National Health Service (Primary Dental Services) (Amendment) Regulations 2022

Lord Hunt of Kings Heath Excerpts

Tuesday 24th January 2023 Lords Chamber

Moved by

[Lord Hunt of Kings Heath]

That this House regrets that the changes to dental contracts in the National Health Service (Primary Dental Services) (Amendment) Regulations 2022 (SI 2022/1132) will not have a significant impact on improving access to dental treatment whilst current workforce shortages persist.

Relevant document:18th Report from the Secondary Legislation Scrutiny Committee

[Lord Hunt of Kings Heath (Lab)]

My Lords, it is good as ever to know that dentistry excites such interest amongst your Lordships. I am very grateful for those noble Lords who are going to take part in what I think is a very important debate tonight.

Like many aspects of the NHS, our dental services are under great pressure at the moment. Indeed, there are reports that some patients are resorting to DIY dentistry and removing their own teeth because they cannot get access to an NHS dentist. In August 2022, the BBC reported that, based on a survey of 7,000 NHS practices, nine out of 10 NHS dental practices across the UK were not accepting new adult patients for treatment under the NHS. The BDA believes that NHS dentistry is facing, as it calls it,

“facing an existential crisis with the service hanging by a thread”.

The problem predates the pandemic, but it has now reached an unprecedented scale. The BDA estimates that over 40 million dental appointments have been lost since the start of the pandemic. Those from low-income or vulnerable groups are being disproportionately impacted, with 1 million new or expectant mothers having lost access to care since the start. Dentistry has been subject to cuts unparalleled in the NHS; in real terms, estimates suggest that net government spend on dentistry in England was cut by over a quarter between 2010 and 2020. The BDA argues that chronic underfunding and the current NHS dental contract are to blame for long-standing problems with burnout, recruitment and retention. We know morale among NHS dentists is very low, and we are facing an exodus of them from NHS practice.

The regulations before us today are welcome, but they will not turn this around. Under the regulations, subdividing band 2—putting more complex treatments into categories 2b and 2c—should hopefully reward dentists’ time and input more accurately. More generally on access, I understand the NHS has started commissioning “access sessions”, remunerated using a sessional fee in practices with an NHS contract in the north-east, using existing flexibilities within the current regulations. I hear that this scheme has worked very well, and I congratulate the commissioners and providers on this. Can the Minister confirm this and say whether it is to be rolled out across the country? I certainly think that this should be a priority. Because it can be done under existing regulations, and because of the protracted delay in moving from the long pilot scheme we have had to a new contract, this surely is an area where Ministers could make some progress in the short term, provided they provide resources to the health service to do so.

We are debating one element of a package that was announced by the Chief Dental Officer last year, designed to improve access. Two weeks ago, we agreed on one of those planks—regulations which gave dental care professionals the ability to open new courses of NHS dental treatment when they are trained and competent to do so. I do not want to go over the ground again; I think that this is a significant change that should be applauded, but there are still blockages in making it work effectively.

First, under previous regulations, a DCP would have needed a performer number to open a course of treatment, and with that would have come associated pension benefits. I understand that, under the recently issued guidance from the NHS, the DCP has to demonstrate competence by entering their GDC registration number, but the dentist whose performer number appears on the NHS form signing this off actually accrues the pension benefit. That does not seem to me to be fair, it is potentially discriminatory, and I wonder if the Minister could give me some justification for that, perhaps in writing.

Secondly, work has been going on for over a decade to allow DCPs to give local anaesthetics without having the direction of a dentist. Can I ask when that is going to be implemented?

Thirdly, given that the current system of remuneration of our dental schools means that it is much more attractive financially to train dentists, will they be incentivised to train more DCPs? If not, how are we going to see a substantial increase in DCPs? If I may just take the Minister back to our debate two weeks ago and the decision to exclude overseas dentists from working as DCPs, I still fail to see the justification for that.

The third plank of the package announced by the Chief Dental Officer to improve access was in relation to NICE guidance published in 2004. The concept of six-monthly recalls is embedded in our society and among patients, but it is not evidence-based and recall intervals need to be tailored to risk—in some cases, six months may be appropriate, but not all. The time taken up by unnecessary recalls could be used to grow access, and I would like to know how the Government intend to make sure this guidance is complied with.

Putting this all together, it is inevitable we come back to the issue of the critical shortage of workforce. Opening new dental schools is clearly one solution—I would like to see that—but we know that it takes up to 10 years from taking the decision to open a new school to clinicians entering the workforce. We clearly do not have 10 years, so we need to train more dentists, but in the near-term we have got to make NHS dentistry a more attractive option to improve retention of existing clinicians, while also making it easier for overseas dentists to work in the NHS.

The obvious way to make NHS dentistry more attractive to dentists in the UK is by increasing the budget for NHS dentistry. Given the real-terms cuts that we have seen—a quarter since 2010—this is essential.

In the short term, overseas dental professionals are one key to addressing the workforce pressures and ensuring access to NHS dentistry. One way that we can achieve this quickly is by streamlining the GDC processes for accepting individuals on to the register. This can be done by the UK striking more mutual recognition agreements for dental qualifications with countries of comparable standards and creating more places for the overseas registration exam. The GDC’s current mutual recognition of EEA-qualified dentists is also vital in boosting short-term applicant supply; this must not be removed.

Then there is the performers list validation by experience process, which all dentists not qualifying in the UK must go through to practise in the NHS—it needs standardising, simplifying, and streamlining. Does the Minister agree?

We also need to look at the work dentists do. I was briefed by BUPA that 24,272 dentists did some NHS work in England in 2021-22, but 15% of the workforce—almost 4,000 dentists—did no more than one patient course of NHS treatment a month on average; that seems quite extraordinary. How can that be justified? Can the Minister confirm that dentists do keep their performer number active by that process, which means that their historically earned NHS pension is dynamised on an annual basis? How can that possibly be justified?

Finally, we want to hear from the Government what priority they give to NHS dentistry. I put it to the Minister: is he content to see the dismantling of the service with access problems, piling up the misery of millions of people, and the frightening growth in self-treatment? Let me remind him of the BDA’s belief that

“NHS dentistry is facing an existential threat and patients face a growing crisis in access, with the service hanging by a thread.”


Are the Government essentially saying that they are content for this to happen? If not, then we need to see concrete plans to increase resources and the workforce to ensure that patients who want NHS treatment can get it in a timely way, confident in the quality of care they receive.

When I was Minister for Dentistry from 1999 to 2003, the then Prime Minister Tony Blair made a pledge that any patient who wanted to see an NHS dentist would be able to do so—and we achieved it. It can be done with strong leadership and the support of the profession. I hope the Minister will tell us whether the Government are going to go down that route tonight. I beg to move.

--- Later in debate ---

I hope that this will be seen as the first step along the way. As ever, I will endeavour to write in detail to everyone to make sure that I have reported on all the other points raised tonight. I thank the noble Lord, Lord Hunt, for bringing this matter to us for discussion. I hope that he would feel that, rather than a regret Motion, this is more a good opportunity to discuss measures which we would all agree are sensible first steps, with more needed to come. Before too long, I hope to be standing here able to talk in much more detail about those further steps.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I am very grateful to noble Lords who have taken part in this short debate. As the Minister mentioned fluoridation, I should just remind the House that I am president of the British Fluoridation Society and patron of the National Water Fluoridation Alliance. I agreed with the noble Baroness, Lady Bennett, when she talked about the WHO and preventative measures. The single most important measure would be to introduce fluoridation where it is not present at the moment. I was delighted when the Government took powers back to themselves to do this. I know that progress is being made: I just urge the Government to speed it up.

I also say to the noble Baroness, Lady Bennett, that she is right to identify the levelling-up Bill. It is a long Bill, but there is room for more amendments in relation to health. There are some already, but I would encourage her to think about that. She and the noble Lord, Lord Allan, raised the issue of the south-west. I had a meeting today with Stonewater, a very large social housing provider, which is very concerned about the lack of housing in the south-west. I would definitely make the link between housing and health, which is a very important issue if we are serious about levelling up.

The noble Lord was right to identify that these problems started before the pandemic, and that we are now facing particular issues, but the underlying structural issues are still not being dealt with. I also agree with him about post-implementation evaluation. I hope that the Minister, when he responds in writing, might be able to say something about that.

My noble friend Lady Merron was absolutely right to hone in on retention and recruitment. Although there are various initiatives, at the moment I do not think enough is being done to retain the profession within NHS dentistry. We need to do very much more about that. Her point about practice information going on the NHS website is really important, and I hope that the Government will respond to it.

Ultimately, it comes back to prioritisation and money, and I was grateful for what the Minister said. I am delighted that his wife is present to hear our debate, and indeed that he is celebrating his father’s 80th birthday. It reminded me that I took my wife with me—for a romantic 50th birthday celebration—to address the Pharmaceutical Services Negotiating Committee dinner. She has never forgotten that or forgiven me for that great sin, nor has she forgiven Alan Milburn for making me do it.

Anyway, the point is that we come back to the workforce strategy, because without a properly funded workforce strategy, with numbers, we will not get anywhere. In the meantime, there is still a lot that can be done to streamline GDC processes, recruit dentists from overseas and, crucially, give dentists currently in the profession but not doing NHS work some confidence that it will be worth their while to do NHS dentistry.

I was very interested in the point the Minister made about the cost for dentists coming into NHS dentistry and starting a new practice. He will, of course, have been interested in what Wes Streeting had to say about the future of primary care. He came in for some criticism for suggesting that maybe the current model of GP partnerships might not always be the right one. He is absolutely right that we have to think rather radically about how we will develop primary care in the future.

The argument for a proper strategy for dental access for NHS patients is very persuasive indeed. Having said that, I thank noble Lords and beg leave to withdraw my Motion.

Motion withdrawn.