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NHS Dentistry: Waveney

Volume 696: debated on Tuesday 25 May 2021

Motion made, and Question proposed, That this House do now adjourn.—(Rebecca Harris.)

Can I just pause a second to ask those who are leaving to do so in a covid-friendly manner, and to give the Minister an opportunity to come in? There we go.

Thank you, Mr Deputy Speaker.

There has been an underlying problem with NHS dentistry in the Lowestoft and Waveney area for a long time, with dentists retiring, leading to resources and dental capacity being taken away from the area, notwithstanding the need and demand for NHS dentistry. Many, but not all, of the remaining practices have difficulties in recruiting and retaining dentists. The situation has been exacerbated by a lack of funding, with net Government spending on general dental practice reduced by a third over the past decade. In recent months the situation has reached crisis point, due partly to covid but primarily to the closure due to retirement of two NHS dentist practices in Lowestoft and the closure of the mydentist practice at Leiston in the constituency of my right hon. Friend the Member for Suffolk Coastal (Dr Coffey). The latter was due to the difficulty of recruiting dentists to work in the area.

This is a national crisis. Official figures in March 2020 showed that 26% of new patients could not get access to an NHS dentist. The situation has worsened during covid, with more than 20 million NHS dental appointments lost nationally since the start of the pandemic. As has been reported today, the British Dental Association’s members survey reveals that almost half the respondents intend to stop working in NHS dentistry in the next 12 months, and two thirds estimate that they will not meet the new 60% activity targets they have been set. This is the worst survey that the BDA has ever carried out, and urgent action is required to stop dentists leaving the NHS in their droves.

The situation is worse in Waveney. Community Dental Services, an employee-led social enterprise, has recently opened a new dental clinic in the old magistrates court in Lowestoft. That investment is greatly welcomed, although CDS highlights the challenges that it is facing in the area. It is concerned about the lack of access to NHS dental services. Lowestoft and Waveney is an area of high need for dental services, yet there is a serious lack of provision, which has been exacerbated by the backlog caused by covid and, as I have mentioned, by the retirement of well-established local general practitioners. The perceived remote location of the Waveney area and the distance from all the existing centres of dental training make recruitment difficult.

CDS emphasises the need for a focus on prevention, particularly among children. The treatment of children under general anaesthetic for the removal of teeth that cannot be saved is the highest cause of admittance to hospital for general anaesthetic treatment in England and Wales. CDS advises that the reduction in local authority funding to support targeted or universal prevention—I am not attacking local authorities for this—has had a significant impact on the Waveney population due to reduced oral health improvement services. This limits CDS’s ability to reach out to all the people who need its services.

The impact on young people needs particular focus. In Suffolk, the proportion of children who saw an NHS dentist fell by half due to the pandemic: 60% in 2019 compared with just 31% in 2020. This translates to 43,000 local children missing out on their dental appointments compared with the year before. CDS, which is a paediatric dental specialist, has a high number of referrals from other practices of children with multiple decayed teeth that require complex treatment, quite often under general anaesthetic. The lack of general dental services locally makes safe discharge difficult, if not impossible, thereby creating further pressure on services. This has a devastating impact on children’s life chances, and could well prevent them from achieving the best start in life.

Covid has made the situation worse. The interruption of routine dental care and the subsequent reduction in patient appointments has created a backlog of patients. The pandemic has also meant the cancellation of and significant interruption to the dental general anaesthetic list at the James Paget Hospital at Gorleston in the constituency of my right hon. Friend the Member for Great Yarmouth (Brandon Lewis), which causes greater problems. The list will recommence on 1 June, and the backlog of patients needing urgent care is substantial, but this increases the pressure on dental practices, which have responsibilities for their patients’ dental care. It should also be pointed out that there has been no consultant orthodontist at the James Paget since mid-2020, resulting in patients having to travel further for care, and for children this disrupts their education.

I am receiving approximately 10 emails a week from constituents, many of whom are in agony, looking for an NHS dentist. Some will go private, but for many who are on relatively low wages this option is not open to them and is one they cannot afford. One constituent has been quoted £2,400 for a new front tooth and £2,000 for a bridge repair. Others who are in need of urgent attention, as I have mentioned, go to A&E at the James Paget in Gorleston. There, all that the exasperated consultants can do is to prescribe them antibiotics and painkillers. This is completely unacceptable. Another constituent, who had a new denture fitted in 2019, needed it to be adjusted as it made his mouth sore and had a poor bite. He had no option but to use his old dentures, which were worn down and had a tooth missing. He has only just seen a dentist and is now awaiting the new dentures. These are just a few cases that highlight the agonies that many people are going through.

Andy Yacoub, the chief executive of Healthwatch Suffolk, summarised the situation well. He said:

“We are living through a dental disaster, with little to no clear sign of when these problems will ease.”

He also said:

“This latest review by Healthwatch England strongly supports our own local view that there is huge inequality in the availability of NHS dental care amongst our population…This includes that some people have waited unreasonable lengths of time to get an NHS dentist appointment, while being told private appointments were available within a week.”

In Suffolk, he said that we are being

“inundated by feedback on a daily basis from those struggling to access these services. One individual revealed to us”—

Healthwatch Suffolk—

“that they required urgent hospital treatment after overdosing on painkillers to combat their symptoms,”

while another

“told us they couldn’t find a dentist to treat a tooth which had reached a point where it was decaying.”

I confess I have a slight self-interest in this, because my father was the NHS dentist in Fakenham for 34 years. The problems in North Norfolk with dentistry are terrible, with long waiting lists and people not being able to be seen. The Healthwatch report from the past day or so corroborates that. It strikes me that the contracts are some of the root causes of that, as is the disparity between the private and public sectors. What can we do to try to get more people to join this profession? I have one example in North Norfolk where, for more than 10 years, no newly recruited dentist has wanted to come and work at the surgery.

I thank my hon. Friend for that intervention. The situation is very bad in Waveney. It is also bad in other parts of East Anglia, not least in North Norfolk and in the constituency of my hon. Friend the Member for Peterborough (Paul Bristow). It is particularly bad in East Anglia, and one reason for that is that we are perhaps a little away from the centre of things, and it can be difficult to recruit people to work in the area. My hon. Friend is right that one solution is to reform the existing contract, which dates from 2006, and I will come on to that as I look at some short and long-term solutions that need to be instigated immediately.

In the short term, I urge my hon. Friend and Suffolk colleague the Minister to take the following actions. First, we must reduce units of dental activity targets. The previous target of 20% was appropriate, but the new 45% target is wholly unrealistic. Many practices will be forced substantially to reduce the number of emergency cases that they provide and to replace them with routine check-ups that are less time-consuming, resulting in an even longer backlog of outstanding emergency and urgent care cases.

Money that is currently clawed back by the NHS if dentists do not deliver UDAs must be reinvested in the Waveney area. Dentists under-delivering does not indicate low local demand, and any clawback should be reinvested into local dental services, not transferred to other areas. That situation is particularly prevalent in East Anglia. In 2019-20, 9.1% of total contract value was clawed back in the region, compared with 4.8% nationally across England.

I confess that I do not completely understand the opaque world of UDAs, but I know that the system is short-changing my constituents, many of whom are in agony. For children, there could well be lifelong consequences. Some NHS dentistry practices in the Waveney and Norfolk area want to take on more patients, but they are not able to do so as the UDAs are not available. John Plummer & Associates is a privately owned family dental practice with 10 NHS practices in Norfolk and Waveney. As NHS dental practices in the Lowestoft area have closed in recent years, dentists from those practices have joined John Plummer. Naturally, their patients would like to follow them, but because no more UDAs are now available, the dentists have been unable to treat them, as they will not be able to provide adequate treatment for their regular patients. Those UDAs are then lost to the Waveney area forever. So much more NHS dentistry could be provided in the Waveney area if more NHS dentistry was allowed. John Plummer & Associates would open a walk-in emergency NHS dental service, but it is not able to do so as it is not allowed to do any more NHS work.

The continuing problem with covid is limiting the number of people that dentists can see each day. That can be eased by installing high-capacity ventilators in dental surgeries. That will reduce the period between appointments, during which the rooms are cleaned, but most practices cannot afford that. I recognise that there is quite a bit of devil in the detail, but the Government can directly increase access to NHS dentistry by providing capital funding for this equipment, as the devolved Administrations in Wales and Northern Ireland plan to do.

In the long term, root-and-branch reforms need to be instigated immediately. There is a need to get more NHS dentists practising in this area, and the Association of Dental Groups has put forward a six-point plan to achieve this. First, the number of training places should be increased. Earlier this month, Healthwatch Norfolk called for a dental school to be set up: based in Norwich, it would be able to serve the Waveney area and, indeed, the constituency of my hon. Friend the Member for North Norfolk (Duncan Baker). As quickly as possible, the Government must instigate a recruitment drive, increasing the number of UK dentistry training places and introducing incentives for dentists to relocate to areas such as Suffolk and Norfolk.

Secondly, EU-trained dentists should be recognised. Their role is vital, and there must be continued access to NHS dentistry for EU-trained professionals, thereby preventing further shortfalls from arising. Thirdly, overseas qualifications should be recognised. The General Dental Council’s recognition of dental qualifications should be automatically extended to approved dental schools outside the European economic area, ensuring a smooth process for suitably qualified dentists to work in the UK—notably those from countries such as India. That should also include the doubling of places available under the overseas registration examinations.

Fourthly, the complex and lengthy process of completing the performers list validation by experience examinations—known as the PLVE—for overseas dentists should be speeded up, simplified and harmonised right across the country, with additional measures introduced to ensure that the process takes no longer than eight weeks.

Fifthly, whole dentistry teams should be allowed to initiate treatments. Allied dental professionals are, at present, not able to open a course of treatment. This means that they cannot raise a claim for payment of work delivered, with many practices unable to fully utilise therapists as a result; allowing whole dentistry teams to initiate treatments would address this problem.

The Association of Dental Groups’ sixth and final point is that the Government should create a new strategy to promote NHS workforce retention. They must reform the NHS contract, which is the major driver of dentists leaving NHS dentistry. A new contract, focused on the oral health needs of patients and targeting improved access and preventive care, should replace it.

With regard to the forthcoming health and social care Bill, with the commissioning of dentists set to move to integrated care systems, it is vital that dentists have a voice and are properly represented on ICSs. There is a worry that the possible pooling of budgets across primary care could lead to further cuts to NHS dentistry, and everything must be done to ensure that this does not happen.

Fluoridation of water can play a key preventive role in oral health, and it is very important that changes to the framework under which fluoridation schemes are carried out are accompanied by the capital funding that is necessary for those schemes to actually be put in place. I anticipate that we will consider this matter in more detail over the next few weeks when we debate the Bill.

I now come to the topic of new dental contract arrangements. As mentioned, underlying most of the problems of NHS dentistry is the fact that the current contract, which dates from 2006, is inadequate and now completely unfit for purpose. It must be replaced as quickly as possible. The BDA is looking for this to happen by April 2022 at the latest, and the new contract must break with the units of dental activity, ensure that NHS dentistry is available to all those who need it and prioritise preventive care.

My hon. Friend and Suffolk colleague the Minister is faced with a major task. From her perspective, it is unfortunate that the music has stopped on her watch. In summary, there are three things we need to be doing. I urge her, in the very near future, to provide practices, such as John Plummer & Associates, that will tackle the enormous the backlog of work with the resources to do so. We must end the cycle of retirements leading to funds being removed from the Waveney area, never to return. Secondly, we must tackle the growing scandal of children having to undergo major dental surgery. That requires much work in the short term in hospitals such as James Paget University Hospital, but in the longer term the introduction of major public awareness preventive initiatives is vital. Thirdly, the dysfunctional 2006 contract should be replaced as soon as possible.

First, I congratulate my hon. Friend and Suffolk colleague the Member for Waveney (Peter Aldous) on securing time for this important debate. I also congratulate my hon. Friend the Member for North Norfolk (Duncan Baker), who for the second time today has spoken about the challenges of dentistry that we have.

As my hon. Friend the Member for Waveney said, this is not a new problem; it was a problem and challenge pre-covid. The pandemic has definitely shone a light, and things have become much more challenging in the world of dental provision during the pandemic. Dentistry has been significantly impacted because of the risks associated with the aerosol-generating procedure that dentists do and, obviously, with the saliva generated when someone is carrying out a procedure on someone else’s mouth. In response, dental practitioners have been required to wear full personal protective equipment to keep them, their teams and their patients safe.

Public Health England is reviewing the current guidance on infection prevention and control. I mention this because it goes to my hon. Friend’s point on fallow time—the time between the dentist putting their instrument down and cleaning down their room, and then seeing the next patient. These things have been big constraints in trying to have a rapid throughput of patients through the consulting room. Fallow time now is as low as 10 minutes in many cases, although that does depend on material factors such as the ventilation and so on.

I am talking to NHS England about the use of ventilation and the ability to support dental practices in putting ventilation in, but I gently point out that what sounds easy in a sentence in this place is often challenging. The buildings are not always owned by the dental practices, and in order to put ventilation systems in we have to take the rooms being used to deliver care out. So there is that combination of challenges, but there is new research on ventilation and lighting, and we are constantly looking at these things to see how we can further support the profession.

An important step forward has been to reduce the amount of time between seeing patients, in order to facilitate more care for more patients, but we have taken the action we have because infection control sits at the heart of what we have to do. I stress that because, with the variant of concern in some of our towns and cities around the country, we have to very mindful that we are looking for progress as to how we proceed with dentistry. I agree with much of what my hon. Friend said about making sure we are looking for opportunities, but we have to be mindful of the fact that we are not yet clear of this pandemic, and that brings enormous constraints.

The thresholds that have been set for dental practices since the start of the year have been based on data on what is achievable while also complying with infection prevention and control. My hon. Friend alluded to the 45%, which was the level of dental activity placed on practices in the fourth quarter of last year. That figure is now 60%, and 80% through orthodontics. This is the tension that exists in this whole area. Sixty per cent is still 40% lower than what we delivered in pre-covid times—obviously. The challenge is to make sure that we are able to see the backlog, that we drive forward with looking after the most vulnerable and those with the highest degree of need, and that we do not lose ground on what has gone before, while also having to deal with complexities such as retirements and contracts coming back and so on and so forth. However defective the 2006 UDA contract is, it is not just a question of swapping one for the other.

The current thresholds are monitored on a monthly basis, and the new thresholds have been put in place for six months. Dental practices have been asked to deliver as much care as possible, prioritising urgent care, particularly for vulnerable groups. They are delaying planned care, ensuring that they are dealing on a needs basis with those in the most acute need.

In addition to these activity thresholds, NHS England has provided a flexible commissioning toolkit. I am very keen for the profession to get real-world examples of what can help deliver the service, based on the successes that have been achieved locally. Some of those successes have been achieved in our own particular area. Flexible commissioning is used to convert units of dental activity, or UDAs as my hon. Friend has referred to them, to activity that focuses on priority areas, such as improving access to urgent care, or targeting high-risk patients, which was exactly what he was asking us to look at in his speech. We are already doing that. It is good practice and regional commissioners can implement it. I am very keen to make sure that that practice is being used as much as it possibly can be. I am having very frequent discussions with NHS England to make sure that we are monitoring the use of these measures.

As well as flexible commissioning, support is also available to local NHS commissioners to put that capacity where we need it most. In the east of England, NHS England has developed the transformational dental strategy, the aim of which is to prioritise urgent care, prevention and inequalities. Despite our efforts to increase services, we know that patients are still experiencing acute difficulty in finding an NHS dentist—that is also true in my constituency.

A feature of the debates that we have had today is the availability of private provision in areas where there is no NHS provision. NHS England is charged with commissioning to the need in an area. Making sure that we commission to the need in an area is something that contract change, which I am very keen to see delivered by April 2022, addresses, but it is highly complex. I have met stakeholders in the UK. Some people suggest that the Welsh system is better. Others favour the French system or the one that exists in some of the Scandinavian countries. I have met members of the dental profession from all those places and, actually, no one has a perfect system. We are trying to take what is good about the various systems and ensure that we deliver in localities so that people can have access to care when they need it, with a particular focus on prevention.

We have a web-based programme in the east called service provider, which provides up-to-date information on dental services that are available. Patients experiencing difficulties are able to contact NHS England’s customer care centre and call 111 for help in accessing emergency dental care. All NHS dental practices in the east of England have been asked to reserve at least one slot per day for urgent dental care to improve capacity and, as my hon. Friend the Member for Waveney said, allow greater access. In addition, we have not stood down the 600 urgent dental centres that we had across the country during the height of the pandemic; we have left those in place, and we have a network of them across both Norfolk and Suffolk.

However, we know that information on NHS dentists is not always easy to access. Alongside increasing access for patients, it is crucial to support NHS dental practices and mixed practices—and, arguably, private practices—in order that we can start to have a more balanced approach. As my hon. Friends the Member for Waveney and for North Norfolk mentioned, part of the challenge that we have is retention. That is the case particularly in our area, but it is something that I have discussed with Cornish colleagues too; my hon. Friend the Member for St Austell and Newquay (Steve Double) and I have discussed at length how the problem is not unique to the east of England.

Practices have continued to receive their full contract payments minus agreed deductions, providing that levels of activity are met. An exceptions process has also been put in place for practices that have been disproportionately impacted by the pandemic. It is wrong to say that we want anyone to feel that they are not supported to deliver what they can. We have also made personal protective equipment available free of charge through a dedicated portal; and as of a week ago, we had delivered more than 367 million items free to dentists, orthodontists and their teams.

If it has done anything, the pandemic has continued to highlight the fact that transformation in dentistry is necessary, particularly if we want to make sure that we drill down on the oral health inequalities that exist across the country. I am meeting the chair of Healthwatch tomorrow, and I am sure that, among other things, we will discuss access to dentistry at some length. We need to develop a sustainable, long-term approach to dentistry that is responsive to the population. It needs to provide high-quality, urgent treatment and then restorative care where clinically necessary, but prevention must sit at its core.

The majority of oral health failures are preventable. My hon. Friend the Member for Waveney spoke about children. There is nothing more upsetting than a child being in acute pain and having all their teeth removed. That is a broader problem. Through flexible commissioning, we can ensure that we are doing supervised tooth brushing by encouraging local authorities to put that in, but we can also enable parents to do their part and ensure that they can help their children learn good habits right from the early days. Parents can encourage their children to look after their teeth by rubbing their gums before their teeth even appear, making sure that they understand how important it is.

In addition, any system that we design must improve patient access and oral health, and offer value for money for the taxpayer. It must also be designed in conjunction with, and be attractive to, the profession. NHSE is leading on dental contract reform work. Importantly, it is engaging with stakeholders, including the ADG, which my hon. Friend spoke about. It will be looking at what changes can be made to dental contracts in the short term to offer some improvements and some relief and respite to everyone, while details of the next stage of reform will be agreed by April 2022. Making NHS dental contracts more attractive to the profession will help with vital recruitment and retention, and I know that all my hon. Friends in the Chamber, particularly across rural and coastal areas, will welcome that.

Health Education England’s Advancing Dental Care programme has also been exploring opportunities for flexible dental training pathways and how we train our dental workforce to improve recruitment and retention. I am also very keen to make sure that we use the broader dental team as efficiently as we can, because dental technicians, dental nurses, hygienists and so on hold many skills that, particularly, could be used for prevention. However, with another hat in my portfolio on, I think of the obesity agenda and making sure that we all look after ourselves a bit better and have healthier lifestyles. Everything that we consume goes in through our mouths. Dentists are wonderfully placed, as are their teams, to help to encourage us to have a healthier lifestyle and to eat a little less sugar.

We remain committed to prevention and improving oral health, and I am pleased that my hon. Friend the Member for Waveney supports—I think, from his asks—the direction that we are trying to go in by changing the UDAs, concentrating on making sure that we have the skill mix right, focusing on prevention and looking at retention. As he said, however, this is a complex area. I am also having discussions with the GDC—he spoke about recognising dentists who have trained overseas and making sure that once we are assured of standards of education and so on, things are a bit simpler.

On making sure that we can expand schemes, subject to funding being secured and consulted on, I want to look at the expansion of fluoridated water. As my hon. Friend said, it is one of the simplest ways that we can improve oral health intervention, and we could significantly improve children’s health across the country. It is unacceptable in this day and age that young children have total dental clearances due to preventable tooth decay. The return on investment on fluoridation is very compelling and there needs to be a renewed focus on the investment in prevention.

We are committed to increasing dental access both in the short and the long term so that we can ensure equality of access no matter where in the country a patient lives. But this is complex. We are working hard at it. We are working with the profession, but we all need to double down both on prevention and making sure that we are all walking in the same direction to bring accessible oral healthcare to people.

Question put and agreed to.

House adjourned.