All of us at some point will suffer from toothache. We would like to think that getting treatment through the NHS would be a relatively painless thing to achieve. Indeed, most of us have grown up with the thought that a regular check-up and work when it is needed is something we can access through our local NHS dentist, but in reality the presence of an NHS dentist in towns and villages has slowly been eroding, and charges have been in place for NHS dental treatment for some time, with only a limited number of people eligible for free treatment, including young children and those on very low incomes. The likelihood of being able to find a dentist who will do the work on the NHS is becoming more and more remote. The reasons that sit behind these changes and the necessary support needed to improve access to NHS treatment is the issue I want to raise in this debate with the Minister.
I know I am not alone in receiving correspondence on this topic, but hearing from constituents in Warrington South, reading their letters and trying to help them find a dentist has led me to the conclusion that the system needs radical changes. These problems are not all as a result of the pandemic, but it is worth saying that dentists are struggling in relation to their NHS contracts at the present time because of their experiences in recent months. NHS dental statistics show that only 12 million courses of treatment were carried out by general dentists in the year 2020-21, which is down almost 79% compared with the figure for the previous year.
The whole House will be grateful to my hon. Friend for raising an issue that matters to every Member of Parliament. Our local newspapers point out that trying to find a dentist is like trying to find a needle in a haystack. Most of us have fewer dentists than we had in 2017, and the sooner his encouragement brings about a big change in co-operation with the British Dental Association and individual dentists, the better it will be for our patients, many of whom have aching teeth.
I thank the Father of the House for his intervention, and I agree with him—the needle in a haystack analogy is absolutely right. In my role as a local MP, I am representing both providers of dental treatment and patients who want to access that treatment. So I have tried to take time in the past couple of weeks to speak to dentists in my constituency about their experiences and how the system is operating today. Many of them have been providing NHS services for many decades.
I congratulate the hon. Gentleman on bringing this debate to the Chamber, because this is an important subject, not only for him, but for all of us. Does he agree that unless we have more support for the dental industry and for affordable dental care, this will not be possible for those who are working and not entitled to help yet who are struggling with the increased cost of living? Does he further agree that there is a dental catastrophe waiting to happen in the near future if we do not do something right now?
I absolutely agree with the hon. Gentleman. That is the purpose of this debate: to highlight to the Minister the concern that I and other Members around the country have that NHS dentistry is on the brink and that there has to be radical change.
As well as talking to dentists, I have spoken to constituents who have written to me, completed an online survey that I placed on my website or messaged me directly following publicity in local newspapers about this debate. This topic matters not only so that people can access urgent treatment for toothache. More and more studies are confirming what dentists have always argued: that tooth decay and gum disease are increasingly linked to a heightened risk of serious health problems such as stroke, heart disease and diabetes. A healthy mouth is the gateway to a healthy body. Neglecting oral health can sabotage our long-term overall health. As the hon. Gentleman indicated, this topic really does matter to many, many people.
One of the first issues I want to highlight is the challenge people face when they move house. Finding NHS treatment can be almost impossible as a new resident in a location. I wanted to say, “getting on to a surgery’s list,” but it is clear from speaking to dentists that the notion of getting on to a list does not exist any more; there are no such things as dentists’ lists today.
In my quest to help residents, I have spoken to NHS England, Warrington clinical commissioning group and the regional dentists’ team. They have all pointed me to an NHS website that lists details of dentists who are accepting patients in my local area. The reality is that the website is massively out of date. In most cases, surgery information has not been updated for about two years. Despite being assured that there are dentists accepting new patients in Warrington, it is simply impossible to find them. As my hon. Friend the Member for Worthing West (Sir Peter Bottomley) indicated, it is like looking for a needle in a haystack.
A dentist in my constituency, Matt Hooper, has contacted me several times regarding this matter. He says that morale in dentistry is extremely low at this moment in time, specifically due to the contracts that my hon. Friend is discussing. Does he agree that we really need to value our dentists? When most of us are going about our day-to-day business, we do not think twice about our dentists, but when we get toothache, all of a sudden they become our best friends. We need to make sure that they are there for us.
My hon. Friend is absolutely right: many of the dentists I have spoken to say that working with these activity targets is like being on a treadmill. It wrongly puts the focus on meeting targets, rather than delivering the sort of patient care we need to be delivered in our dentists’ surgeries.
On the back of receiving news from constituents who contacted me that a surgery in Appleton was to close, I went to see Dr Mansour Mirza, who runs Appleton Park dental surgery. He talked me through his decision to give notice to the NHS. He was handing back a contract worth hundreds of thousands of pounds which his practice had had for many years. I want to thank Dr Mirza for being so open and so frank with me about the decision that he had to take earlier this year. Providing the treatment that he is required to deliver under the contract just does not add up. It costs him more to provide the services than he is paid. No one can survive over the long term if that is the case, so it is hardly surprising that his contract, like many others around the United Kingdom, is being handed back to the NHS.
I am also grateful to David Flattery, a dentist who lives in Lymm and owns and manages a practice in Altrincham, for his insights. He says that the incentives to take on new NHS patients at his practice are slim to none, owing to the workload and the quotas that he has to meet under the “units of dental activity” system. When he explained how the system works, with units attributed to particular types of treatment, I came away scratching my head. Dentists are effectively paid the same for delivering a check-up as they are for root canal work, although one of those procedures involves a tremendous amount more work than the other. That makes little sense.
The Minister will know that UDAs simply do not work, and it is time to replace the contract with a more modern system which reflects dentistry in the 21st century. Dr Miraz told me that his private work had been subsidising the NHS contract for many years, and that despite wanting to continue, he simply could not afford to provide the NHS services that he had signed up to. Shockingly, the regional NHS team did not seem to want to find a solution: they have simply left people without access to any NHS dentist.
Cherilyn Mackrory (Truro and Falmouth) (Con)
My hon. Friend is advancing a compelling argument, and much of what he is saying rings true in Cornwall as well. One of my passions relates to childhood dentistry, or the lack of it. When we question the authorities in Cornwall, we often find that they are not entirely aware of the scale of the problem that they have. Many Cornish Members are currently conducting their own online dentistry survey.
When I was a child—I do not know whether other Members had the same experience—we used to have dental checks at school, and our parents were told if there was a problem. When I investigated, I was told that it was not necessary for a dentist to carry out the checks; a dental professional could do them, and a letter would then go home to the child’s parents. Would my hon. Friend support piloting such schemes again, particularly in deprived areas, along with preventive medicine to stop children needing to go to the dentist with serious problems in the first place?
My hon. Friend raises an interesting point. I spent Friday afternoon with a GP practice in Warrington South and heard from the doctor there about the work that is now undertaken by nurse practitioners in the surgery and in the community. It seems sensible to me to upskill dental nurses to become dental nurse practitioners who can work in the community, and in schools in particular, to try to give guidance to parents to support families and to ensure that children’s dental health is a priority.
My hon. Friend identifies issues in child oral health. If we are not careful, we will store up an incredible problem for the future. We need to see it as a priority. The notion of having a six-month check-up has gone, for many good reasons, but many children are not seeing a dentist over a 12 month or even two-year period. We need to think carefully about that, so I absolutely support her point.
According to the NHS workforce study, 147 fewer dentists are working in the NHS in the north-west than in the previous year. In Warrington, there are 64 dentists per 100,000 of the population and we are seeing considerable falls on previous years.
In the long term, root and branch reforms need to be instigated in the dentistry sector. I hope that the Minister can explain what steps the Government are taking to increase training places in the north of England. I ask her to instigate a national recruitment drive to increase the number of people going to university to study dentistry and to introduce incentives for dentists to relocate to areas such as Warrington and to work in smaller practices where they provide an incredible service to local communities.
I ask the Minister about the new dental contract too. As I mentioned, I think most of the underlying problems in NHS dentistry spring from the fact that the current contract, which dates back to 2006, is not fit for purpose. It is inadequate and does not reflect the needs of dentists and their patients today. I hope that she can explain what steps she will take to bring forward a new contract and how she can work with dentists, patient groups and other interested parties around the country to ensure that the contract reflects what dentists and their patients need for the next decade. Does the Minister agree that we must break the idea of units of dental activity and ensure that NHS dentistry is available to all those who need it, as well as prioritising preventive care?
I congratulate my hon. Friend the Member for Warrington South (Andy Carter) on securing this important debate. Is it not amazing that when we have toothache or need some treatment, we go to these wonderful people, get an injection, lie back with our mouth open while they drill away, then stagger away with a numb jaw, and as we leave, we always say, “Thank you”? We say that because, as my hon. Friend said, they are doing us a great service and we appreciate them.
When I look at the most common issues in my digital postbag—my constituents write to me about health issues all the time—close to the top is dental care. The issue is widespread, as we all know, and in every corner of Britain, but I will briefly tease out some of the more shocking figures.
Some 85% of dental practices are closed to new NHS patients. Nearly half of patients are forced to get private treatment because of access problems. Every 10 minutes, a child is admitted to hospital for a tooth extraction—let us imagine the cost of that, let alone the trauma involved for the children. Some 1,000 clinicians have left the profession in the past year, with yet more significantly reducing their NHS hours. This is utterly unacceptable.
So we have the levelling-up policy. I welcome the levelling-up agenda, but I do not believe that we are all being levelled up in a fair manner. Areas such as Clacton, my constituency, are often considered to be rich and well-heeled because we fall into the wider eastern region, which is considered to be an economic powerhouse—and it is, but not necessarily on the coast. If we really want to level up public services for those suffering and at risk, we must consider areas such as Clacton when it comes to dental care. Let us ensure that levelling up follows the data and not just the rhetoric, and gives coastal communities the help they need.
There are two key areas we need to hit in an age of integrated care systems where we are devolving more and more power over primary and acute care to local leaders. I increasingly question the role of certain state monoliths such as NHS England and NHS Improvement. My constituents do not need more national mandarins; they need local, empowered leaders with devolved budgets. I reflect on my former clinical commissioning group and the outstanding leadership that it and its accountable officer, the brilliant Ed Garrett, provided locally. Clacton primary care is measurably in a much better state thanks to his and his office’s work. Give local systems the commissioning powers and budget and we will level up in a local, focused and measurable manner. The primary care trusts have had their day. Local care leadership is now delivering. It is time for NHS England to be devolved in the same manner.
It is always a pleasure to follow my hon. Friend the Member for Clacton (Giles Watling). I thank my hon. Friend the Member for Warrington South (Andy Carter) for securing this debate on an important subject both for the country as a whole and for my constituents, because we are one of the coastal, rural communities badly affected by the lack of NHS dentists. Islanders are facing a serious dentistry issue. I have raised this with the previous Minister and the Secretary of State on a number of occasions. Frankly, it is now almost impossible to find an NHS dentist on the Island if you do not already have one. Some Islanders have written to me about having to go into the mainland as far as Surrey. That stretches a family budget, because we have some of the most expensive ferries on the planet, so it is a painful decision.
As my hon. Friend the Member for Clacton said, 85% of dental practices across the country are closed to new patients, and seven out of 10 people find it difficult to access an NHS dentist. This does not only have immediate consequences such as toothache but is dangerous, because there will be a significant rise in oral cancer cases, which are increasing in the UK. In 2020, 2,700 Brits lost their lives to mouth cancer. The lack of dental appointments means that we will not be able to spot those cancers early on, so those figures are likely to increase. We had a case on the Isle of Wight of somebody who was sadly diagnosed late and then misdiagnosed, who now has untreatable cancer. We also know there is a correlation between gum disease and heart disease. There is no doubt that a significant knock on will feed through from the lack of appointments.
Dental practices were clearly facing challenges before covid, and it is, in part, a workforce challenge. The British Dental Association has found that 75% of dental practices are struggling to fill vacancies, on which I will make some suggestions shortly. More than half of NHS dentists under the age of 35 are thinking of leaving the NHS in the next five years, which is a potentially serious and significant problem that will only make the issues more acute. It is one reason why areas such as Clacton and the Isle of Wight are significantly suffering from a lack of NHS dentists.
I congratulate my hon. Friend the Member for Warrington South (Andy Carter) on securing the debate and on raising such an important issue. I answered another Monday Adjournment debate on dentistry recently, and on Thursday there will be another debate on it in Westminster Hall, so it is obviously a significant issue for many hon. Members across the House. I also thank my hon. Friends the Members for Clacton (Giles Watling) and for Isle of Wight (Bob Seely) for raising issues on behalf of their constituents.
I am not going to stand here and say that there is not an issue around dentistry, because there absolutely is —it has been significantly affected by the pandemic. I will touch first on the short-term problems that the pandemic has created for dentistry and for patients, before going on to the longer-term problems around the contract, which my hon. Friend the Member for Warrington South raised and which have existed for a significant time.
A significant backlog has been created during covid. The majority of dental procedures are aerosol-generating, so covid creates a significant risk both for patients and for dental teams. When the lockdown measures initially came into force, only urgent dental procedures were allowed to go ahead. It was not until 8 June 2020 that non-urgent procedures were allowed, and only 20% of normal activity was allowed to go ahead at the time because of infection control measures. Even at that stage, we could see that a significant amount of work was backing up.
For most of last year, dental teams were allowed only up to 40% of normal activity. It was not until the end of last year that they could go up to 65%, and just around Christmas time that they were able to go up to 85% of normal activity. Even today, they are still not allowed to go back to 100% of normal activity, simply because infection control measures make it important that space, intervals between patients and cleaning between patients continue.[Official Report, 21 February 2022, Vol. 709, c. 3MC.] Even with dentists working at pace and as hard as they can, a backlog is still accumulating nearly every day because those measures are in place.
I thank the Minister for setting out very clearly how dentists have come back to operate in their surgeries. As she mentions and as I said in my speech, dentists were asked just before Christmas to deliver 85% of the UDAs for the three-month period from January to March. A number of small dentistry practices operating with one or two people are saying that we have increased the amount that they are required to deliver in order to be paid, at a time when covid is at its highest with the most infections ever. If a staff member, dentist or patient is unable to attend, the risk that the dentist will not be able to deliver is very significant, which means that they could be financially penalised. Does the Minister understand that the way the contract has been set up can really work against the current timeframe?
I absolutely have a lot of sympathy for dentists. It is due to their and their teams’ hard work that, since December 2020, urgent care is back to pre-pandemic levels. I reassure my hon. Friend that when we were at 20%, 40% and 65%, dentists were getting paid 100% of their contract value; it is only since the Christmas period, when we went to 85%, that they have not been paid the full 100%. Throughout most of the pandemic, even though they were seeing fewer patients than their contract allowed because of infection control measures, they were getting 100% of their contract value.
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On Friday, I had it confirmed by constituents I spoke to that NHS England could not provide them with the details of any dentist in Warrington, Cheshire or Merseyside who was accepting new NHS patients. They could provide details of emergency dental treatment services available in Manchester or Liverpool, but NHS England confirmed that no dentists are currently taking on new NHS patients across an area with a population of about 1.8 million people. I am afraid, Minister, that the signposting we are offering online is woeful and urgently needs to be updated.
In early January, I heard from many people living in Appleton, who had received notice from their local practice that after many years of providing NHS treatment, it would no longer be offering services through the NHS. On Friday last week, I met Paul and Paula Green, who have been patients at Appleton Park dentist surgery for many years. They are two of about 8,000 local people who received the notification that their provider was changing the way it offers services, and that the only way they could continue to get treatment at the local practice was to become part of a dental plan or to pay for their treatment. Mrs Green has been at the same surgery for about 50 years. In fact, the whole family are patients. They were suddenly informed that treatment provided by the NHS would no longer be available from the end of March. They will have to look further afield for a practice—there are no other practices in the village— and there is no guarantee that they will be taken on by any practice in Warrington, Cheshire or Merseyside.
Many of those 8,000 people will be left without an NHS dentist. Some could even be mid-treatment. They have paid their national insurance and their taxes, in many cases over many years, but now they cannot get NHS treatment. Understandably, they are pretty cross. They are cross with the dentist for making this change. They are cross with the regional NHS team. They are cross with me as their Member of Parliament. They are cross with the Government. They want to know what the Minister is going to do to help them find an NHS dentist who can look after their family’s oral health.
Myriad factors are driving practices across the country to make such moves, and I will cover a couple of the main issues that I hear when I talk to owners and senior dentists across my constituency. One of the first issues I want to discuss is the need—much like in many other sectors—to bolster and boost skills. Dental practices stand or fall based on the quality of their people, and if a dental practice cannot recruit enough good staff with the right level of training, that practice obviously has a serious problem. However, unfortunately, research suggests that this is a common problem for small and medium-sized dental practices right across the UK. Most dentists are SMEs: they are run by a senior dentist, receiving payment from the NHS to provide services through an annual contract, which I will discuss in more detail shortly.
The problem is that the UK does not seem to be producing sufficient numbers of dentists with the skills that those SMEs need. On top of that, the difficulty with dentistry is that when people graduate, they tend to work where they qualify or where they live, and they are not necessarily going to dental schools in the north of England—in fact, most of the dental schools in this country are in the south or the midlands. We are simply not training enough people in the regions who want to become dentists, who want to take on those NHS contracts, and it is not sufficient to say that we pay trained professionals well. We seem to have a lack of supply and over-demand.
What is the sector looking for? By widening access and participation in training, the Government need to create more flexible entry routes, including for overseas dentists, as well as develop training places for dental professionals right across the UK. This is not just about dentists: it is about upskilling dental technicians and dental associates by providing them with more training, so that they can provide a greater range of services. There are many vacancies for salaried dentists available in the UK—anyone who searches online can find details in pretty much every town around the country—but the problem is particularly bad in small towns and villages across the north of England, and the ability to track new entrants into NHS roles is limited, particularly when dentists working in the private sector can earn much more than they do in the NHS.
There is also an immediate need for dentists from outside the European economic area, and we should be making much more of our fantastic links to the Commonwealth countries, where there is often a surplus of trained dentists. Will the Minister look to extend the General Dental Council’s recognition of dental qualifications to schools outside the EEA? When needed, candidates could work in a provisional registration period with close supervision and training for a year before registration with the GDC is granted, a measure already used for overseas doctors by the General Medial Council, but not currently employed by dentists. I ask the Minister to look at recruitment, with a target to increase the number of UK dentist training places and incentives for NHS dentists to move to areas where there is less access to NHS provision.
I mentioned the NHS contract earlier, and I want to move on to that topic now. One of the main points that I have heard from dentists is that urgent attention needs to be paid to the 2006 NHS dental contract. Without fail, every dentist I have spoken to has said that the current system of renumerating dentists purely on activity is simply not fit for purpose. It has received criticism from dentists; from Governments of both political persuasions; from the Health and Social Care Committee; from the chief dental officer for England and Wales; from the British Dental Association; from patient groups; from all the major providers of dentistry in the UK; and, I think, from numerous Health Ministers who want to see changes. I suspect that my hon. Friend the Minister also wants changes to be made to the dental contract.
There is a real fear that NHS dentistry will disappear in the months and years to come. Dentists want to do the job of dentistry. It seems from what I have heard about the experience of dentists working through the pandemic that the likelihood of having payment clawed back by the NHS has grown. In the current quarter, dentists need to deliver 80% of their contracted UDAs, at a time when the prevalence of covid and the omicron variant is at its highest point in the entire pandemic, but the targets that have been set for dentists have risen during that period. If patients cancel or staff are sick and dentists cannot deliver that 80% of UDAs, the dentists lose funding, which means that they cannot pay the salaries of their staff, meet the rent, or provide future services for children or those with the lowest earnings. I believe that dentists are conscientious and caring healthcare professionals. They want to treat their patients, but they also want to be treated fairly by the NHS. Mr Flattery told me:
“If we really want to incentivise prevention, we need to see change urgently. ‘Incentives’ to just drill and fill is what the industry has been arguing against for many years.”
The latest NHS dental statistics show that in NHS Warrington clinical commissioning group, only 33.6% of child patients were seen by a dentist in the 12 months to June 2021, a fall from 54% patients the year before.
Finally, what can she say to my constituents, such as Paul and Paula Green, who have paid their national insurance contributions and paid their taxes but who, because of where they live in Warrington, can no longer get access to NHS treatment because nobody wants to provide a service through an NHS contract? I thank the Minister and look forward to hearing her reply.
Let me move on to the workforce. Increasing the number of UK-trained dentists will help, but it will take at least six years to make that vital difference. Urgent action is now needed to increase places on the overseas registration exam, develop an adaptation programme, and recognise qualifications from top dental schools around the world. Our membership of the EU forced us to look away from people in areas like our wider Commonwealth who were being trained in first-class dental care. Now we could see more of those practitioners in areas such as Clacton, which would be the very Brexit dividend that we were promised. I am delighted that Clacton has been selected as a pilot area for such training courses, but clarity is needed on how existing budgets can be used to support it to improve dental access in my constituency. I hope the Minister can help me with this.
Levelling up is not just about expanding employment outside London, but must be about addressing inequalities wherever we find them, such as decreasing NHS dental care in coastal communities such as Clacton. We can do that by forcing cash and power out of NHS England alongside using our Brexit freedom to open the nation to the dentists of the world we have so long spurned.
I will not take up too much time, because so much has been said so eloquently by my hon. Friend the Member for Warrington South, but I conclude with some constructive suggestions. It would be great if the Minister could address some of them. If she cannot, and I understand that I am bouncing her into this, I would be grateful if she could write to me. I wrote to the Secretary of State on this issue a couple of months ago, and I know the Department is very busy, but I have yet to receive a reply.
First, we should introduce a section 60 order to increase the General Dental Council’s discretion on recognising overseas dental qualifications. Secondly, we should develop a 12-month UK adaptation course for experienced, qualified overseas dentists to gain GDC recognition. Thirdly, we should maintain the mutual recognition of professional qualifications with European economic area countries indefinitely, and we should extend it to overseas territories, potentially as part of future free trade agreements.
Fourthly, and this is potentially the most important, we should fund a catch-up programme of overseas registration exams to make up for missed opportunities during the pandemic, with a view to recruiting 1,000 additional dentists within 12 months. This could specifically target the Indian subcontinent, which, according to all the dentists and dental experts I speak to, produces a very high standard of dentists and overproduces the number of dentists it needs. We are not talking about depriving another country of its dentists; we are talking about getting a job lot of 1,000 subcontinent dentists who speak English and who are very well trained. Some of them will be eager to work in this country, and we will get them here now.
Fifthly, we should introduce an expedited six-month performers’ list validation by experience programme for candidates with more than 1,500 hours of dental experience. Finally, we should accelerate changes to dental therapists’ scope of practice to allow courses of treatment without prescription from a dentist.
Others have spoken eloquently about the need to change the contract, so I am focusing on how, in the short and medium term, we can dramatically increase the number of dentists in this country. All these ideas were suggested to me by the Association of Dental Groups because, like others I have spoken to about this, it thinks they could be brought in relatively quickly and could have a reasonable, and potentially significant, impact in the next 12 months.
These are not unreasonable requests and, as we all have in this debate, I stress that the NHS was established on three significant and unalienable principles: that it meets the needs of everyone; that it is free at the point of delivery; and that it is based on clinical need, not the ability to pay. Certainly with NHS dentistry, we are struggling. We see that not only in kids’ and adults’ teeth being untreated but in serious diseases not being recognised as a result, potentially costing us far more not only in lives but in the money spent when cases come in as an NHS emergency, rather than as dental treatment that should be part and parcel of everyone’s rights in this country.