I beg to move,
That this House
has considered the effect of the covid-19 outbreak on dental services.
I thank my hon. Friend Barry Gardiner who co-sponsored the application for this debate, and the Backbench Business Committee for granting it. I also thank many MPs from across the House for their support for this important and timely debate.
I am speaking on behalf of everyone who has suffered toothache under lockdown, or who will suffer it this year, for all the children whose orthodontal treatment has been delayed or is in disarray—that includes two children in my own house—and for all those whose more serious dental problems would have been spotted in routine check-ups, but who have not yet had them spotted. I speak also on behalf of dental practitioners and laboratories in my constituency and across the country who have felt ignored during the pandemic, and not treated as the frontline health workers they are.
During the pandemic, one constituent told me that he had to pull out his own tooth, and a local dentist told me of an elderly lady whose dental pain meant that she could not eat solid food throughout the lockdown, and had lost weight as a result. There are serious consequences to the implications of covid-19 on dental practices. I would like to thank the dentists in my constituency and across the country, who have kept going in very difficult and stressful times, and often against all the odds.
My message today is simple: we are sleepwalking into the biggest oral health crisis since the creation of the NHS. Unless the Government begin to recognise that dentistry is an essential health service, the sector will collapse. For now, the current activity targets are unattainable and need to be scrapped—I am sure other Members will be talking about them today. In the longer term, we also need better targeted financial support to save the sector. Overall, we need a national dentistry recovery plan to provide safety for dentists and patients, funding to stop closures, and ways to address the huge backlog of dental appointments. There is an NHS England phased recovery plan, but it does not address the whole dental sector. Dental care is not a middle-class luxury, but it is moving that way. It is a fundamental aspect of good health and a key indicator of health equality. We neglect it at our peril.
From March to June last year, all routine dental care in England was paused and according to the British Dental Association over 20 million appointments were lost between March and November. That has created a huge backlog that will take years to clear unless it is addressed now. In my own borough of Wandsworth, nearly 6,000 fewer courses of treatment took place in the final quarter of 2020. It did not have to be this way. For example, in Germany, personal protective equipment and guidance was put in place straightaway and dentists were not shut. Funding of PPE and ventilators remains a major issue for enabling dentists to function and see patients even during the pandemic.
Dentists have faced acute financial problems. They are both frontline health services and important high street businesses in all our communities, yet they did not receive the same funding as other frontline health services or high street businesses. Financial support remains either absent or uneven. As many as 53% of dental practices estimate that they can only maintain their financial stability for 12 months or less in the face of lower patient numbers and higher overheads. Beyond access to the furlough scheme and Government credit, support for private practice has been close to non-existent. There has been a failure to recognise the mixed economy on which dentistry is based. Dentists are among the only businesses on the high street that continue to pay business rates. That is totally unfair. Many of my local practices have not received any financial support, such as business grants, and this must be renewed.
Now, on top of that, there are targets. In December, NHS dental practices were instructed by the Government to deliver 45% of all their targets, based on pre-covid levels, to earn their contract value from January to April. This was a hasty, not negotiated and widely discredited target-based dental contract, and it is incompatible with providing safe and sustainable services for patients during the pandemic. I understand that the targets were set before lockdown, but now is the time for the Minister to tell us that they will be reconsidered, they are not achievable and there will be a change of policy. The targets need to be scrapped.
Most dental practices are small high street buildings and they cannot expand to meet the guidelines on social distancing and fallow time as well as meeting the targets. The British Dental Association found in a recent practice poll that 40% of practices in London alone have seen more than half their capacity wiped out by cancellations, staff sickness, self-isolation and difficulties accessing childcare. If there was ever an excuse not to visit the dentist, we have one now. We have told everyone to stay at home, so they are staying at home and they are not going to the dentist, but that is just building up huge problems for us in the future. Dentists cannot be financially penalised because of that.
The latest UK data show high levels of cancellation and non-attendance during lockdown. One local dentist told me that at absolutely full stretch before Christmas he was able to meet 30% of pre-covid activity levels. He cannot meet them now, and he is worried about being penalised and losing money retrospectively, because he is obviously having to pay out for those contracts during these months. We would all like more people to be able to see dentists. We would like them to reach 100% of the targets and to clear the backlog, but the targets are simply unachievable at the moment and will put the future of dental practices at risk. By implementing this target, the Government are effectively removing the safety net from NHS dentistry at a time when covid-19 rates are surging. It is important to note as well that the target is set not by the chief dental officer, but by the Government. The wider implications of these issues extend beyond just bad oral health or a bit of toothache. It is predicted that it will increase emergency attendances at hospital A&E, increase antibiotic prescribing, increase admission to hospitals and longer stays, and increase missed oral cancer diagnoses, which is really worrying. The Oral Health Foundation found that mouth cancer referrals fell by 56% during the lockdown.
In my constituency, the waiting list for tooth extractions by children’s tertiary care is now two years and growing —that is an almost emergency treatment. I met with dentists in my own constituency in the lead-up to this debate, and they made it clear that the 45% target is just unacceptable. One said to me:
“How can the dental profession be expected to transition to this flawed quota system? Practices that fail to reach targets, through no fault of their own, will face penalties and clawbacks which will result in mass closure of dental practices as the funding to provide dental care will not make it viable to stay open. This is a reckless and unsafe decision”.
Today, the Faculty of General Dental Practice UK, the College of General Dentistry and the Royal College of Surgeons Of England issued a joint statement saying that
“safety must take a clear priority over dental activity levels during the…lockdown.”
There is a universal call to scrap the targets, and I hope that we will hear about that from the Minister later.
To wrap up, I have five demands of the Minister. First, we need a national plan for dentistry following the pandemic and a way that the backlog of appointments will be addressed, created in full consultation with the national professional dental bodies. Secondly, the activity levels for January to April must be scrapped. The 45% target will undermine patient care and safety. Thirdly, we must provide urgent support to practices to enable them to increase the number of patients that they can see. That means supplies of PPE and ventilation equipment to keep fallow time down. Fourthly, we need to be clear that all dental teams, including receptionists, must be given priority access to covid vaccines alongside other healthcare professionals. Fifthly, we need to maintain and expand the business rates holiday to dental practices and backdate it to late March.
In conclusion, many parts of the country already had poor access to dental care before the pandemic. Current levels of capacity across the service mean that, unless something is done now, problems are likely to reach an unprecedented scale in every community up and down the country, and we will see a whole generation growing up with poor dental health. Let us recognise the dental sector as the essential frontline health care service that it is and do everything in our power to support it through this crisis and for our future.
Order. I have a few housekeeping notes. The wind-ups will start at 4.42. There will be eight minutes each for the Front Bench teams, two minutes for Fleur to wind up, and a three-minute limit on all Back-Bench contributions starting now.
Three minutes means that I cannot answer Fleur Anderson. I congratulate her on obtaining the debate. I am chair of the all-party group for dentistry and oral health. I have a surgery in the Putney constituency—she did not visit me. Sensibly, dental surgeries, after the initial lockdown, have remained open, but, as she has mentioned, there are costly new anti-covid requirements. Currently, the figures of the backlog of appointments are staggering and, in response to those figures, new NHS targets have been set. Understandably, they are high. I have seen the British Dental Association’s sponsored letter. I went for a pinch of salt when it arrived on my desk. I understand that 60% of the practices are actually meeting those targets and that those that are unable to meet the targets can obtain dispensation. Scaremongering on safety in surgeries is just that—scaremongering. Dentists are medical professionals. They are overseen by the Care Quality Commission and by the General Dental Council. Safety is paramount. Most alarming—and this has been mentioned—is the drop by a third, as I understand it, of oral cancer detection and referral.
My next concern is that many of the clinical teaching staff at our hospital dental schools were drawn away to assist in urgent dental care and covid patient care. As a result, many of our final-year students are facing graduation with a clinical educational deficit.
However, I think it is worth looking forward. First, I thank the Minister for helping to move inoculations for dentists and all staff into category 2, which is a recognition of the dangers of the aerosol dispersal spray. Secondly, can she look into the long fallow time? Other nations have managed to make this somewhat shorter and safe. Next, we need to look after the children who require hospital general anaesthetics. In the long term, that has to mean prevention, and the very best long-term means of prevention is to introduce fluoridation into water supplies, particularly in deprived areas. While this backlog must—and in time, will—be cleared, prevention has to be the long-term aim. Caries is preventable, and it is something we can do something about in this nation as is progressively being done in others, by teaching children to brush their teeth and to use a fluoride toothpaste, and putting fluoride into the water supply.
I am grateful for the opportunity to raise the increasingly urgent problems with dental care in my constituency. Portsmouth is a densely populated city, and pre-existing problems with patient access and the retention and recruitment of dentists have been exacerbated by this pandemic. Figures from the BDA suggest that 43% of adults in Portsmouth had seen a NHS dentist in the past two years up to June 2020, compared with 48% across England. Figures also show that the fall in the proportion of patients seen in my city during the pandemic has been greater than the average across England. I am very concerned that Portsmouth has been disproportionately affected by the weakness of the current contract system, and that we face the prospect of generational damage to patient care.
The recently imposed NHS activity cut targets are particularly illogical, with practices facing steep financial penalties if they fail to hit 45% of their pre-pandemic NHS activity during the current quarter. Those targets effectively force NHS practices to prioritise volume over need, leaving them with little choice but to conduct routine check-ups instead of clearing the backlog of more time-consuming treatments. This creates an unsustainable situation, in which patients are unable to access the treatment they need while practitioners are in a race against time to maintain their financial viability. Although the Government have committed to reforming the system, we have seen no action and little appetite to do so.
Earlier this week, I met with the BDA’s local dental practice committee and Healthwatch Portsmouth. They told me that the situation is untenable, and practices are increasingly concerned that they will not survive beyond the pandemic, which will further restrict patient access. With nowhere else to turn, one constituent contacted me to help arrange a dental appointment over Christmas. Having been unable to register for a NHS dentist, another constituent joined the 7.6% of English households that have attempted a do-it-yourself tooth extraction using pliers to relieve their pain.
While these stories are anecdotal, they increasingly reflect the reality of dental care in my community. Without urgent change, NHS dentistry in my constituency and across the country could be decimated, permanently damaging patient care for decades to come. I call on the Minister to take action to protect patients and dental practices in Portsmouth, and to hear my concerns today.
May I take this opportunity to thank all in the dental profession for all they have done and, in particular, for how they have adapted to implement the huge changes needed to be covid-secure? I have direct experience of this, having received urgent care both during the first lockdown and yesterday. I know that I am not alone in thanking them, as several of my constituents have told me of their own experiences. On behalf of all of us, I thank them very much for what they are doing during these trying times.
At the beginning of the pandemic, dental practices across the country were instructed to close. This meant that dentists took a huge financial hit, which was compounded by the fact that many were ineligible for the Government’s financial support package. This was particularly true of private dentists. We rely on these practices as much as NHS ones to meet local demand, and that should be considered going forward.
NHS dentists have recently been asked to fulfil their contractual obligations in the last quarter of the financial year. However, in order to meet additional safety guidelines, they now see fewer patients. Indeed, 64% of practices surveyed by the British Dental Association last year estimated that they could only treat less than half the patients they saw before the pandemic. Practices also have to cater for the self-isolation of staff and patients, the general fear of older residents leaving their home for any reason and cancellations at short notice for all of the above.
I emphasise that dental practices are safe and continue to be so. I am grateful to the Leicestershire and Rutland Local Dental Committee, which allowed me to attend its Zoom meeting last night and hear the concerns of 112 local dentists. In an online vote, 80% of those dentists said they would not be able to hit the target for quarter 4. The added dimension is that should dentists miss the target by as little as 1%, they receive considerably less revenue for the work they have already carried out. Dentists are also given no leeway for last-minute cancellations and no-shows in their contracts, even though that may lead to those missed targets. I therefore ask that that be urgently reviewed, so that dentists are not punished for trying their hardest to continue to provide the care needed.
I can fully understand why the target was set when it was put in place just before Christmas. At that time, little was known about the new variant of covid and the case rate was dropping at a rapid rate. If it had remained in that arena, I certainly would have been clamouring for tier 2 in Loughborough and fighting to get as many businesses and facilities open as possible. Unfortunately, the new variant has put paid to that idea and a national lockdown has ensued. I ask that the target for dentists be reviewed in light of the current situation.
Order. Scott, you sound like a Dalek, and I do not mean that unkindly. There is clearly a communications problem. We will switch to the next speaker and then we will get you back, Scott.
The Book of Proverbs says:
“Confidence in an unfaithful man in time of trouble is like a broken tooth.”
We are in a time of trouble and there are lots of broken teeth. While I make no aspersions about the fidelity of the Prime Minister, I can tell him that confidence in his Government, even before covid, was already at an all-time low with the dentists I speak to in Brent. There has been a total lack of investment in dental laboratories, a failure to recruit and train dental technicians, flawed dental contracts and chronic underfunding.
My hon. Friend Fleur Anderson has lucidly set out the key demands of the British Dental Association: abandon the activity targets; support practices to increase the number of patients they can see safely; prioritise access to the vaccine; safeguard the supplies of PPE; and extend the business rates holidays to dentists. I will not rehearse and repeat her excellent arguments; I want to give voice to the frustration felt by the dentists who continue to serve my constituents in Brent so well.
The BDA has catalogued the failure to properly communicate with the public, but what I had not appreciated until I spoke with my local dental committee is just how poor the Government’s communication with dentists themselves had been. I quote from their letters. One said that
“dental services have often been treated as an afterthought with no understanding of the NHS contract imposed on the profession. Dental practitioners found out in May on the news, at the same time as patients that they were to reopen in June…The panic and frustration this caused is deplorable. Dental practices, despite being high risk because of the aerosol generating procedures, were not able to access PPE from the Government portal until September and the vital FFP3 masks were not added to that until November. It is clear that little thought, if any, had been given to dentists and their teams.”
One dentist wrote:
“When on the 8th June our high street practices in England were allowed to resume face-to-face care, the reality of what a new normal might look like hit…fallow time means the number of patients able to be seen is significantly reduced. It was anything but ‘business as usual’. I ask myself, at this time, what would be the worst thing to impose on dental practices? Very high up on my list would be precisely what the government has decided to impose—targets. The emphasis on targets from the NHS clearly prioritises a metric and finance over patient interest. To achieve targets, footfall would have to increase and non-urgent patients be prioritised.”
My local dental committee tells me:
“Many practices are already finding the conflicting strain too much, and this comes on top of the emotional and physical drain of wearing full PPE for hours every day…The imposition of a target at this time serves no purpose whatsoever other than to destabilise, perhaps terminally, NHS dental provision, and to demoralise an already exhausted profession further.”
Covid-19 has been felt most severely by those who were already more likely to have poor health outcomes—
Access to dentists in North West Norfolk, particularly for children, was one of the issues that I raised in my maiden speech, when I reported that constituents were being advised to register in Skegness. As I said at the time, that remains good advice for pink-footed geese, but it is not very practical. Prior to covid, my constituency had the highest population per dentist across Norfolk and Waveney. West Norfolk was the second lowest area for dental activity actually delivered in the country, with only 65% of contracted activity carried out, and it had the highest percentage of patients who were unsuccessful when trying to get an NHS dental appointment. That was before covid.
During the pandemic, access to services has become even more severely limited, as the early results of a survey that I am carrying out in my constituency show. Many patients are unable to get treatment. The British Dental Association has said that 20 million appointments have been lost nationally, and access to emergency dental care has also been very challenging. I have helped constituents to access the urgent dental care that was there, but the General Dental Council reported that 50% of people did not know that it existed, which may explain why a fifth of people experienced pain or even took action into their own hands.
It is crystal clear that the level of provision in North West Norfolk is simply not good enough. This is a long-running issue. I have spoken on numerous occasions to the NHS east of England direct commissioning group, whose responsibility it is to commission those services, to underline the need for improved local access. I certainly acknowledge that there are challenges in attracting and recruiting dentists in North West Norfolk, and there have been positive developments, such as the opening of the surgery at Marham, which my constituents have been using successfully. I know that the commissioning group is actively exploring the increased use of training places to play a part in the sustainable approach to this issue, but it is of course important that the significant backlog due to covid is addressed and done so safely. Like other hon. Members, I have been contacted by dentists in my constituency, who are concerned about the activity levels that they are being asked to deliver and question whether they will be achievable. I am sure that my hon. Friend the Minister will address those concerns in her remarks.
What my constituents really want is a commitment to short, medium and long-term improvements, so they can actually see a dentist. My dentist in King’s Lynn high street closed in November, and the money for that should be used to recommission services locally. Prior to covid, the NHS planned to open another practice by the summer and to issue a procurement exercise offering in-perpetuity contracts, which should be more attractive to providers in the long term. Understandably, those plans are now on hold, which is disappointing for my constituents. They want a public commitment to address these issues, so that they know improved provision will be coming. I ask my hon. Friend the Minister to meet me to discuss these issues so that we can urgently address the provision, which is certainly inadequate for my constituents.
Apologies from North Cornwall, Mr Deputy Speaker. I thank Fleur Anderson for bringing forward this very important debate. In the three minutes that I have got, I would like to address the wider issues around covid and NHS dentistry in places like Cornwall, the 2006 contract, and the challenges of recruitment and retention in rural areas.
We have exceptionally long waiting lists for NHS treatment in places like North Cornwall, with many people waiting years on the NHS list, and at the moment we have a limited number of dentists providing that NHS work. Many of the practices and dentists in my constituency are servicing more than 8,000 or 9,000 patients. That is not sustainable in the long term. Population growth in Cornwall has compounded that issue. Having met many dentists in my constituency, I am aware of the problems, and I look forward to working with the diligent Minister on the Treasury Bench to resolve some of them. The 45% target should be looked at again, because meeting those demands in the current environment is quite tough.
Those local issues are magnified in the national picture. Normally, someone presenting to an NHS dentist needs emergency work, which takes quite a lot of time. The contract is onerous. The 2006 contract was not great when it was introduced, but with time it has become less and less effective. It needs to be reviewed. I know Cornwall is not unique, but the problems become more acute the further one gets from the big cities. We do not want oral health inequalities across the country. The levelling-up challenge is an economic one, but we need to be aware that there are health shortcomings affecting those who live remote areas.
Looking at solutions, I have picked up on the fact that we used to have a scheme to recruit dentists in the short-term from the Commonwealth. Now that we have left the European Union, we can look again at the rules that apply, and I think we should do so. We should also look again at the 2006 contract and work with the General Dental Council to see whether we can fast-track people becoming dentists and working in practices.
We should consider how we can manage costs. Someone who earns £100,000 a year has as much chance of having an NHS dentist as someone on a low income. We could handle that better. All power to the Minister—I know she gets this. I look forward to working with her to get better dental health outcomes in North Cornwall.
I congratulate Fleur Anderson on securing the debate.
Before the pandemic, my engagement with the dental sector led me to form a number of views on how it served our communities. Those who work in dentistry are highly competent and well qualified professionals, but there are problems in recruitment, and it is increasingly difficult to find an NHS dentist. When good and highly respected dentists retire, they are hard to replace. There is a lack of accountability in NHS England and NHS Improvement, and the world of UDAs—units of dental activity—is opaque and difficult to understand.
One readily reaches the conclusion that in normal times, the system does not work in the best interests of local communities and public health. Covid-19 presents those working in dentistry with enormous challenges. They are placed in a position of significant health risk, there is a dramatic reduction in capacity, and there have been some problems with those working in the sector being recognised as key workers.
The Government were right to set up a network of urgent dental centres, and in many respects this has worked well, although I have received a lot of complaints about where and how to find them, being kept waiting on the phone for seemingly hours on end, and then difficulties getting an appointment. Not only is there the challenge of getting through the current lockdown, but the shadow of covid will hang over the sector for a very long time. There is an enormous backlog of work, and yes, although some of that may be classed as non-emergency, it is important to bear in mind that it is often a routine visit to the dentist that picks up cancer at an early stage.
The position has been exacerbated by the Government writing to dentists before Christmas seeking to impose a 45% target of UDAs for January, February and March. The proposal has been described to me by dentists in my constituency as “completely irresponsible”, “disrespectful”, “neglectful”, “unsafe” and “inconsiderate”. It should be dropped. The Government need to work with dentists to come up with, first, a short-term plan to get through the immediate crisis, and then a long-term plan that is easy to understand, provides proper accountability and full national coverage of NHS dentistry, and ensures the recruitment and retention of highly trained professional staff.
Like so many aspects of our lives over the last year, the pandemic has meant changes for dentists and for our constituents as patients. During the first lockdown last year, dental care was paused and emergency dental hubs were set up as back-up, naturally creating a backlog of patients in the system. Already in this new lockdown, practices are facing patient cancellations and staff sickness and self-isolation. It is clear that Government support is needed. No patient or dental practice should be put out for doing the right thing during the pandemic.
Over the last year, I have met dentists and heard from practice managers across Luton North, who have told me about the challenges of keeping people’s mouths healthy during a global pandemic. One Luton North practice got in touch this week to tell me that dentists have been told that they must still hit their targets of 45% for dentistry and 70% for orthodontics, even in this new lockdown. That seems grossly unfair.
Across all health services right now, patients are reluctant to attend appointments for non-emergency treatment. Many GPs are not seeing patients face to face unless absolutely necessary, but the Government and the NHS are asking dental staff to put themselves at risk. The new obstacles that covid has brought are preventing dentists from being able to do their best for their patients. Will the Minister take these issues away and consult dentists?
I was shocked to find that dentists are not recognised as key workers, so they will not be in the highest priority groups for the covid-19 vaccine. I understand that priority must be given to those most at risk of serious illness or loss of life, but dentists are healthcare workers. Dentists are essential, and they are put in high-risk situations with respect to covid on a daily basis. Will the Minister please lobby her colleagues and NHS England to put dental workers on the same level as healthcare workers when it comes to vaccinations?
Let me finish with an even bigger ask. We know that dental health is a determinant of other health and public health issues and matches up with other health inequalities that are caused by or can lead to poverty and other kinds of ill health. I therefore want to see the Government listen and rise to the challenge that dentists in Luton North have put to me over the last year.
I congratulate Fleur Anderson on securing this debate.
The impact of covid on the dental sector has been profound, from the sector’s closure in March to the 20 million lost appointments, the 15 million-appointment backlog and the year-on-year decrease in those who visit the dentist. In previous years, being able to avoid the dentist may have seemed an art form, but it is rapidly becoming a significant and desperately serious problem, with mouth cancer diagnoses significantly down and major operations being put on hold or just avoided due to lack of access.
It is right that we have to clear the significant backlog. While I do not oppose the concept of a UDA target, I do oppose the mechanism that penalises dentists who do not meet that target. I respectfully ask the Minister to consider whether the target could be rejigged so that people have the security and understanding that if they are unable to meet it, they will not see a loss of salary or any penalisation from the Government. Of course, we have already heard that 50% of dental practices are meeting that target, so we have seen an ability to deliver.
The intent is right, but the mechanism is wrong and only adds to the extra stress that those who work in dental practices are already suffering. I do not deny that dental practices in my constituency are safe, but the individual set-up of each is very different; things such as the air purification systems that they implement will mean that they have different fallow times and will therefore also impact the UDA issue. There is a result here whereby different circumstances will mean that the overall target is unable to be met.
I ask the Government to consider taking away the penalisation mechanism of UDAs, reimbursing the VAT costs faced by dentists on PPE, and ensuring that our dentists are treated as part of the primary healthcare network. We hope to encourage people to stay in this sector. We want them to do so—we do not want them to go towards private alone—so I hope that the Minister will be able to reassure me and many of the dental practices in my constituency.
Dentists are not asking for any more than anyone else, but they have received significantly less than many of those out there. All that we ask the Government today is to treat our dental sector with the respect that it deserves and to help it deliver for those who most need it across the whole United Kingdom.
I will start by commenting on the imposition of activity targets. On
“agreement…has been reached with the dentists”—[Official Report,
However, that is not how the dental profession interpreted the end to negotiations. The BDA has made it clear that it could not agree to such terms and that new contract requirements had been imposed on them. That in no way, shape or form constitutes an agreement. In the interests of accuracy, will the Minister clarify today that no such agreement was reached and that these targets have been imposed on dentists against their will?
Dental practices are now being asked to deliver 45% of their annual UDA target in order to receive their usual contract value. Surely the Government must recognise that this is simply impossible during a national lockdown. Many contract holders will hit a financial cliff edge and be required to return the majority of their contract value. Other practices will be forced to prioritise routine work such as check-ups for lower-risk patients, at the expense of urgent care and preventive work, simply to survive financially. For some years now, the Government have accepted that the dental contract needs reforming and that we need to move away from flawed UDAs. It is therefore unbelievable that the Government have decided to enforce a system based on UDAs in the middle of a pandemic. These are the wrong targets at the wrong time, and the Government should think again.
Unfortunately I know all too well about the crisis in access, because barely a week goes by when I do not have a constituent contacting me because they are unable to get a dental appointment for either themselves or their families, and often they are in severe pain and discomfort. Just last week, I was contacted by a nurse at a mental health hospital who is unable to get dental appointments for her patients. The shortage of community dentists, who are too thinly stretched, and high street practices that have to prioritise reaching UDA targets means that these vulnerable patients have no access to dental treatment at all.
That is one shocking example of what many Members know is true: it is increasingly difficult for our constituents to get an NHS dental appointment at all. The choice the Government now face is to either allow the situation to keep getting worse or to act now and bring in a new contract that does away with UDAs, to ensure that every patient gets the care and treatment they need.
I feel compelled to speak in this debate following my meeting with several dentists from Don Valley last week. I want to start by commending the work of NHS England and the British Dental Association in reaching a compromise in July, which saw the abatement figure agreed at 16.75% for the period when dental practices were instructed to close. At the time, the British Dental Association stated that this was a “fair number”. However, it is my understanding that the abatement has not yet been collected from the practices. Can the Minister provide greater clarity to practices and state when the abatement will be expected to be paid?
As Members will know, dentists are currently being expected to hit 45% of pre-pandemic activity, at a time when people are being told to stay at home, and triage activity is no longer being included in activity measures. If activity falls below 36%, practices will have to return the majority of the NHS funding they receive in the first three months of this year. That policy will directly put NHS dental practices at risk of closure, as the clawback is potentially disproportionate. With the country now in full lockdown, patients’ reluctance to leave home is leading to many missed and cancelled appointments, so for many practices this demand is impossible. In fact, figures from NHS England show that the demand for dental practices to reach 45% of pre-pandemic activity is already failing.
Penalising dental practices at this difficult time will not help reduce the backlog. The Government have continually adopted a pragmatic approach throughout this pandemic. Would it not therefore be reasonable to abandon the activity target of 45% while the country remains in full lockdown, and include triage as part of the activity measures? Increased targets should be delayed until
I would like to finish by stating something I saw scrawled on a wall in one of our many public houses: “A man with toothache thinks everyone’s happy whose teeth are sound”. We would be wise to remember this, as we could all be in a very sad state if we lost our dentists.
Can I, too, express my gratitude to my hon. Friend Fleur Anderson for securing this debate? Dentistry often does not get the attention it deserves when we are looking at health provision for the country, and today is an opportunity to address that.
Clearly, the pressure on dental services preceded covid-19, but the pandemic has exacerbated it. In normal times—if we can remember them—the demand for NHS dentistry in Sheffield was huge, with unmet need amounting to more than 35,000 patients. That clearly has a long-term impact on oral health, and one that is particularly worrying for children.
Then came covid-19, which has hit the sector hard. Frankly, to choose this time to impose new targets, without warning or consultation, shows either a lack of understanding or a lack of regard for the consequences. The 45% target will disrupt the priorities of dentists by imposing penalties for failing to hit levels of what are described as normal NHS activity in what are blatantly abnormal times. It will threaten the viability of practices, and worsen access to dental care across Sheffield and the rest of England.
Dental practices have made huge efforts to be covid-secure, with cleaning and air-clearing procedures that mean they cannot see as many patients as usual. Many have therefore prioritised emergency and urgent care, and this normal activity target will skew their priorities away from those patients most in need. As one dentist explained it to me, they will be
“forced to stop seeing emergency patients…and to push the limits of the sound infection control procedures brought in to protect patients and staff”.
Another simply said:
“These targets are the wrong choice at the wrong time”.
This is not scaremongering, as has been suggested, but a real and genuine concern from dental professionals who care about the services they provide.
Sheffield Central is in the top 10% of areas where NHS dental care was most impacted by the pandemic, according to a survey, and the Association of Dental Groups says that problems are particularly acute in the most deprived urban, coastal and rural areas. Imposing this target will hit those most in need—levelling down, not levelling up. We need to be growing our dental services, not threatening them with damaging targets.
I have great regard for the Minister—we have worked together on other issues, and I know she takes her responsibilities seriously—so I do hope that she will listen to the concerns she has heard today from both sides of the House, talk to colleagues and review this contract.
It is an honour to be able to speak on this topic, but I have to admit to a slight conflict of interests, as my father, who worked as an NHS dentist for 39 years, is now deservedly enjoying his NHS pension.
Dentists were allowed to return to work on
Dentists were adapting to these new conditions and striving to meet new targets when suddenly, just before Christmas, and without agreement from the profession, their target of activity was increased from the original 20% to 45%, and it had to be completed by
I will quickly touch on the real problem of the lack of NHS dentists in my constituency. There may be many problems, but I have constituents simply not able to get treatment and having to go private for services. One surgery told me that they have not had a UK graduate apply in 10 years, as they want to work in London. What can be done to help that situation? Here is my plea: if you are a graduate dentist wanting to work, do not go to London, come to North Norfolk, where you will have a better quality, will be paid well and will have a lower cost of living, and your patients will be eternally grateful to see you.
Despite all this, patients overwhelmingly express appreciation for the efforts dentists are making at this challenging time. They and the patients deserve proper assistance from us.
The breakdown of talks on NHS dentistry targets between NHS England and the General Dental Practice Committee is a failure of leadership on the Government’s behalf. The Government should intervene to reach agreement and alleviate the concerns shared widely across our dedicated dental profession.
Like others, I have been contacted by a dentist in my constituency who is concerned that, with the new covid variant being highly transmissible, and with the national restrictions, or lockdown, it is
“unfathomable that the government has chosen this time to introduce an increase in the target for activity required by dental practices holding an NHS Contract, by effectively more than doubling the minimum requirement of activity to 45%”.
I agree that, with covid rates still high, many patients will be understandably reluctant to go to the dentist. Indeed, British Dental Association analysis shows that more than 20 million appointments were lost between March and November 2020, more than half the treatment in a typical year. I agree with my constituent who queries why Ministers are encouraging potentially unsafe volumes of patients into NHS dentist practices under the imposed new activity targets.
The imposition of severe penalties for not reaching these minimum targets will be untenable for many practices already struggling to meet additional costs due to covid. Many will be at increased risk of closing for good. This would be a terrible situation for my constituents in Luton South, as Luton struggles with a very high level of poor oral health in our children: the severity of tooth decay in children aged five years is above the national average, at four teeth affected. Evidence suggests that deprivation accounts for 40% of the variation in levels of dental decay. Children aged five years living in the most deprived areas of Luton have higher rates of tooth decay than their counterparts in the least deprived areas and are two and a half times more likely to have experienced dental decay. If dental practices are forced to close, it will be harder for my constituents and their children to access the vital dental care they need. The long-term impact of poor oral health affects people not only physically but psychologically, as it influences how they look, speak, eat and socialise.
As my hon. Friend Fleur Anderson said, access to dental care must not become a middle-class luxury. The current target and penalties are bad for practices and patients. I urge the Minister to get back round the negotiating table and revisit the activity targets for January to April to protect our vital dental practices during the pandemic and give them the support they need.
One of the very first issues I was contacted about as MP for North Devon was poor NHS dentistry provision, long before covid took hold. I knew that was the case because the only NHS dentist practice I could register with is a 45-minute journey from home.
This time last year, a dental nurse contacted me to advise:
“We are seeing more new patients with severe treatment requirements and high levels of decay because they have had to wait so long to get a dentist and cannot afford private treatment. This leaves patients in pain and at risk of sepsis in some cases. Dental Nurses in North Devon are poorly paid as there is no band structure like other nurses, this means there is a high staff turnover”.
She was concerned that dental nurses could earn more in a bar or supermarket, but with less responsibility.
Now, during covid and heading towards post-covid, it is nearly impossible to get anything other than emergency NHS dental treatment in North Devon. I was fortunate enough to see an NHS dentist in London, but my constituents should be able to access NHS services here in North Devon. Private dentists have begun to fill the gap here and NHS dentists are moving to the private sector.
Those in the private sector are also now in contact with my office with their concerns about the dental health of patients here. One advised:
“As a private dental surgery owner we have been very quick to return to near normal levels of service despite carefully implementing the increased Covid secure measures. NHS services have not! As a result we have been inundated with poor patients in pain and unable to access their NHS services. When they have been treated many are being forced to pay private charges. For too long NHS practices were allocated I believe 80% of the contract value for delivering 25% of the contract and for Q4 of the contract year they now have to only deliver 45%. This is woefully inadequate as it is far more profitable for these surgeries to not deliver care than it is for them to open.”
There are concerns that NHS patient contributions are not being charged correctly and that patients simply cannot access the treatment they need from their NHS dentists.
We had to travel long distances to get dental treatment in North Devon long before the pandemic. Distance and now cost are stopping far too many people seeking the dental treatment they need, and I hope steps can rapidly be taken to address the situation with NHS dentists in North Devon as well as the wider position described in the Chamber today.
One of the more surprising effects of covid-19 is that I miss going to the dentist—a phrase I never expected to use. Although we might recognise the impact on ourselves, we should be in no doubt about how difficult the situation has been for those who continue to work and provide vital dental services in the pandemic. It is different from the situation in hospitals, but still difficult and exhausting, and it carries the constant underlying worry of infection.
The situation affects the whole UK. I hope that the Government will take the impact on dental health into account in discussions with Holyrood. That is a significant motivation for me today, because we have accounts of problems across the UK. James Craig of the Scottish Dental Association has described the experience of wearing a respiratory mask so tight that it was like breathing through a pillow. Another dentist felt that the profession had been thrown under a bus. Dentists have had to try to deal with public demand and then abuse when they cannot deliver through no fault of their own.
We must also accept that there are wider consequences for our health services as existing NHS dental health care becomes stretched, meaning that NHS-commissioned activity targeted at oral health inequality will be at risk. Many of us could find it difficult to get timely access to urgent, unscheduled dental work. As that begins to take hold, increased unmet care will have a widespread impact on our general health and wellbeing, leading to more and more people turning to GPs, emergency care and potentially hospital admissions.
Research shows that, as with so many of the impacts and so much of the collateral damage from covid-19, the vulnerable will suffer most. That will exacerbate the health inequality on which the pandemic has brought a stark focus.
Recently, I was contacted about an issue that young dentists assure me affects them across the UK. Associate dentists’ earnings have been halved because their payment is based on the work they carry out and the number of NHS patients on their books. We are currently awaiting the outcome of discussions between Holyrood and BDA Scotland to find a solution. Like everyone else affected by the pandemic, they need a solution soon.
I once put off having a toothache checked out, because it was not much of a nuisance and I was busy with other more important and pressing stuff; I would mention it at my next check-up. Before that was due, it flared up, became much worse, and I needed emergency root canal treatment. I also got a lecture from my dentist about leaving problems so that they escalate and become more serious. It is sound advice that we should perhaps listen to in this situation.
I call Janet Daby. Janet, I will stop you at 4.42 pm, so please ignore the clock at the bottom of the left-hand side. Then we will come to the Front-Bench contributions.
We are all aware of the widespread impact of the coronavirus pandemic. A&E departments are overwhelmed, intensive care units have been described as warzones, and essential operations, for example on cancer patients, are being postponed at great cost. In the midst of the sprawling crisis, the effect on dentistry has been overlooked. People have not received the essential dental care that they need, and dental practices have experienced crippling blows to their finances during the pandemic.
The Association of Dental Groups has found that dental practices in England suffered from an average of 45% losses in 2020. Dentists are crying out for Government support, but the Chancellor’s recent announcement applies only to the hospitality and retail sectors. Dental practices will receive no grants and no business rates exemption. The Government need to act so that it does not have a negative effect on our economy.
The ADG found that 35% of business owners expect to employ fewer staff next year, with some planning redundancies. We will lose practices from our high streets, and communities will be deprived of the care that they need. That needs urgent Government intervention and attention. The Department of Health and Social Care must work with other Departments to provide business support grants and relief. Additionally, dentists are still not acknowledged to be critical care workers in this lockdown—a matter that has already been mentioned by other Members, and that the Secretary of State needs to review. Patients have also had to—
Thank you, Mr Deputy Speaker. I join colleagues in commending my hon. Friend Fleur Anderson for securing this important debate. Timing is everything in politics, and this is well timed indeed. I will cover the point that she made about imposed targets shortly, but I do not want to miss the contributions that she made about health inequalities and cancer, which I thought were really important.
I do not think that it is a great surprise that there was cross-party coverage and, frankly, a lot of consensus. Concerns about the targets were expressed by my hon. Friends the Members for Portsmouth South (Stephen Morgan) and for Bradford South (Judith Cummins), the hon. Members for Loughborough (Jane Hunt) and for Don Valley (Nick Fletcher), my hon. Friends the Members for Luton North (Sarah Owen), for Luton South (Rachel Hopkins) and for Sheffield Central (Paul Blomfield), and the hon. Members for North Norfolk (Duncan Baker) and for Totnes (Anthony Mangnall). I must say, though, that a spirited case for the defence was made by Sir Paul Beresford.
I was glad to hear dental labs brought up by my hon. Friend Barry Gardiner. I will address them myself, but they are too often lost in this conversation. I also thought that important contributions were made by the hon. Members for North West Norfolk (James Wild), for North Cornwall (Scott Mann), for Waveney (Peter Aldous) and for Edinburgh West (Christine Jardine) about the pre-covid status quo not being what we should aspire to. Again, I shall address that myself.
Dentistry, like every industry, has had to battle its way through this pandemic—closed at first, worried for jobs and livelihoods, reopening desperate to address growing need, and innovating to do that as safely possible in challenging circumstances. We should be very grateful for the work that dentists and their staff have done and are doing, but even with that work 20 million appointments were lost between March and November. That is a backlog that we will live with for many years.
Although the dental profession has adapted well to provide urgent care through covid, the crisis has highlighted the need to do things differently and to do things better. As we rebuild post covid, we have a unique opportunity to not return to business as normal but instead shift the focus of dentistry in this country from the short term to the long term, and from the reactive to the preventative. I strongly believe that a more prevention-focused approach is something that many dentists across the country want for the benefit of their patients. I know that the chief dental officer is a big advocate of prevention being at the heart of NHS dentistry.
I spoke to the hon. Gentleman beforehand. There are some 6,000 registered dental technicians who provide dental implants such as crowns and bridges to 80% of UK patients. It is predicted that 1,000 of them will lose their jobs by July 2021. If that happens, we will be unable to address the issue of dentistry in the future.
I completely share that perspective, and I will cover that in my final points.
Of course, there is a more immediate issue at hand. On
Allowing negotiations to break down like that, rather than intervening to ensure that an agreement was found, is a failure of leadership by this Government. Where have they been on this issue? Whether we think that dentists are right or wrong in their perspective, and whether we think the figure should be 45%, 55% or 35%, surely we would agree that an imposed target is a failure of leadership.
It simply will not do that such a crucial part of our health service has working arrangements that discomfort it so greatly. NHS England would never pursue a work pattern that is dangerous, but there are reasonable questions about how practical it is. It is not just dentists raising that; we have had public pronouncements of concern from the faculty and the colleges. There should have been a negotiated deal that found common ground. I know the Minister is a consensus builder and I enjoy working with her. I hope she will say that she will step in to build consensus and fix this, and Labour will support her in that venture.
In the meantime, I hope the Minister can offer some reassurance on areas of concern relating to this: first, if practices do not hit that 45% of pre-covid activity, and instead land at between 36% and 45%, any reduction will be proportionate to the full payment; it will be downscaled in ratio. However, below 36%, a practice will drop off the cliff edge and not get its contract. That is concerning because in November that would have applied to 40% of practices. Those targets were put in prior to the third wave of the pandemic gripping, and we know that is having an impact. Eight in 10 practices have seen increased cancellations or missed appointments, and three quarters of practices have experienced staff absences this month alone.
Will the Minister therefore reassure the House that she will look again at that element to ensure that dentists have a fair chance of meeting targets and are not unfairly penalised if they do not, through no fault of their own? I know there will be a regional analysis of whether there are extraneous factors. I hope the Minister will endorse and double underscore that today.
Secondly, will the Minister offer reassurances that the use of units of dental activity will not incentivise just the treatments that fit in a little more easily—for example, check-ups that do not require fallow periods—while disincentivising more urgent complex care, and care that does not count towards the target? Thirdly, I am concerned about the wellbeing of dentists and their staff, because 45% of UK dental professionals feel that their mental wellbeing is worse compared with the start of the pandemic. What steps are in place to support our workforce? We have a duty of care towards them.
I will conclude with a point about dental laboratories. They make the crowns, bridges, dentures, and more, on which dentistry relies. While the Government acted quickly to protect the dental industry—as I said, we supported them on that—there has been nothing for dental labs, which have seen their orders collapse. Many have shuttered and will never reopen. People are leaving that skilled profession, but we are going to need them again, and in greater volumes as we catch up. Instead, we will now buy those products from the continent and beyond, all around the world, and we will have lost skilled work because we let it wither. I hope that the Minister will use this opportunity today to announce relief for that.
Dentistry is a vital part of our NHS. Dentists and their staff have fought valiantly to keep the industry going in unprecedented times. Now they are at a crossroads and need political help. The Government must step up and resolve the contracting issue, and work with dentists to build a new exciting future for dentistry, preventing ill health, rather than chasing it. If they meet the moment, we will support them, but if they do not we will call them out.
I congratulate Fleur Anderson and indeed Barry Gardiner on securing this important Back-Bench debate. It is the second debate we have had on dentistry in about 10 weeks. Access to dentistry is, I think, something that unites us across the House. There has been something of a paradox during the debate, however. On the one hand, we have spoken about how patients cannot access the service they need and how we have seen demand rise so that now we essentially have only urgent and essential care waiting out there for us when we get through the pandemic; and then we have spoken about the fact that it is challenging—I agree, it is challenging—to reach 11.25% of an annual quota in the next three months. I hope to explain how we are ensuring that that is to support patients. I was quite saddened that support for patients was perhaps a quieter voice in the debate than support for the profession. This is only going to work if we support them both.
The pandemic has had, and continues to have, a significant impact on dentistry. First, I want to put on record my gratitude to dentists and their teams for their work in this difficult year. Dentists and their staff kept vital care going through the initial peak both remotely and in frontline urgent dental care centres. In addition, many volunteered to be deployed, if needed, on frontline covid services. Their contribution as healthcare professionals has been, and continues to be, greatly appreciated.
In early 2020, the nature of the novel virus that causes covid-19, and consequently the risks for dentistry, were unknown. However, we knew that the risk of transmission via aerosols, which are frequently generated in dental procedures, was high. As a result, face-to-face urgent care at the start of the pandemic was restricted to designated urgent dental care centres. Over 600 were stood up and they remain open to support all our constituents. The remainder of NHS high street practices were asked to provide remote consultations, complemented by the triple As: advice, analgesics and, where appropriate, antimicrobials.
In the initial guidance issued by Public Health England, dentists had to wear enhanced PPE and, crucially, to upgrade transmission-based precautions through their practices. This meant, obviously, that there was more time between patients and fewer patients could be serviced. I would just like to clarify a point. All NHS dentists can access free PPE from the e-portal, which has now delivered over 1 billion items to our frontline NHS services. To reduce the risk of subsequent transmission by airborne or droplet route, a post-procedure fallow time is needed.
All dental practices, as we have heard, were able to start offering face-to-face NHS care from
All NHS dental practices in England should now be offering face-to-face care, but during this difficult period practices have been asked to prioritise urgent care, address any delayed planned care and ensure provision for vulnerable groups. So they are not taking the easy route of just doing the routine, but focusing on the people who need it most. Actually, dentistry was difficult beforehand in rural and coastal areas. The UDA introduced in 2006 does not work particularly effectively, but we cannot change that here and now, so we have to try to provide care to as many people and as many of the most vulnerable as we can.
We have been working closely with NHSE on what level of NHS dental services can be safely delivered to the end of March. The letter was published in December setting out the requirements for NHS dental contractors in the next three months, and where activity targets are not met, perhaps through sickness or other challenges, an exceptions process is quite rightly in place. We are asking dentists to record the DNAs—patients who did not attend—sickness and all other things that might militate against them being able to deliver 11.25% down to 9%, so less than 10% of the activity they were delivering last year.
I hope that provides reassurance, and I hope that all hon. Members will understand that at the forefront of these considerations is the safety of patients and the safety of dentists and their dental teams. They are essential workers. They are in category 2, they are patient-facing frontline health workers and they are to be vaccinated in the first swathe. Indeed, I know that the chief executive of my own CCG is contacting all the dental surgeries that have been listed so that they cannot be missed. Obviously there is little jurisdiction over private practices; we have an influence over NHS practices, but not over how private businesses proceed.
My personal view is that a transformation in dentistry is necessary, particularly if we are to address the challenges that the pandemic has highlighted and the inequalities, particularly around children’s oral health. I wish to see a change in the way we approach dentistry and oral health. I have asked officials and NHSE to ensure that high-quality preventive work is at the forefront of future provision and that a transformation in commissioning takes place. We have an enormously talented profession out there whose skills are not being utilised. They can help us not only with the mouth cancers that are not getting diagnosed if they are not seeing patients but with dietary advice. They can do so much more. They diagnose conditions such as diabetes, by noticing the inflammatory nature of the mouth. There is a huge opportunity to deliver a greater range of health advice, monitoring and support, using dentists and their teams. Arrangements for 2021-22 and beyond are being worked on, and I expect this to be done despite the pandemic and worked on urgently.
Before I close, I would just like to add my support to the call by my hon. Friend Sir Paul Beresford for fluoridation. That is something I am extremely sympathetic towards, for the benefit of children’s health. I am clear that, in looking at these options, nothing should be ruled out and patients should be our first priority.
I thank all the MPs who have spoken in this debate from across the country, showing a lot of cross-party agreement on what we are asking for today. The message from all those people who contacted their MPs about this debate—dentists and patients—is loud and clear: dentists cannot reach their targets at the moment. That will mean financial insecurity and the destabilisation of dental provision that already has problems, which will impact patients. I say respectfully to the Minister that she has not heard the patients’ voice, and that actually, patients really want their dentist to be there in the future. That is the risk that we face at the moment.
I welcome what the Minister said about free PPE—I hope that includes ventilators—and the commitment to vaccinating dental staff, but I respectfully say that I do not think she has provided reassurance. The exceptions process has been demanded by dentists contacting all the MPs we have heard from today. So it is going to be a massive application with a huge amount of red tape. It does not allow for the space constraints of dentists, the sickness being faced by dental staff during lockdown, and the message to stay at home, which is stopping people going to the dentist. I ask her to reflect on the whole debate, to rethink the decision, to get around the table with the British Dental Association, to look again at those targets and to meet me, if possible, to talk about this further.
Question put and agreed to.
That this House
has considered the effect of covid-19 on dental services.