‘Hanging by a thread’: NHS dentists
Sam Ferguson - BBC Shared Data Unit
How to use this document
This story is available for use by the BBC’s local news partners. Please do not share outside of the network. It is under strict embargo until 00:00 on January 20, 2022.
This document has been designed to allow your newsrooms to easily pull out the relevant data for your patch.
Switch between sections by clicking on the tabs below.
Please feedback any issues to sam.ferguson02@bbc.co.uk
What’s the story?
Unions have warned NHS dentistry is “hanging by a thread” with some patients facing two-year waits for routine check ups.
Data from England and Wales shows more than 2,500 dental posts were lost across both countries – made up of more than 1,000 dentists, some of whom worked in multiple areas.
At least one town in England has been unable to attract a single applicant for vacant NHS dentist posts for two years.
The British Dental Association (BDA) said unhappiness with the NHS dental contract was a key factor.
NHS England said patients who needed care the most should be prioritised, and said it had set up 600 urgent dental centres across England.
The number of NHS dentists working in two English clinical commissioning group areas (CCGs) fell by more than a quarter in the year ending March 31, 2021, with the combined equivalent of 2,435 dentists leaving the health service.
The worst-affected was NHS Portsmouth CCG, which lost 26% of its NHS dentists over 12 months.
Meanwhile, 28 other English CCGs have lost at least 10% of their NHS dentists.
The BDA’s Shawn Charlwood warned significant numbers of dentists were planning on leaving the NHS.
“NHS dentistry is hanging by a thread, because without NHS dentists, there will be no NHS dentistry,” said Mr Charlwood.
“It’s a really serious situation and every dentist that is lost or every vacancy for NHS dentistry that remains unfilled affects thousands of patients in terms of care and their ability to access care.”
The BBC understands that one dental practice in Barnsley has had two NHS dental posts vacant for two years - without attracting a single applicant.
“Every practice struggling to fill vacancies translates into thousands of patients unable to access care,” said Mr Charlwood.
"Years of failed contracts and underfunding have meant a growing number of dentists no longer see the NHS as a place to build a career. The pandemic has upped the ante, and we are now facing down an exodus.
"Ministers have failed to grasp that we can’t have NHS dentistry without NHS dentists.
“Rather than punishing colleagues, we need a service that recognises and rewards commitment.”
Concern has also been raised about the usefulness of NHS England’s ‘Find a Dentist’ tool, which was created to help patients find an NHS dentist in their area.
BBC analysis shows around 75% of practices in England had not updated the site to show whether they were accepting NHS patients or not within the last three months.
Interim director of Healthwatch Chris McCann said getting up to date information as to where people can access service is a “real issue”.
“Information on practices on the NHS website can be out-dated,” he added. “We’ve seen some people having to contact up to 20 practices before finding someone to take them.”
In Wales, 6% of NHS dental posts were lost, with 83 fewer dentists working across health boards than the year before.
The worst-affected area was the Swansea Bay University Health Board, which had 22% fewer NHS dentists compared to the year before.
Until last year, NHS dentists in England and Wales had been using the units of dental activity (UDA) system.
UDAs are used to measure a practice’s activity. Courses of treatment - for example, a check up or a filling, are banded into UDAs.
Practices are set targets of UDAs to achieve, and if that target is missed, the contract holder and the practice can be forced to pay back money - known as ‘claw back’.
Critics have claimed the UDA system does not incentivise preventative work, and is a key reason for dentists leaving the health service.
Wales moved away from the UDA system in 2020. The BDA has predicted the number of NHS dentists in Wales will increase in the coming years.
The number of NHS and HSCNI dentists in Scotland and Northern Ireland has remained steady over the last three years.
Background information
What we did
We downloaded and analysed the latest data on the number of dentists carrying out NHS work from the following sources:
Emailed response. See data in this Google Sheet
(Note - while this pack includes data for Northern Ireland and Scotland, it focuses on the data for England and Wales, where the number of NHS dentists has fallen.)
NHS Dental contracts in England and Wales
Dentists can decide whether to take on NHS work, private work or a mix of the two.
Practices receive funding from the NHS to take on NHS work under the NHS Dental Contract.
The 2006 NHS Contract introduced a system of Units of Dental Activity (UDAs) to England and Wales.
UDAs are used to measure a practice’s activity. Courses of treatment - for example, a check up or a filling, are banded into UDAs.
Practices are set targets of UDAs to achieve, and if that target is missed, the contract holder and the practice can be forced to pay back money - known as ‘claw back’.
During the pandemic, the NHS has reduced the target percentage for UDAs, acknowledging that dentists cannot physically see the same amount of patients as before due to social distancing and hygiene restrictions.
The British Dental Association is now concerned that this reduced target could be increased before dentists are back to full capacity - leaving hundreds of practices facing claw back costs.
The UDA system is controversial with dentists, who claim it dis-incentivises preventative care.
Another criticism is the amount of work that goes into completing UDAs. The British Dental Association pointed out that treating a patient for one filling will fulfil the same amount of UDAs as treating the same patients for 12 fillings, despite the extra work and time involved.
In 2021, Wales turned away from the UDA system. This change is yet to be reflected in the data, but the British Dental Association has predicted that dentists will feel more encouraged to undertake NHS work in Wales because of the change.
Why is the data bad for patients?
The fewer NHS dentists there are, the harder it is for people to get dental treatment on the NHS.
Healthwatch England told the BBC that two-year waits for routine checkups were not unheard of, and sources have told the BBC of painful conditions still untreated after a year.
Though adults still have to pay for NHS dental treatment, the costs are much lower than the private sector. A root canal would cost £65 on the NHS, but a private provider could charge up to £970 (source).
Fewer NHS dentists also puts a strain on those dentists who still treat NHS patients, increasing their workload and stress levels, and reducing the amount of time it is viable to spend with individual patients and on preventative care.
The British Dental Association claims 30 million appointments were lost as a direct consequence of the pandemic, and NHS data shows practices operating at around a third of pre-Covid capacity by March 2021.
Healthwatch England told the BBC that 25% of the healthcare feedback they receive now relates to NHS dental treatment - up from just 5% pre-pandemic.
And of that feedback, Healthwatch said only 2% is positive.
NHS England’s ‘Find a Dentist’ tool
We created a website scraper to analyse NHS England’s ‘Find a Dentist’ tool.
The ‘Find a Dentist’ site allows people to enter their postcodes and check whether NHS registered practices in their areas are taking on NHS patients.
Our research found that more than 75% of dental practices listed had not updated their information within the last three months - making it impossible for the majority of patients to accurately assess whether NHS services are being offered in their area.
You can access the tool and search for practices in your area here.
What does the data show?
Use the tabs below to flick between UK countries. Two geographical breakdowns are available for England and Northern Ireland.
England
Detailed data (clinical commissioning groups)
This table (scroll down) shows the number of dentists completing NHS work in every Clinical Commissioning Group (CCG) in England over the last five years.
You can use the search bar on the top-right of the table to search for NHS CCGs within your patch and view the number of dentists carrying out NHS work over the last five years.
(Note: Only CCGs that have existed for each of the last five years were analysed. New CCGs or old CCGs that no longer exist have been discounted.)
Here’s a breakdown of the column names for this table:
CCG: The name of the CCG
2017/2018/2019/2020/2021: The year in question. Each year ends on March 31
Change last year: The change in dentists completing NHS work between 2020 and 2021
Percent change last year: The above figure in percentage terms
Change last five years: The change in dentists completing NHS work between 2017 and 2021
Percent change last five years: The above figure in percentage terms
In all, 106 CCGs are included in the below table, with 10 displaying on each page. Use the numbered or ‘Next’ buttons in the bottom right of the table or the search bar in the top right to navigate.
You can also download the data using the ‘Download data’ button at the bottom left of the table.
Detailed data (NHS region)
This table (scroll down) shows the number of dentists completing NHS work in every NHS region in England over the last five years.
You can use it to easily find the NHS regions covered by your patch, and view the number of dentists carrying out NHS work over the last five years.
Here’s a breakdown of the column names for this table:
NHS Region: The name of the region
2017/2018/2019/2020/2021: The year in question. Each year ends on March 31
Change last year: The change in dentists completing NHS work between 2020 and 2021
Percent change last year: The above figure in percentage terms
Change last five years: The change in dentists completing NHS work between 2017 and 2021
Percent change last five years: The above figure in percentage terms
Use the search bar in the top right to navigate.
You can also download the data using the ‘Download data’ button at the bottom left of the table.
Wales
This table (scroll down) shows the number of dentists completing NHS work in every NHS health board in Wales over the last three years.
You can use it to easily find the NHS regions covered by your patch, and view the number of dentists carrying out NHS work over the last five years.
Here’s a breakdown of the column names for this table:
Health Board: The name of the health board
2017/2018/2019/2020/2021: The year in question. Each year ends on March 31
Change last year: The change in dentists completing NHS work between 2020 and 2021
Percent change last year: The above figure in percentage terms
Change last five years: The change in dentists completing NHS work between 2017 and 2021
Percent change last five years: The above figure in percentage terms
Use the search bar in the top right to navigate.
You can also download the data using the ‘Download data’ button at the bottom left of the table.
Scotland
This table (scroll down) shows the number of dentists completing NHS work in every NHS health board in Scotland over the last three years.
You can use it to easily find the NHS regions covered by your patch, and view the number of dentists carrying out NHS work over the last five years.
Here’s a breakdown of the column names for this table:
Health Board: The name of the health board
2017/2018/2019/2020/2021: The year in question. Each year ends on March 31
Change last year: The change in dentists completing NHS work between 2020 and 2021
Percent change last year: The above figure in percentage terms
Change last five years: The change in dentists completing NHS work between 2017 and 2021
Percent change last five years: The above figure in percentage terms
Use the search bar in the top right to navigate.
You can also download the data using the ‘Download data’ button at the bottom left of the table.
Northern Ireland
Detailed data (local government districts)
This table (scroll down) shows the number of dentists completing NHS work in every Local Government District area in Northern Ireland over the last three years.
You can use it to easily find the NHS regions covered by your patch, and view the number of dentists carrying out NHS work over the last five years.
Here’s a breakdown of the column names for this table:
Health Board: The name of the health board
2017/2018/2019/2020/2021: The year in question. Each year ends on March 31
Change last year: The change in dentists completing NHS work between 2020 and 2021
Percent change last year: The above figure in percentage terms
Change last five years: The change in dentists completing NHS work between 2017 and 2021
Percent change last five years: The above figure in percentage terms
Use the search bar in the top right to navigate.
You can also download the data using the ‘Download data’ button at the bottom left of the table.
Detailed data (HSCNI health board)
This table (scroll down) shows the number of dentists completing NHS work in every NIHSC health board in Northern Ireland over the last three years.
You can use it to easily find the NHS regions covered by your patch, and view the number of dentists carrying out NHS work over the last five years.
Here’s a breakdown of the column names for this table:
Health Board: The name of the health board
2017/2018/2019/2020/2021: The year in question. Each year ends on March 31
Change last year: The change in dentists completing NHS work between 2020 and 2021
Percent change last year: The above figure in percentage terms
Change last five years: The change in dentists completing NHS work between 2017 and 2021
Percent change last five years: The above figure in percentage terms
Use the search bar in the top right to navigate.
You can also download the data using the ‘Download data’ button at the bottom left of the table.
What do the experts say?
The British Dental Association (England and Wales)
Shawn Charlwood, Chair of the British Dental Association’s general dental practice committee (Picture credit: The British Dental Association)
Q. Why are so many dentists leaving the NHS?
I think this has been a long process over the last decade, where the NHS system has become less attractive for dentists and their teams.
The system is not delivering the care that patients want, in terms of prevention particularly, and it’s not allowing dentists and their teams to deliver that care. Covid has exacerbated the fracture lines within the NHS dental service.
What really concerns us for the future is that NHS dentistry is hanging by a thread, because without NHS dentists, there will be no NHS dentistry.
We’re seeing significant numbers of dentists indicating that they will be leaving the NHS dental service.
It’s a really serious situation and every dentist that is lost or every vacancy for NHS dentistry remains unfilled affects thousands of patients in terms of care and their ability to access care.
It’s an absolute nationwide problem and it doesn’t particularly come to a surprise to me or my committee or the BDA, and we’ve been flagging this up to NHS England for over a decade.
Q. Why has NHS dentistry become a less attractive option for dentists?
For almost 15 years dentists and their teams have been working in what we call a UDA system – that stands for units of dental activity.
In essence it’s a system full of arbitrary tick boxes and targets and it doesn’t prioritize the ability for dentists to deliver preventative care, which is what is appropriate.
It also actually doesn’t encourage dentists to see new patients who often have quite significant health needs.
It is just not sustainable for practices to operate within that system if they are having to devote lots of clinical time which, in essence, is not being adequately funded. Dental practices are small, small businesses, they pay for everything, and so if the income coming to a practice is not enough to cover the costs of practice it is not financially viable.
Within two years, the system was discredited and there were calls for reform within Parliament for the system to change and what we’ve seen is perpetual delay, prevarication, and kicking the can down the road and now we’ve arrived, exacerbated by Covid, at this crisis point where dentists and practices are having to make decisions in order to survive, which means that they’re moving away from NHS dentistry.
In some areas they’ve lost a quarter of their NHS dentist. At that sort of rate of loss the NHS dental system becomes increasingly precarious.
There are some 30 areas that have lost at least 10% of their NHS dentists.
Reform is pledged in England, but it has to be a decisive break with a failed contract.
There’s no other sector of the NHS that has seen this level of under investment and what we’re calling for is a rapid reform of the contract in order to encourage dentists and teams to remain working in the NHS and, indeed, to encourage people to start to work in the NHS, to replace and fill these vacancies that we’re talking about.
Q. What do you fear specifically for the industry? What might it look like in five years’ time if this trend continues?
If the trend continues with the numbers that you’ve reported you’ll get to a point where practices will not be able to offer appointments to NHS patients, or the number of appointments that they can offer will be much reduced.
Not all patients can afford private health care.
We will be looking at a system that continues to decline.
People describe it as withering on the vine. A lot of dentists feel punished for working in the NHS. It’s not about pay, it’s about working within a failed system that doesn’t reward improving the health of patients. It’s more about arbitrary tick boxes and targets, and we need a system in place that rewards the commitment of dentists and team members to the NHS.
The other thing I’d like to pick up on it’s not just dentists, that are leaving the NHS dental service. All of the important members of the team, whether it be nurses, hygienists, therapists, or receptionists. They are increasingly turning away from the NHS dental services. These are highly experienced valued members of the team delivering really difficult skills and benefits to patients.
I think they will be very, very difficult to replace, so if NHS England don’t address this very quickly, I really do feel that we’re in a sort of tail decline of further problems and the headlines that we’ve seen for the last two or three years in terms of problems in accessing NHS dentistry will get worse and worse.
Q. What is the situation with the UDA threshold targets? Is it set to increase?
We’ve not had confirmation of the projected thresholds for January to March this year (2022).
But I think given the difficulties that teams are experiencing and obviously with the arrival of the Omicron virus mutation, I think that’s causing an awful lot of doubt and worry for dentists patients and their teams.
We’re seeing an increasing number of cancellations of appointments by patients because understandably they’re concerned about attending ,and I think they’re listening to government advice in terms of minimizing visits and social contacts.
If they can defer their dental appointments they’re probably doing that, which of course is not going to assist any meeting of activity targets in the middle of a highly infectious mutation of the virus.
Q. Has the NHS offered any support in terms of a reduction in threshold targets during Covid, when dentists physically cannot see as many patients as they were able to pre-Covid?
The target at the moment is 65%. And, as I say, the indications are that that will rise in 2022.
Practices are typically meeting a third [of pre-pandemic levels], but you can see they’re not meeting the target.
It may be because some of their staff are isolating, the PPE and the various regulations that we’ve had to work under in terms of allowing a period of time between patients for any potential virus to settle and the cleaning down process.
It means that dentists have not been able to see patients at the same level as they were before Covid.
At the end of the year, money will be taken away for practices and for some practices, it will be very, very significant amounts of money.
We are increasingly nervous if NHS England are trying to increase the target further, given that we know there are significant numbers of practices who aren’t even meeting the current target.
Q. Wales has turned away from the UDA system. Would you expect to see numbers of dentists doing NHS work increase there in the coming years?
We broadly welcome what has happened in Wales.
They’ve moved away from the UDA system in quite an imaginative and courageous way. That is something we would really like to see in England.
I think, as a result of that renewed energy and commitment from the government in Wales that NHS dentists have looked at that and thought ‘we will stay with the NHS system’.
I think you will see an improvement in the figures in Wales. And I think you will see a renewed commitment to NHS dentistry because that’s the leadership that’s been shown – in moving to a different system of assessing patients and trying to identify those patients that need the most care and being able to deliver it.
Q. What changes are needed in England? Do you want to see an end to the UDA system there too?
I would like to see two things: A commitment to end the UDA system in 2022, and a replacement reformed contract in place for 2022 with the associated increased financial commitment by governments to NHS dentistry.
Healthwatch (England)
Chris McCann, Healthwatch interim national director (Picture credit: Healthwatch)
Q. What kind of impact will the fall in NHS dentists have on patients?
The main impact will be the increase in waits for treatment. We’ve heard examples of people being told that they have to wait for up to two years for routine check-ups, and up to six weeks for emergency care.
These lengthy waits can lead to more serious problems and long term that leads to increased pressure on the NHS like we’ve even seen, and in the most extreme cases people performing DIY extractions.
But in the long term you’ve got the issue that if people aren’t seeing their dentists then more serious conditions, for instance, most cancers, might not be picked up, which obviously is very serious and it bleeds to further pressures elsewhere in the system.
We can see that the struggle to access dentistry is having a real impact on the quality of people’s lives.
What we’ve also seen throughout the pandemic is a massive increase and the percentage of our feedback that is related to dentistry.
In certain areas of the country people have struggled to access NHS dentistry for quite some time, but pre-pandemic dentistry accounted for about 5% of the feedback we hear from the public. Now it’s almost around 25%.
And it’s not just the volume of feedback. Prior to the pandemic about 30% of the feedback we received would have been positive. I know that’s dropped way down. Over the past year or so the percentage of people with feedback that is about positive experiences dropped to 2%.
Q. Does Healthwatch advocate for a change to the UDA system in England?
There are issues with UDA in that it doesn’t encourage preventative treatment, for instance. We think that there’s a broader need for reform of dental care.
A look needs to be taken at the NHS template contract, as a matter of urgency so that the service provision allows for equal and affordable access for everyone.
The government and NHS have to pick up the pieces.
We know in so many areas of the, we just need more dentists and other dental practice staff. Information on practices on the NHS website can be out-dated. We’ve seen some people having to contact up to 20 practices before finding someone to take them.
Trying to get up to date information as to where people can access dental services is a real issue and it’s something we do hear a lot about.
Q. Is there a section of the population that Healthwatch have found are being more affected by this issue – for example, children?
I don’t think that that’s affecting one section more than the other, but we know that it’s definitely affecting children. There are children as young as five who are in pain and unable to access treatment.
Quite often there is an inequality in terms of impact. We know that some of those who have really struggled the most have been children, disabled people, people who live in care homes.
There’s also issues around dentistry being harder to access in more deprived areas of the country.
It’s a twin crisis of accessibility and affordability.
For some people even the NHS charges can be a struggle. We did research last year and I think around 60% of people find that NHS charges are expensive.
But that’s if you can get an NHS dentist. What really puts people under pressure is when they can’t get an NHS dentist and they’re being pushed towards private treatment.
Q. Does this issue predate the pandemic?
Absolutely, this is an issue that definitely predates the pandemic.
The conversation about reform of the dental contract has been ongoing since 2009. There is a recognition that we can’t just go back to how things were pre pandemic.
Although the pandemic has massively exacerbated the situation, which is understandable, the issues that we’re seeing now have been building for a long time.
What we would like to see is the NHS and the Department of Health and Social Care going back and having a real look at the NHS contract to see what root and branch reform is required of it to make it work.
For us it’s about building back a system where NHS appointments are available to people so that further health inequalities aren’t deepened.
It’s an issue that’s been kicked down the road for over a decade now, so what we would like to see is that it’s a major priority along with the other areas where there are pressures on the NHS.
Right of reply
NHS England
An NHS spokesperson said:
“The NHS has taken unprecedented action to support NHS dentists throughout the pandemic by providing additional funding for practices unable to deliver their usual levels of activity, alongside rapidly setting up 600 urgent dental centers across England so patient services could be maintained during the pandemic.
“People should continue to come forward for the dental care they need, and the care and treatment of people who need it most should be prioritised.”
Background notes:
As the Healthwatch reports shows it is clear more action must be taken to increase access and dental activity for our patients, who are struggling to get appointments.
In March 2021, NHS England was asked by the Government to lead on the next stage of dental system reform. The NHS has published six aims of dental system reform which have been endorsed by the British Dental Association and we continue to work with the sector to reform dentistry.
Dentists were limited in how much activity they could perform due to strict infection prevention control measures, however these measures were eased in November 2021. In November 2021, before the infection prevention control (IPC) changes, mean performance was 75% of contracted monthly activity, with over a third of practices delivering above 85%.
Therefore, the changes to IPC guidance allowed the NHS to take a further significant steps towards the full recovery of NHS dental provision for our patients.
The NHS is asking practices to deliver 85% of their usual activity for 100% of their payment, which is substantially more income protection than private dentists, or many other industries, receive.
In addition, NHS dentists receive free PPE from the Department of Health and Social Care and the Government recently awarded NHS dental contractors an increase in pay along with other NHS staff and workers.
The gradual return to pre-pandemic activity thresholds has reflected the proven ability of NHS dental practices to deliver and has been designed to maximise safe access for our NHS patients whilst offering fairness to contractors.
Welsh Government
A Welsh Government spokesperson said:
“We are committed to meeting the needs of NHS dentistry patients in Wales through preventive care and increased access, supported by contract reform. This will see a gradual move away from using Units of Dental Activity targets.
“While the pandemic has paused some of this work, we will continue to support practices during the recovery period as focus is placed on increasing access to those most at risk.
“As Covid-19 is still in circulation, public health measures such as physical distancing, enhanced PPE, and infection control requirements mean fewer patients can be seen in person and practices have been asked to treat people according to need.
“We are providing health boards with £3m in 2021-22 to boost access to NHS dental services, and £2m recurrently from 2022-23 to support increased provision.”
Background notes:
https://gov.wales/dental-services-wales-given-3m-funding-boost-recovery-pandemic