Oral Health and Dentistry: England

Mohammad Yasin Excerpts

Tuesday 25th May 2021 Westminster Hall

[Mohammad Yasin (Bedford) (Lab) [V]]

I beg to move,

That this House has considered oral health and dentistry in England.

It is a pleasure to serve under your chairmanship, Ms Bardell. I was compelled to call for this debate after an NHS 111 call handler contacted me to describe the hardship that they experienced in trying to get patients in severe pain emergency dental appointments—too often without any success. Dental practitioners and lab technicians have also approached me, detailing the many obstacles in their profession that are preventing them from giving the care that they so desperately want to give their patients. The different perspectives make it blatantly clear that dentistry in this country is in crisis and patients, including children, are not getting the care that they need.

There is a lot of work to be done to fix what has long been a broken system, so let me start with thanks to all my colleagues who are contributing to this debate and to all those organisations, including the British Dental Association, the Association of Dental Groups, the Faculty of Dental Surgery and Healthwatch, and dentists in my constituency, who not only briefed me for the debate but have been working day in, day out, for years to raise the serious issues that I will go on to mention and who have the solutions, if only the Government would listen.

I hope that the Minister will come to the table today with a response that matches the gravity of the situation, because access to dental care in England is in a parlous state. A constituent employed by the NHS 111 service first got in touch with me in September 2020, in the midst of the pandemic, to tell me, in his words,

“about the woeful state of the dental service or more precisely the lack of a dental service”.

He covered Hertfordshire, Bedfordshire and Essex, but was aware that his comments applied nationwide. He told me that he spent the majority of his day speaking to people who were literally crying out for an appointment and even emergency treatment, but he had absolutely nothing to offer them. He told me that if someone is lucky and already registered with a dentist, they might be offered an appointment at some future date, often weeks in advance, but if not, they had no chance of being taken on. He said that that applied to everyone, including children and pregnant women. That was of course during lockdown, but many of the barriers to finding appointments persist.

I contacted the constituent again in February and he told me that, if anything, the situation was worse. He worked almost exclusively on dental calls; they were coming in relentlessly. He described it as a Catch-22 situation. If people are not registered at a practice, NHS 111, virtually without exception, can only tell the callers that practice books are closed to new NHS patients for the foreseeable future. If a patient is registered, they will be told that their practice cannot offer treatment—often for weeks ahead. Let us remember that patients call 111 only as a last resort and are mostly in considerable distress. They mistakenly believe that the NHS runs the dental service, and have nowhere else to go. Many turn up at A&E in desperation, which only adds to the pressure on NHS hospitals which do not have the capacity, expertise or tools to fix dental problems.

My constituent told me it was heart-wrenching to have to listen to these calls for six hours a day. Last week, when I asked for his permission to raise his concerns in this debate, he told me that

“there is real anger and desperation brewing.”

I hope that the Minister is listening carefully to my constituent’s experience, because this is the situation on the ground. I am sorry to say that he has now decided that enough is enough—he will leave his role because he says he

“can see no possibility of any improvement this year.”

NHS dentistry is facing an unprecedented backlog in care that will take years to clear. The BDA estimates that a staggering 30 million NHS dental appointments have been lost since the start of the pandemic, and a report published yesterday by Healthwatch found that 80% of people struggled to access timely care during lockdown.

Even before the pandemic, only enough NHS dentistry to cover just over half of England’s population was commissioned. Over a quarter of people either struggle to or cannot pay, so they avoid dental treatment altogether. Capacity is severely limited by infection control measures, and access problems have now reached an unprecedented scale in every community, with deep existing inequalities set to widen even further.

If the Government are serious about levelling up, tackling health inequalities needs to be at the top of the agenda. Healthwatch found that, among people living in the north-east of England, those on low incomes and ethnic minority groups were hardest hit by the twin crises of access and affordability.

The Care Quality Commission’s “COVID-19 Insight: Issue 10” report published last week rightly questions whether enough NHS dental capacity is being commissioned, and challenges NHS policy leaders to deal with the demand and ensure that everyone—especially the most vulnerable—has equal access to NHS care.

The system has long suffered from chronic underfunding. Even if you factor in the income from patient charges, which have been increased by an inflation-busting 5% in each of the last five years, the total NHS dental budget was lower in cash terms just before the pandemic than it was when Labour left power in 2010.

The dental contract introduced in 2006 is structured with ridiculous, counterproductive targets which do not make things any easier. Totally discredited and unfit for purpose, it is incompatible with providing safe and sustainable services for patients, both during and after the pandemic, and must be reformed. The peculiar Units of Dental Activity system effectively caps the number of patients a dentist can see on the NHS and actively disincentivises dentists from taking on new NHS patients, especially in poorer areas where a new patient is more likely to have large, unmet dental care needs.

I am grateful to the Parliamentary Engagement team, who ran a survey in relation to this debate. When asked what key changes would enhance their ability to do their job every single respondent, 78% of whom were oral health professionals, wanted to abolish what one described as

“the aberration that is the UDA system.”

Another said that they would have no problem committing to provide 100% NHS dentistry if they were paid for the work they did. However, under the current system, a root canal treatment—which can take up to three hours of highly technical and skilled work—is renumerated the same as a little filling that may take 30 seconds to place.

Why can the Government not understand that a work- force work best when they are respected and incentivised? We need to get more patients through dentists’ doors, but aggressive and punitive activity targets are not the way to go about this. The targets have been the driving factor behind the recruitment and retention crisis in NHS dentistry. While the Minister is keen to point out that the headcount of dentists providing NHS services has been pretty stable, when dentists need to do only an hour of NHS work a week to be considered an NHS dentist, that is meaningless smoke and mirrors.

In reality, many dentists have been reducing the NHS work they do, and the Minister’s written answer last week revealed that the number of practices providing NHS dentistry in England fell by 1,253 between 2015 and 2020. As in other parts of the NHS, the pandemic has brutally compounded the pre-existing problems in the dental system.

I appreciated and welcomed the Government’s support for NHS dentistry in the early stages of the pandemic. The Minister quite rightly decided to pay dentists their historical contract values when they were told to close their doors to patients in the first lockdown. After dental practices reopened last summer, dentists were asked to work their way through the backlog, prioritising patients on the basis of need, instead of focusing on delivering units of dental activity.

Just before Christmas, however, the Government changed course. Despite standard operating procedure continuing to severely limit the number of patients that can be seen safely, the Government expected dentists in England to deliver 45% of their historical activity between January and March or face financial penalties. This target was further increased to 60% in April. The BDA members survey suggests that a large proportion of dentists managed to meet the target only by taking extraordinary measures, such as cancelling all annual leave and working beyond their contracted opening hours—all of this while working many hours a day in heavy-duty personal protective equipment.

Dentists in my constituency tell me the same story: the situation is not sustainable. To put this in context, the Labour Government in Wales have not introduced any such targets, recognising that chasing activity measures is good for neither patients nor dentists in the context of a pandemic. I would welcome the Minister’s explanation of the extreme difference in approach between England and the rest of the UK, and I urge her to follow the lead of the Administrations in Wales and Northern Ireland, who have committed capital funding towards buying high-capacity ventilation equipment, which can drastically cut down the fallow time required between treatments. This sensible investment allows dentists to see more patients safely and will pay for itself in increased patient charge revenue.

Morale in the profession is at an all-time low, and there is a real danger that the pressures will turbocharge the flight of dentists from the NHS, driving them into private dentistry or early retirement, and making the problems with access for patients a permanent feature of our dental health service. That is on top of the significant loss of overseas dentists as a result of Brexit. The backlog created by the pandemic cannot be tackled if we have no workforce left to do it. Dental practitioners must urgently be added to the shortage occupation list. I hope that the Minister will outline the Government’s road map out of the current high-intensity infection prevention and control measures.

There can be no more kicking the can down the road when it comes to contract reform. It is now a matter of urgency. I would welcome the Minister’s assurances that the new system will be rolled out more quickly, and certainly without any further delays, and that it will decisively break with the discredited units of dental activity and instead prioritise increasing access for patients, and prevention. It is vital that the Government seriously invest in preventive measures.

Oral health is an essential precondition and indicator of overall health, and it deserves to be given priority in our health system. One in eight children in Bedford has obvious tooth decay by the time they are three, and the figure rises to one in five by the time they turn five. The Government are letting children down. In the year before the pandemic, over 23,000 children between five and nine were admitted to hospital because they had tooth decay. It is absolutely shameful that a completely preventable disease continues to be the No. 1 reason why young children in England are admitted to hospital. In the last five years, 540 children in Bedford have been admitted to hospital for tooth extractions, wasting over £500,000 of precious NHS resources just in our town, as well as causing pain and stress.

Procedures under a general anaesthetic are another area of dentistry where the pandemic has taken a heavy toll. They are often necessary in children with extensive decay and adults with special needs, and waiting times were very long even before the pandemic, with patients often waiting in excess of a year. The suspension of most non-urgent surgeries has left tens of thousands of patients in pain for months, with some taking huge amounts of painkillers or resorting to do-it-yourself interventions or multiple rounds of avoidable antibiotics while they wait for this completely preventable surgery.

I welcome the plans to legislate to recentralise water fluoridation as a preventive measure, but would welcome assurances that changes to the legal framework will be accompanied by proper funding, otherwise it will be meaningless. Water fluoridation is highly effective, but it will take years before we see its effects, so proper investment in preventive oral health programmes, such as supervised toothbrushing, is needed. Supervised brushing is estimated to save over £3 for each £1 invested over five years. I hope we will see a consultation and a roll-out of this sensible and highly effective intervention very soon.

Finally, I turn to the forthcoming health and social care Bill. Beyond the measures on fluoridation, the White Paper barely mentions dentistry at all. I hope to hear a commitment today that dental services will be properly represented in the governance structures of the integrated care systems, and that the changes to commissioning structures—and particularly any possible pooling of primary care budgets—do not result in further cuts to dental budgets.