NHS Dentistry

Richard Graham Excerpts

Thursday 20th October 2022 Commons Chamber

[Richard Graham (Gloucester) (Con)]

This is the first debate for a long time in which I have agreed with every single word of the motion, so I congratulate my hon. Friend the Member for Waveney (Peter Aldous) and the hon. Member for Bradford South (Judith Cummins). Frankly, we and all our constituents are concerned about the growing crisis in NHS dentistry. We are worried that nine out of 10 practices are not accepting new NHS patients, including large numbers of children. We also regret the number of dentists who are moving away from NHS practice. Those are all issues to which all hon. Members could strongly relate, if they were here.

I have been asking myself how the problem came to be and what can be done. First, it strikes me that there is a wider issue with the delivery of public services. Governments will always be judged on the same things: whether they can achieve economic growth to provide jobs and fund public services; whether they can manage those public services competently; and whether they can do so with compassion so that our most vulnerable constituents are looked after. In the health and care sector as a whole, there is no doubt that there are significant challenges in all three aspects. Dentistry is just one aspect of the effective delivery of public services, an issue that we all recognise from emails and telephone calls with often very frustrated constituents.

However, there is a particular aspect of dentistry that is unique. With acute hospitals, mental health services, ambulance trusts and so on, MPs have some agency: we can organise regular meetings with NHS trusts, hold them to account, ask difficult questions, discuss problems and find out what they need from the Government. With dentistry we have no agency, because the local NHS organisations—they are currently known as integrated care systems, but frankly in most of our constituencies it is easier to refer to them as the local NHS—have no agency. They have no say in the contracts between NHS England and the dentists.

As my hon. Friend the Member for Mole Valley (Sir Paul Beresford) helpfully pointed out, the contracts go back to 2006. Most of us have no idea what is in them. I have never seen them; I was not aware of them. No dental association, nationally or locally, has ever contacted me—or, I suspect, many of us—to say that there is a problem that needs to be resolved or to ask for help. The first we hear of it is when constituents contact us to say, “I cannot get an NHS dental appointment for myself, my children or my family.” At that stage, we go back to the local dentists and ask what the problem is.

This is what a local dentist in Gloucester has come back with:

“The majority of dentists move away from the NHS because of the continual pressures that the NHS contract places upon them in terms of requirements, payments, audits…and many other factors”.

She writes that an NHS dentist in her surgery, who has ceased to be an NHS dentist,

“was under a prototype contract that was patient-centric and when this was discontinued and changed to align with the usual NHS contract, the dentist did not feel this gave the best type of care for patients”.

She goes on to say:

“I’ve continually battled”—

she has been doing this for 25 years, by the way—

“to ensure that any patients who want NHS dental services should be able to access them, but there needs to be correct remuneration for the time and quality of services, removing a treadmill of patient care.”

That suggests that there is a problem with the contract, as my hon. Friend the Member for Waveney rightly says, as well as the problem of there being no local NHS involvement.

I welcome the Minister to his role. I know that he will bring to it the same quality of analysis and compassion that he brought to his role in the Department for Work and Pensions. I hope that he will look closely at how the contracts can and should be changed—I believe that there is a window of opportunity in April—to allow all local NHS organisations to play a key role in the distribution of resources, emphasis, recruitment and so on. We will then finally have some agency, so we can do better than replying to our constituents with “I am very sorry to hear this, but there is absolutely nothing I can do,” which frankly is more or less the situation at the moment.

Several colleagues have helpfully indicated solutions beyond the contract. I agree with the point about making it far easier for dentists, whether they come from the nations of the Commonwealth, such as New Zealand and Australia—mentioned by my hon. Friend the Member for Mole Valley—or from India or Hong Kong, which is another example that was given earlier. The Government clearly have an opportunity to do something about this if they wish, not just in the short term but in the longer term, and I hope the Minister will give us some good news in that regard.

There is also the issue of skills and training. Setting up a new dental school, first, takes time; secondly, is expensive; and thirdly, will not solve short-term problems, although we do need to look at capacity for the longer term. There is a continuing problem with longer-term thinking—in the context of public services, and indeed in other contexts—to which all Governments have been susceptible for too long.

The private sector certainly has a role to play. At the risk of plugging a particular organisation, I will mention an organisation of which I think the Minister will be aware: Genix, which has a training facility in Leeds. Its founder and CEO, Mustafa Mohammed, has a strong track record of supporting the whole business of upskilling and training dentists and providing NHS dentistry services around the country. Let me reassure my constituents and others who feel that dentistry is an entirely public-sector activity by saying that just as the private sector, through GP surgeries, plays such an important part in, for example, the delivery of covid vaccinations, it can play an important part in dentistry as well.

There is, in fact, a role for a mixed economy, and, as was pointed out earlier, there is an opportunity for some short-term contracts. Perhaps the Department could step in directly, with NHS England, to provide relief for those in pain and for those with children who may never have seen a dentist in their short lives. I am sure we would all welcome that.

That leads me to the question of what some term the nanny state—the role of education and proselytising about the value, particularly for young families, of getting stuck in with toothpaste and toothbrushes, and, perhaps, the opportunity to relieve them of VAT. We know that, just as with education, if things start well there is a strong likelihood that they will continue well, whereas if they start badly and people’s teeth do not get the treatment they need at an early stage, there will be problems later. I believe that the Government have an opportunity to play a part in this, although not uniquely, for everyone can play a part; and I hope the Minister will allude to that as well when he winds up the debate.

Let me finally say that dentistry clearly needs to be represented in local NHS bodies—especially if they are actually going to play a role in it, which I very much hope they will—and that cash will be crucial. Nothing comes cheaply, but I think we can all agree that sorting out dentistry and making sure everyone has access to NHS dentists is a very precious cause, and we all hope we will find solutions fast.

--- Later in debate ---

[Jane Hunt (Loughborough) (Con)]

I congratulate my hon. Friend the Member for Waveney (Peter Aldous) and the hon. Member for Bradford South (Judith Cummins) on securing what is clearly an important debate.

I take this opportunity to thank those in the dental profession in Loughborough and across Leicestershire for everything they have done over the past few years and particularly for the way they adapted to implement the huge changes needed to ensure the safety of their patients throughout the covid-19 pandemic. This year I have met with nearly all the dentists in my constituency, who have highlighted a number of issues they face and the impact they have on the profession and the patient experience more broadly.

[Richard Graham]

The points my hon. Friend is making are particularly important to constituencies such as hers, which have towns but are also rural.

[Jane Hunt]

I thank my hon. Friend, who is a true hero in every way.

One concern is about the UDA system, with the recurring message being that the system in its current form is not fit for purpose. I welcome the package of initial reforms to the NHS dental contract announced in July, in particular the introduction of enhanced UDAs to support higher-needs patients.

However, the reforms do not address my local dentists’ concerns that the current system is based on rewarding reactive treatment, rather than preventive, meaning that dentists are driven to do the minimum necessary to meet the terms of the target. That is a source of frustration for some, who have expressed their preference for being remunerated for using their initiative and working in the best interests of their patients.

Furthermore, while it is welcome that a minimum indicative UDA value of £23 has been introduced, UDA payments are not rising in line with increasing overhead costs, which is devaluing contracts and, in some cases, leaving dentists out of pocket. That was highlighted recently during a conversation I had with Bupa in Loughborough. Bupa expressed that that is compounded by the fact that UDA payments vary geographically, so that a UDA is worth £36 in its Sheffield practices but only £24 in its Loughborough one. Finally, the reforms do not address the issue of dentists not being given leeway under their contracts for last-minute cancellations and no-shows, even though they can lead to missed targets. I ask that this be urgently reviewed, so that we do not punish dentists for trying their hardest to continue to provide the care needed.

It is clear that there is still a way to go to make NHS dental contracts more attractive, both in terms of the nature of the dentistry performed and the level of financial reimbursement received for services performed. I fear that if the Government do not continue to work at speed, we will lose even more NHS dentists through early retirement, a reduction in time spent completing NHS work, or a full move into private practice. That would be detrimental to patient care and the availability of NHS appointments. I know that the former Minister of State for Health, my hon. Friend the Member for Lewes (Maria Caulfield), was working hard to review UDA contracts, and I would welcome confirmation from her successor that they will continue that hard work.

As well as difficulties retaining dentists, I have been informed that locally, we are having difficulties recruiting them. One reason for that is that there is no dentistry school in the east midlands, our nearest being in Sheffield and Birmingham, and students are choosing to enter into the workplace close to where they study. That is causing supply issues in the NHS service, and has created a gap in the market that is being filled by private dentists with a focus on cosmetics. We therefore need to ensure we are training up enough dentists and providing them with incentives to move away from where they are studying to areas with greater demand. Bupa has also advocated for putting dental practitioners on the shortage occupation list in order to increase overseas recruitment and fill shortages, then upskilling those practitioners via short courses to meet UK standards. Could the Minister please comment on the actions being taken to increase the number of dentists from overseas?

I am very concerned that NHS England has proposed closing the intermediate minor oral surgery service in Loughborough, meaning that local residents will have to go as far as Leicester for treatment. That city is some considerable way away, and there has been a recent cut in bus services, the No. 2 bus service in particular. Loughborough is effectively Leicestershire’s county town, so there is more than enough demand there for that service. Closing the centre will only increase pressures on the Leicester centre, extending waiting times and further impacting on patient care. That centralisation of services does not meet the needs of the patient, and I ask that the Minister look with some urgency at local services’ availability throughout the country, especially throughout Leicestershire.

Having listened to the whole of today’s debate, it has been very interesting: there are a small number of points that need to be addressed, which have been made by Members from all across the Chamber and all over the country. I do not think this is an insurmountable problem to solve, and I feel sure that the Minister will be able to address it.

--- Later in debate ---

[The Minister of State, Department of Health and Social Care (Will Quince)]

I thank the hon. Member for Denton and Reddish (Andrew Gwynne) for his kind words. He will be pleased to know that, despite what he said, I scribbled my own speech today and I can confirm that it will be a fudge-free zone. In fact, I have not had any fudge for about three years and I do not intend to start now—not least because it would not be great for my teeth.

I congratulate my hon. Friend the Member for Waveney (Peter Aldous) and the hon. Member for Bradford South (Judith Cummins) on securing time for this hugely important debate. I thank the Backbench Business Committee for allowing the time and all right hon. and hon. Members who have made constructive contributions to the debate. It would be remiss of me not to thank all those who work in NHS dentistry, not just for their work throughout the pandemic, but for the work that they continue to do serving people up and down the country.

In the relatively short time that I have available—I am conscious that there is another important debate to follow—I will endeavour to respond to as many of the points, themes and questions raised as possible. I hope that right hon. and hon. Members know me well enough already, however, to know that my door is always open. I have never turned down a meeting with a parliamentary colleague and I do not intend to start now. This is an important issue and I hope that we can continue to talk about it at length, even if not in this Chamber.

As the new Minister—or new new Minister—for primary care and therefore dentistry, I have spent the first few weeks in post learning more about NHS dentistry, including by meeting dentists; meeting people at the coalface and the grassroots is really important. Of course, I have my constituency experience too. Despite the events of today, I very much hope to be here for some time to come.



Let me say at the outset, in response to I think nearly all of the contributions made today, that I get it—I really do get it. I know that in many parts of our country access to NHS dentistry is difficult or far more difficult than it should be, and I want to make it clear that dentistry is an incredibly important part of the NHS. The Government and I are committed to addressing the challenges that NHS dentistry continues to face across the whole country, and as the hon. Member for Denton and Reddish rightly pointed out, it is in our ABCD strategy.

I turn to some of the themes raised. The first is access, which was raised by my hon. Friend the Member for Waveney, the right hon. Member for Knowsley (Sir George Howarth), my hon. Friends the Members for Mole Valley (Sir Paul Beresford), for Gloucester (Richard Graham) and for Salisbury (John Glen), the hon. Member for Bootle (Peter Dowd) and my hon. Friend the Member for North Devon (Selaine Saxby). Access to NHS dentistry varies across the country—we know that—and it was an issue, as the hon. Member for Denton and Reddish rightly pointed out, even before the pandemic, but the pandemic has exacerbated it and added further pressure to the system.

The Government are taking a number of important steps that will improve dental access for patients and make NHS dentistry a more attractive place for dentists and their teams to work in. I will outline just some of those. These changes include improvements to the current NHS dental contracts—I will come on to that in a moment—and of course to the recruitment and retention of dental professionals. I say dental professionals specifically because this is of course about far more than just dentists, as important as they are. As the hon. Member for Denton and Reddish pointed out, rightly, we have seen an additional 539 more dentists returning to NHS dentistry last year, which of course means they are able to treat more patients, but I recognise the point he rightly made, and we do need to go further and faster.

On the steps taken, notwithstanding the points made by the hon. Member for Bradford South, we made £50 million of extra funding available for NHS dental services at the end of 2021-22, which provided more appointments and increased capacity in NHS dental teams. I noted her points, and we have learned from that. Given that experience, I would certainly want to do things a little differently if we considered such a proposal again. We announced a package of improvements to the NHS dental system on 19 July, as a number of Members have pointed out, which was set out in our plan for patients. These are an important first step to system reform and are designed to improve access to dental care for patients, particularly patients with the most complex treatment needs.

A number of hon. Members raised the much criticised—and that is as far as I will go, the hon. Member for Denton and Reddish will be pleased to know—2006 contract. We are making improvements to ensure that dentists are more fairly remunerated, especially for more complex oral health needs. The one example we hear very often is of dentists getting paid the same for doing one filling as for six fillings. As numerous hon. Members have pointed out, we have also set a £23 minimum UDA value, notwithstanding the points made about the variation around the country.

My hon. Friend the Member for Gloucester raised accountability locally, including to Members of Parliament. In part the answer to that is their coming within the remit and purview of integrated care systems. I have no doubt that my hon. Friend is well aware of the chief executive of his integrated care system, and will know how to contact and meet them on a regular basis.

[Richard Graham]

The Minister is absolutely right: not only do we know the chief executive, but all Gloucestershire MPs have had regular meetings with them, including one specifically on this issue. That is why I raised the importance of their being given the opportunity to take responsibility, which I hope my hon. Friend will welcome.

[Will Quince]

I certainly do welcome that, because this is not just about commissioning, but about accountability and oversight.

Our changes will allow NHS commissioners to have more flexibility in commissioning, and I think that is really important, because if they have that flexibility in commissioning additional dental services, they are the ones who know the local need within their area. I want to see far more responsive management of contracts, so if they have underperforming practices and practices that can do more, we should enable such practices to do that. For example, a high-performing practice should be able to deliver beyond its existing contract to make up for the fact that a neighbouring practice is not doing so. That addresses some of the points made by my hon. Friend the Member for Waveney about the clawback of UDA funding at the end of the year, and then its not necessarily being spent on dentistry. As part of that, I also want and expect more transparency. We will make it a requirement for NHS dentists to update the information on their NHS website, so people can see which dentists are accepting new NHS patients for treatment.

On that point, I want to bust the myth about being registered with a dentist. There is no such thing as being registered with a dentist or a dental list. People approach an NHS dentist for specific treatment. They go on their list, register and have the treatment. They can have an ongoing relationship with a dentist, but anyone can book an appointment with any dentist with an NHS contract, regardless of where they live in the country. It is important to get that message out, because when our constituents say to us, “I can’t get a dentist locally”—I want to address that point—I want to ensure that they know that they could travel to a neighbouring town or city. They could travel half way across the country if they wanted to, for example if they had relatives there, if there was a NHS dentist who had capacity to see them.