Hayes)—two NHS practices just over a mile apart are being paid £23 and £28 per UDA respectively, a difference of more than 20% for the same work in the same town. That illustrates how dysfunctional Labour’s dental contract has become, making it more difficult for practices with lower UDA rates to recruit because they cannot pay the dentists whom they hire as much for the same work. When we compare this with private practice, where remuneration is based on actual work done, it is clear why this flawed contract has had a devastating impact on recruitment and retention among NHS dentists.

Research by the British Dental Association shows that nearly half all dentists plan to stop providing NHS services or to reduce their NHS commitment, and more than a quarter plan to move to fully private provision in the next 12 months. That has been seen in Lincolnshire, where there has been a net drop of 30 dentists providing NHS services in the year to the end of April 2021.

I am pleased that the Government have recognised the problems that this contract is creating, and are piloting alternatives. It is crucial that they deliver on their commitment to roll out new contractual arrangements by April 2022. Within the new contract, remuneration needs not only to reflect the number of dentists working in high-need areas, but to address the problems of attracting dentists to work in rural areas.

Dentists trained overseas can play an important role in filling vacancies in under-served areas. They already contribute to our NHS, and many more wish to come here, but despite the lack of NHS provision, dentists are not currently on the shortage occupation list. Moreover, it is possible for dentists from countries such as those in the EU where we recognise the equivalence of university dental qualifications to come and work here in the private sector immediately, but additional paperwork and training, with additional costs, are required for them to work in the national health service. That is a clear disincentive to working in our health service, and I would like the Minister to elaborate on what she is doing to remove bureaucratic burdens such as those that limit NHS capacity.

The covid pandemic has further exacerbated problems with access to NHS dentistry. In the spring of 2020, all routine dental care in England was necessarily paused for two months. With social distancing, gaps between treatments and decontamination between patients having been essential since then, dentists have been able to see only a fraction of their usual patient numbers. In North Kesteven alone, 22,733 NHS dental appointments were lost between April 2020 and March 2021, further adding to the unprecedented backlog.

In the short term, to address the impact of covid-19 infection prevention and control protocols limiting the number of patients who can be seen, funding for ventilation equipment could drastically reduce the time lost between seeing patients by reducing the number of times the air is changed over an hour. Currently, after each aerosol-generating procedure—which includes most courses of dental treatment including drilling—dentists are required to leave the treatment room empty for up to an hour, which dramatically lowers the number of patients they are able to treat. The experience of my constituent Emma highlights this. Her seven-year-old daughter is still waiting for a routine check-up from November 2019, and Emma is being told that the surgery is running at 50% capacity due to coronavirus prevention controls.

This fallow time can be reduced, and patient throughput increased, by installing high-capacity ventilation. However, this can cost a practice up to £10,000. England does not currently invest in ventilation for dental practices, although the devolved nations of Wales, Scotland and Northern Ireland do. Capital funding for ventilation equipment would have a transformative effect on the throughput of patients, and would in effect pay for itself through increased patient charge revenues from paying NHS patients. Could the Minister please outline what review mechanisms are in place to reduce dentists’ covid measures—particularly now that the fantastic vaccine programme this Government have put in place means that more than 90% of people have antibodies—so that dentists can increase capacity from 65% to 100%?

Lincolnshire is proud to be the home of the Royal Air Force, including RAF Cranwell, RAF Digby and RAF Barkston Heath, which are in my constituency of Sleaford and North Hykeham. Repeatedly moving location can pose particular difficulties for service families as they find themselves on lengthy dentists’ waiting lists. My constituent Karen waited five years for her and her three children to access an NHS dentist after her husband was posted to my constituency, and she is still having difficulties in securing adjustments for her disabled son. Our veterans, cared for by the Ministry of Defence during their service, often find it difficult to get an NHS dentist at the point of retirement. The Armed Forces Bill will enshrine in law the military covenant, our commitment to our brave service personnel and their families. Will the Minister outline what work she is doing to ensure that military families and veterans can access high quality NHS dental care wherever they move to, in order to meet their particular challenges of moving around frequently?

Without significant changes soon, the problems facing NHS dentistry in access and in the recruitment and retention of dentists will continue to grow. My constituents in Lincolnshire deserve to be able to see an NHS dentist, and dentists working in Lincolnshire deserve a contract that correctly rewards them for the work they do and addresses the perverse incentives that currently exist. After a decade of work on the new system, there can be no more delays. I hope the Minister can give me assurances that the Government will stick to their commitment to roll out new contractual arrangements by April 2022, so that my constituents can smile once more.

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

I congratulate my hon. Friend the Member for Sleaford and North Hykeham (Dr Johnson) on securing this important debate. I am really pleased to hear dentistry getting some more parliamentary time and being put on the radar, because it is such an important issue. I am aware that there are long-standing concerns around dental access in parts of the east midlands. In my response I will consider the impact of covid on access to dentistry. We are aware of this, and I will focus on it initially. However, we have to acknowledge that there were problems in accessing NHS provision before covid. Even once we are through the recovery from the pandemic, we will need to address those issues once again. They will not disappear once the pandemic has passed.

As my hon. Friend highlighted, dentistry posed a significant risk during the pandemic because of the aerosol-generating procedures. I thank all the dental teams across the country who showed such resilience and dedication during this period, because they kept going and provided urgent care while facing considerable risk and anxiety. The steps we took during the pandemic ensured the safety of both dental patients and staff, but they have led to a reduction in the number of patients who can be seen.

We have worked closely with NHS England to consider the level of NHS dentistry that can be safely delivered in the environment of a pandemic. The thresholds that have been set for dental practices since the start of the year are based on what is achievable while maintaining infection control measures.

My hon. Friend will be pleased to know the UK Health Security Agency published new guidelines on 27 September that include three pragmatic changes to infection prevention and control measures, with a focus on elective care that allows providers to start making further safe changes to open up their services. I take her point, and I will consider what more support can be given for ventilation to help dentistry premises open up further still.

In the light of the reduction in activity, dental practices have now been asked to deliver as much care as possible, prioritising urgent care, care for vulnerable groups and children, and delayed planned care. Practices are now being asked to deliver 65% of their units of dental activity and 85% of contracted units of orthodontic activity from 1 October. Our figures suggest that we are starting to see a natural return to pre-covid levels of activity in dentistry, and I am pleased to see that in England urgent care has been back to pre-pandemic levels since December. We have made real progress there.

[Sir John Hayes]

It is widely acknowledged that the Minister brings both understanding and diligence to her role. Does she recognise that there are particular problems in rural areas such as Lincolnshire? We hear a lot in the place about urban deprivation and metropolitan needs, but we hear rather less about rural deprivation. In healthcare, public services and dentistry in particular, our county is peculiarly deprived. Will she take particular measures to help rural places such as Lincolnshire?

[Maria Caulfield]

My right hon. Friend makes an excellent point, which I was going to address. Officials tell me that the areas where we are seeing significant gaps are referred to as “sheep” and “seagulls,” with the sheep being rural areas and the seagulls being coastal stretches. They are the two areas of the country with a significant shortfall in NHS dentistry provision, and they are the two areas on which we will particularly focus.