Access to NHS Dentistry

Kevin Hollinrake Excerpts

Thursday 10th February 2022 Westminster Hall

[Peter Aldous]

While there are particular problems in rural, coastal and more peripheral locations, which it is difficult to get dentists to move to, it is clear from looking around the Chamber today that the problem is not confined to such areas and is an issue in metropolitan areas as well. Sir Robert Francis, chair of Healthwatch England, has commented:

“Every part of the country is facing a dental care crisis, with NHS dentistry at risk of vanishing into the void.”

I believe there are five issues that need to be tackled to address the problem. First, a secure, long-term funding stream must be provided. Secondly, we need to step up the recruitment and retention of dental professionals. Thirdly, it is vital that work on the new NHS dental contract, which has been being developed for more than a decade, is completed as soon as practically possible. Fourthly, it is important to highlight the role that water fluoridation can play. Finally, there is a need for greater accountability and for dentistry to have a voice in the emerging integrated care boards and partnerships.

[Kevin Hollinrake (Thirsk and Malton) (Con)]

I congratulate my hon. Friend on securing this important debate. Another point that needs developing is that in Helmsley, in my constituency, the commissioners have still not recommissioned services after 20 months. The commissioning of dental services by the NHS is simply too slow and too bureaucratic. It is a real deterrent for new dentists to take these contracts.

[Peter Aldous]

I thank my hon. Friend for that intervention, and he is right. There has been a recent procurement process in East Anglia, but it has been only half successful. There are places that have not been able to get dentists to fill those voids.

Figures published in March 2020, before the pandemic, show that 25% of patients new to practices in England could not get an appointment. The situation has got worse: the most recent figures, from 2021, show that that number has increased to 44%; in my area, it is 56%. Dentistry was locked down from March to June 2020 and the ongoing restrictions on dentists—fallow time between appointments—are still limiting the ability to see more patients.

The latest figures on workforce, published in August 2021, show that 951 fewer dentists performed NHS dental activity than 12 months earlier, with 174 of those losses in the east of England. Those figures confirm that parts of England are becoming dental deserts; beyond Suffolk and Norfolk, that includes the east Yorkshire coastline, Cornwall, Portsmouth and the Isle of Wight.

The lack of access to NHS dentistry has a fivefold impact on patients. First, millions are missing appointments. Secondly, there has been a significant increase in DIY tooth extraction. Thirdly, the poor are hit hardest. Fourthly, mouth cancers are going undiagnosed. Finally, children are suffering. This very serious situation has been confirmed by the “Great British Oral Health Report” carried out by mydentist.

I apologise for going on at length, Mr Efford, but it is important to emphasis the crisis we are facing. I will now briefly outline some of the solutions. The first issue that must be tackled is getting more dentists and dental practitioners working in the NHS. The Association of Dental Groups has put forward its “six to fix” proposals for solving the workforce crisis, which I will summarise. First, we need to increase the number of training places in the UK. That is a long-term measure. Secondly, in the short term, the Government should continue to recognise EU-trained dentists. Thirdly, there needs to be a recognition of other overseas qualifications. We have an opportunity to make more of our links with Commonwealth countries such as India, which has a surplus of highly skilled English-speaking trained dentists.

Fourthly, the process for overseas dentists to complete the performers list validation by experience—or PLVE—so that they can practise in the NHS must be simplified and sped up. Fifthly, whole teams in dental practices should be allowed to initiate treatments. The largest barrier to better use of the skills mix under the current NHS contractual arrangements is that allied dental professionals are unable to open a course of treatment, which means they cannot raise a claim for payment for work delivered.

Finally, the Government must create a new strategy for NHS workforce retention. The current contract through which NHS dentistry is provided was introduced in 2006 and for some time it has been widely recognised as not being fit for purpose. It is a major driver of dentists leaving NHS dentistry. Reforming the NHS contract is needed to deliver better access and preventive care so as to improve the nation’s oral health. Flexible commissioning, aimed at increasing access to vulnerable groups such as those in care homes should be an important part of the reform. The current dental contract is target-based, and it was accepted before the pandemic that it needed to be reformed. We must complete that reform as soon as possible. I would welcome an update from the Minister as to progress on that and when we might see a new contract.

It is important that NHS dentistry receives a sustainable long-term financial settlement and not a short-term fix. Additional funding is vital if long-term and sustainable improvements to NHS dentistry are to be secured. The pledge of £50 million on 25 January for a dentistry treatment blitz is welcome, and £5.73 million is available to the east of England. However, that is a time-limited one-off injection of funding that is available only until the end of March, and there is a concern that it will barely make a dent in the unprecedented backlogs that NHS dentistry now faces. The British Dental Association estimates that it would take £880 million per annum to restore dental budgets to 2010 levels.

Since my Adjournment debate on NHS dentistry in Waveney last May, there have been improvements to the local service, which it is important to acknowledge. A temporary contract was awarded to a Lowestoft-based NHS dentist to see additional patients, which has definitely helped prevent the situation from getting any worse. Tomorrow I shall be with Community Dental Services, which along with Leading Lives, a Suffolk-based not-for-profit social enterprise, is launching its toolkit to help improve the oral health of people with learning difficulties. It is also good news that from 1 July a contract has been awarded to Apps Smiles for the delivery of NHS dentistry in Lowestoft, but it is concerning that it was not possible to do that in nearby Leiston and across the border in Norfolk, in Fakenham and Thetford. It will be interesting to receive further details as to why that happened, but one can speculate dentists might not have been interested in those opportunities and might have been put off by the existing, unattractive contract.

I have concerns about the procurement process that go back a long time. I am concerned that it does not encourage traditional partnerships to put forward proposals. I urge the Minister to carry out a whole review of the procurement process.

A vital strand of NHS dentistry should be the prevention of oral health challenges—prevention rather treatment. Fluoridation of water supplies can play a vital role in that, so it is welcome that the Health and Care Bill allows for it. There is also a need for greater accountability.

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[Peter Dowd (Bootle) (Lab)]

I thank the hon. Member for Waveney (Peter Aldous) and my hon. Friend the Member for Bradford South (Judith Cummins) for raising this issue and for their tenacity. It is a pleasure to see you in the Chair, Ms Ali.

As many hon. Members have said, dentistry is not just about teeth; it is a vital component of our health. The hon. Member for North Devon (Selaine Saxby) shared a Shakespearian quote, and there is another one worth mentioning. In Shakespeare’s “As You Like It”, Jaques says:

“Sans teeth, sans eyes, sans taste, sans everything.”

If the Government carry on the way they are, it will be “sans dentists” as well. They need to get a grip of the situation.

The hon. Member for North East Bedfordshire (Richard Fuller) talked about the cash and the expenditure. I am happy to have a debate with him on this issue, and if he wants to secure a Westminster Hall debate on public expenditure, I will join him. I will give him an example of what he was talking about: the £10 billion-worth of covid-related fraud. That is equivalent to £153 for every person in his constituency—the best part of £50 million, which would be better spent on dental services in his constituency.

[Kevin Hollinrake]

Will the hon. Gentleman give way?

[Peter Dowd]

I am more than happy to come back to the hon. Gentleman in a moment.

Last week, I took part in a debate on the energy crisis. This week, I took part in debates on the crisis in children’s mental health services, the food insecurity crisis and the cost of living crisis. Today, it is about the access to dental services crisis. There is a bit of a theme beginning to develop here—it is about crisis, and all these crises are not isolated.

It is not as though the Government are having a run of bad luck through no fault of their own and have an otherwise impeccable record; there is something systemic and even endemic going on. I get a bit tired of the Government’s default approach to any deficit in policy application, and we have heard it a bit here: it is the CCGs, the NHS, the officials—it is everybody else’s fault bar the Government’s. They have to take responsibility.

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[Peter Dowd]

In a moment.

Any denial by the Minister that there is a problem is itself a part of the problem. I really do not want to hear any denials.

[Kevin Hollinrake]

The hon. Gentleman is not making a particularly collegiate speech, but never mind. I have a lot of time for him. I do not know where the £10 billion fraud figure he throws out has come from. If it is about PPE, he should look at the facts behind that: £4.6 billion of that was write-down of current value versus value at the time of the pandemic. If we are going to debate in this place, it should at least represent the facts.

[Peter Dowd]

I am pleased that the hon. Gentleman raises that. The bottom line is this: look at the Public Accounts Committee documents. There are more to come out. If the hon. Gentleman wants to have a debate on fraud, I am more than happy to have one. Perhaps he can put in the application and I will come and speak to him about it.

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[Kevin Hollinrake (Thirsk and Malton) (Con)]

I thank the hon. Member for Bradford South (Judith Cummins) and my hon. Friend the Member for Waveney (Peter Aldous) for securing this important debate. It is clearly a huge, topical, cross-party issue that has largely been discussed in a collegiate fashion.

On the rare occasions that I get any press coverage for my work as a Member of Parliament, I am often referred to as “senior” or “veteran”, which I think says more about my age than my experience. When I got here in 2015, this was one of the first things I raised with the then Minister for dentistry, Alistair Burt. To be fair, things have changed since then; they have actually got a lot worse. The reality is that it is impossible for most people in my constituency to get on an NHS waiting list. We must be honest with the public: either we open the gates so that more people can access treatment, or we tell them that dentistry is for some people and not for others.

The Father of the House said that it would be helpful to be able to search for availability in each of our constituencies. I agree, but I know exactly what it would say for my constituency, because this morning I checked across North Yorkshire—which is larger than my constituency—and there is simply no availability on NHS waiting lists. It has been like that for most of the seven years I have been in Parliament. The pity is that I have dentists who will accept NHS patients, but they just cannot get the units of dental activity. There is a real impasse between the issues and our honesty in saying whether NHS dentistry treatment is available in our constituencies.

Of course, that has real-world effects, and I will read from a couple of emails. A Mrs Weston wrote to me this morning:

“My son, an adult with special needs… is on universal credit and PIP, and he has to pay for private treatment as we cannot get on an NHS list… He has had to have a tooth removed because of an abscess, something that could well have been avoided if he had had regular check-ups.”

Even worse than that, a lady from Rillington wrote:

“My daughter has a toothache and needs to see a dentist… Our dentist ceased providing NHS services and there is nowhere else we can get into… They advised us to ring 111… and we were told a dentist would get back to us within 7 days. No one did. Tonight we rang again. We were on hold for 2 hours before we got through to the Yorkshire and Humber Dental Services, who told us they have no capacity to help.”

This is simply unacceptable.

Somewhat different from most of today’s speeches, the key thing that I want to talk about is commissioning. In my constituency—my hon. Friend the Minister knows this, and she has been very responsive on it—the NHS dentist on Bondgate in Helmsley closed totally in September 2020. It will not reopen until April ’22 at the earliest—that is the predicted date of opening—so it will have taken 20 months for the NHS people who commission services to reopen the service, despite the fact that we had someone who was willing to take the contract right from the start. On Kirkgate in Thirsk, it will have taken six months, so that is slightly quicker—apparently, that will open in March this year.

The contract is wrong. This “five plus two” contract, rather than a general dental services contract, deters investment and is very bureaucratic, having to be revisited consistently. We must simplify the commissioning process. We must put a rocket up the people commissioning this—20 months is simply not acceptable. I agree with others who suggest devolving this stuff back to local areas: we can look after it and commission the treatment, rather than having it all done centrally by super-regional managers.

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

It is a pleasure to serve under your chairmanship, Ms Ali. I congratulate my hon. Friend the Member for Waveney (Peter Aldous) on securing the debate and I am pleased that he is seeing a local improvement after we met recently. I also thank the hon. Member for Bradford South (Judith Cummins) for securing the debate.

I agree with my hon. Friend the Member for Stroud (Siobhan Baillie) that we have seen a level of interest in and concern about the matter across the Chamber, and that we need to ensure that we take some of the politics out of it because there are some difficult steps to take to improve dental services across the board. I welcome the contribution from my hon. Friend the Member for Mole Valley (Sir Paul Beresford), whose clinical experience is so helpful in the debate. I reassure colleagues on both sides of the House that since I came into post in September, dentistry has absolutely been a priority for me. I have been working night and day to try to make some short and long-term improvements, because I am live to all the concerns that have been raised.

We have set up some joint working, which was not happening before, between NHS England, the chief dental officer and the Department, and I meet the BDA regularly because we are serious about reform. I say to any dentists watching the debate that I absolutely understand the problems that make delivering an NHS contract unbelievably difficult. The contract is the No. 1 long-term issue that we have to deal with, and we are starting progress on that as soon as possible. I will come to some specifics shortly, but first let me mention covid.

I know that there has been some concern that covid is a lame excuse but, as my hon. Friend the Member for Mole Valley said, it has had a significant impact on access to dental services in the past 18 months. When lockdown happened, services were immediately reduced; only urgent services were allowed. That continued for a significant period. It was not until 8 June 2020 that practices were allowed to open for up to 20% of normal activity and it was not until last year that that went up to 60% and, towards the end of the year, to 65%. Although dentists were compensated for their loss of income during that period, the backlog that that generated is shown in all our postbags right now.

I place on record my thanks to dental teams up and down the country. Urgent appointments went back to pre-pandemic levels in December 2020, but with only 85% of activity allowed the backlogs will only grow. We need to be honest about that; the impact is significant. I completely understand the pressures that that is putting on dentists. We are keen to support dentistry where we can to get it up to 85%. It has been difficult during omicron with staff sicknesses and patients having to cancel when they become covid positive, and I absolutely recognise the stress and strain that covid has put on the system, but we have to be honest. I think it was the hon. Member for Bootle (Peter Dowd) who mentioned this, and I am happy to accept the difficulties we face. There were problems before covid and there are those same problems post covid, and we are absolutely focused on starting to tackle them.

Let me make a couple of points. There is no patient registration system for dentistry—that is one of the myths. It is not like GP practices, where someone signs up and is then on the list. Patients can go from dentist to dentist if there is one available, and we are making sure that we open up capacity where it exists.

We have written to all dentists to ask them to update their capacity so that we can put it on the website mentioned by the Father of the House, my hon. Friend the Member for Worthing West (Sir Peter Bottomley), and we have also asked them to run a cancellation list. If someone cancels, the practice will be able actively to contact the next person on the list. Capacity is being generated by that, but I am aware of the problems with capacity across the board. We have talked about many parts of the country, such as Norfolk and Devon, that are experiencing capacity issues, but all parts of the country have experienced a squeeze in the number of appointments available.

A couple of weeks ago, we announced £50 million to help with some of those issues. I know that some Members have been quite dismissive of that this afternoon, but we know that it will cover the period to the end of this financial year to buy some urgent capacity for the system and to help deliver more than 300,000 appointments that currently cannot happen. There has been good uptake, even in the few weeks since the money was announced. Regions across the country are signing up and because the payments to dentists are much better than under the current contract, there is an appetite among dentists. That shows that if we remunerate dentists adequately they have an interest in taking on NHS work.

I encourage Members from all parties to contact their local commissioners, because we want to ensure that that money is used. If there is no interest, or if they are struggling to spend the money, they should let us know. NHS England has been in contact with local commissioners to get that feedback so that we can make the best use of the money and buy as much capacity as possible.

[Kevin Hollinrake]

Does the Minister think that it is acceptable for commissioners to take 20 months commissioning a service when we have dentists who want to take that work and take on that surgery?

[Maria Caulfield]

Absolutely. I will come on to that point, which is valid. We want to increase capacity and there are dentists who want to take on NHS work. When contracts are handed back, we have to do the whole procurement process, and when there is an interested party, even when they are ready to sign on the dotted line, that takes a considerable amount of time. In the Department, we are looking at how we can change the procurement process. It often falls in the lap of local commissioners, but they are stuck with the procedures they have to follow. I am keen to see how, when someone is willing to take up a contract, we can enable that to happen as quickly as possible.

We have also relaxed the upper tolerance threshold and increased activity from 104% to 110% of dental activity. The current contract penalises dentists if they go over their contracted work, which is a perverse disincentive when dentists have capacity and want to take on extra work.

Before I touch on the nub of the problem, I will mention prevention. I am pleased that prevention is being considered and that the Government’s proposals on water fluoridation are part of the Health and Care Bill. I hope Opposition Members will support us when the Bill comes back from the Lords. We are also looking at options for how to introduce supervised tooth brushing in parts of the country where there is the greatest need. I reassure hon. Members that the prevention and oral health element is as key as getting dental procedures done.

The dental contract is the crux of the matter, and we are absolutely committed to reform. I met the BDA this week to start negotiations. We are looking at some quick wins over the next 12 months and some long-term contractual reform to the UDAs. We have started informal negotiations, and the formal negotiations will start in April. We all—the BDA, patients, MPs and the Department —know the urgency. It cannot be a long, protracted negotiation. However, we are working well with the BDA. We are keen to get negotiations under way and to reach a resolution as quickly as possible. We have to make the NHS a better and more attractive place to work, because dentists have other options; I cannot remember which Member said it, but dentists are voting with their feet when it comes to where they want to practice.

On the recruitment, retention and training of dentists, Health Education England published its “Advancing Dental Care Review” in September. It is working through how we can train not just more dentists but the whole dental team, and on how we can upskill dental technicians and dental nurses. We will bring forward legislative changes to enable other members of the dental team to take on more roles. We are setting up centres of dental development in those areas of the country with the biggest shortages, which tend to be coastal and rural. I take the point made by my hon. Friend the Member for Broadland (Jerome Mayhew) about Norfolk—I think I heard that several times. We are looking at where in the country those dental deserts are and whether we can match them to centres of dental development.

Members may not realise that this week the Department announced a consultation with the General Dental Council on the registration of international dentists and whether we can put in place a process to recognise the qualifications of dentists from around the world, as my hon. Friend the Member for Mole Valley mentioned. The overseas registration exam, which they have to take, was suspended throughout the whole of covid, so we have a backlog of around 700 dentists waiting to take it. The first exams started a couple of weeks ago, and there are exams in place for the rest of the year to try to get through that backlog. We are confident that we can do that.

We need to work on how we recognise existing qualifications to remove the barrier of having to do an exam. Again, I encourage colleagues to respond positively to the consultation on the GDC website and to the developments it is making. My hon. Friend the Father of the House has written to me about international dentists having to take the exams within five years of their first attempt, and whether those rules can be relaxed. That is also part of the consultation. We very much recognise that covid has had an impact on those rules too.

I reassure colleagues that I am working on bringing NHS England, dentists and the BDA together so that we can make a difference as quickly as possible. The changes in the Health and Care Bill on integrated care systems and having accountable people for commissioning locally are crucial. Integrated care boards will be statutory from 1 July, and will have accountable officers. I strongly urge colleagues to speak to their ICBs or CCGs, because there are differences in practice across the country. Some commission dentistry really well, some not so well. Very often, if the money allocated to dentistry is not ringfenced, and if it is not spent locally, it goes into other healthcare provision and is lost from dentistry. I encourage Members to hold the feet of their local commissioning bodies to the fire on what they are doing with the money given to them. We are here to support them, and work will be done on dentistry commissioning going forward.

In the short time I have had, I hope I have been able to provide assurances that dealing with the situation is not without its challenges. There is no silver bullet that will resolve all the problems. There is not a quick-fix solution, but I am working at pace, as is the Department, to reform the contract. Work is starting in April on the formal negotiations, and I hope that will improve recruitment and retention in dentistry. We value the work that dentists do, which for too long has gone unrecognised and has been a Cinderella part of the service. The people who have suffered are not just the dentists, but the patients.